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Lower Back Pain

Lower back pain or lumbago is one of the commonest and most troublesome musculoskeletal conditions which afflict adults. Most people have a back pain episode at some time in their lives and most people get over their back pain, either with no problems or by coping with a manageable level of back problems over the years.

Low back pain is one of the most common reasons for being unable to work in western societies and is a major cause of work loss, disability and expense. Neck pain can be just as troublesome but is less frequent, while upper back pain and middle back pain are often postural and joint related.

Most back pain is thought to be caused by a strain or sprain of the spinal tissues which include the intervertebral disc, the facet joints, the ligaments, muscles and nerves. In many cases the exact back pain cause of an individual's problems will be very difficult or impossible to determine.

Further information on lower back pain is available at NHS Choices and Patient UK.

 

Orthopaedic surgeons mostly decide back pain diagnosis and divide back pain into three major categories:

  • Serious underlying conditions such as cancer, infection, fractures.

  • Specific and identifiable back pain conditions such as disc prolapse causing nerve root compression or spinal stenosis.

  • Non-specific low back pain, the large majority of sufferers being in this category.

     

Back Pain from Serious Conditions

A small minority of people will have an underlying illness or condition which is to blame for their back pain and the signs of this situation, called “red flags” need to be reviewed with each patient. These signs include loss of weight, being unwell, having gait disturbance or bladder and bowel difficulties.

The history will indicate any trauma such as a fall and a careful taking of the history will alert the examiner to any indication that the back pain is out of the ordinary. In all cases the patient should then be referred to a medical practitioner immediately for evaluation.

Kidney pain can present in the side of the body (flank pain) and over the lower back and kidney pain symptoms can include a kidney ache over this area perhaps due to kidney infection, with referral to the front possible and interpreted as stomach pain. A physio can help you with the diagnosis of any musculoskeletal problems and treat as appropriate.

Kidney stones are known to give very severe pain in these areas while kidney disease may not have pain as a major presenting symptom. Kidney pain - alcohol intake may have an effect on the kidneys but again pain is not a major issue here

 

Specific Back Pain Conditions

Once a serious illness has been ruled out the examiner will look for symptoms which fit a specific pattern. Specific back pain conditions include spinal stenosis (mainly in the elderly) and nerve root compressions (e.g. sciatica). Other syndromes such as facet joint arthritis and degenerative disc disease are harder to be specific about

 

Non Specific Low Back Pain

This is the major group of people with back pain, who neither have something that can clearly be pinned to a cause nor do they have anything medically amiss.

 

The Symptoms of Non-specific Lower Back Pain

Acute back pain may come on suddenly such as on bending over, lifting something or pulling something in the garden, while in other cases it just appears for no obvious reason. Sometimes it comes on insidiously (slow and sneaky) and builds up over time. In other cases a person might wake up and suddenly be aware they have significant low back pain.

Back pain symptoms from non-specific low back pain, also referred to as simple back pain, may be very mild and of no importance or very severe and disabling. There is always some back pain, either higher or lower, along with buttock and thigh pain at times. Mechanical lower back pain is related to the stresses and strains on the tissues of the low back so is usually worse with movement, maintained postures, leaning forward, sneezing, coughing or laughing and better lying down.

Once an episode of acute back pain has occurred, it is usually a few days until the pain begins to subside, with a good improvement by a week. It may take many weeks for all the symptoms to disappear and it is common to have repeat episodes. If a significant amount of pain remains over three or six months, then the problem is term chronic back pain and may be persistent over the long term.

 

Long Term Outlook for Back Pain

Many people with acute back pain do see their back pain settle down over a few weeks and go on to have few or no problems in the future. However, it is more common for the pain to take longer to settle, for there to be a pain free period of “normality” and for another episode of pain to occur at some point in the year after the first one.

This pattern of pain resolving and recurring (often called “relapsing and remitting") can go on for years with varying intervals between the episodes until at some point the pain does not completely resolve after another episode. Now the person has a chronic back pain problem punctuated again by episodes of more severe pain.

This pattern may remain for many years and can settle with time to be relatively stable and predictable but in some cases it can worsen to become more severe and disabling.

A back pain cure is often unrealistic and if it does goes away the likelihood is that the back pain relief has been due to the back itself in some manner rather than any particular treatment. Pain relief for back pain is worth pursuing if the pain is getting in the way of day to day activities.

 

Chronic Back Pain

Chronic back pain is defined variously but having continuous pain for six weeks is the time when treatments may have to be reconsidered to address a more chronic problem. However these types of pain often settle over time. If someone has pain for more than three months it is possible to call that chronic but true chronic pain continues for years or for always.

Again there may be low or high level symptoms, with long periods of mild pain followed by a severe episode due to performing an aggravating activity or staying in one posture for too long.

Long term pain can have significant effects on an individual, causing physical disability, work loss, financial difficulties, psychological problems such as depression and social and family disruption.

Back pain treatment for chronic pain is as for acute pain if you are having an acute episode: don't panic; keep active as possible; take painkillers as appropriate; pace activities strictly; increase your activity every day; get back to normal as soon as possible; resume your exercise programme. As you get back pain relief you should push on gently to do more and more.

 

Chronic Back Pain Treatments

For people with chronic back pain and disability NICE in the UK recommends a set of management approaches which includes:

  • A structured exercise programme, usually set and monitored by a physiotherapist, performed in a group of 6-8 people and consisting of eight sessions over eight to twelve weeks. Patients are continually encouraged to take up exercise as part of their normal life. The content of the programme typically includes strengthening exercises, postural awareness and control, stretches, aerobic exercise and advice on self management.

  • Manual therapy which can cover care from a physiotherapist, osteopath or chiropractor and techniques including manipulation of joints, mobilisation of joints, massage, advice and specific exercises.

  • Acupuncture, although scientific evidence for this treatment is still not very good.

  • Cognitive behavioural therapy or CBT has good evidence from scientific work that it can affect people's lives when they have pain and many other problems. CBT aims to change the way we think which is closely linked to how we feel and behave.

Referral to a pain clinic should be considered early on in the chronic pain process to make sure medication is as good as it can be and to allow CBT and pain management strategies to be implemented early. This may forestall the development of a disabling chronic pain problem.

 

Prevention of Back Pain Episodes

There is some evidence that continuing with exercise for back pain and being active is the best way to prevent future episodes of back pain. Gym work, jogging, swimming or any active pursuit may be good enough as there is little evidence that any particular back pain exercises are more beneficial than general exercise. Avoiding obviously difficult positions such as lifting from a very low position or twisting with a weight may also be sensible.

It may be useful in some cases to read other people's experiences such as in a back pain blog as this can reassure you about how things are going and may give valuable tips on coping. Information – back pain is complex and each person's problem is individual so reading around to understand the lack of certainty will give a more realistic view of the problem.

 

Sciatica

About 5% of back pain sufferers develop sciatica, severe leg pain in a defined distribution with the possibility of muscle weakness, reflex loss and sensory alteration. Sciatica symptoms are typically severe in surging type of pain and may be worst below the knee or in the foot. A sciatica cure is often touted by various therapies but may be very difficult to achieve - sciatica treatment involves advice, positioning, painkillers and mobilising exercises, often guided by a physiotherapist. Sciatica stretches are not advised as this will stretch the nerve and worsen the symptoms. More information on aspects of sciatica can be seen at sciatica-pregnancy and sciatica-Emedicine.

 

References

Clinical Knowledge Summary – Low back pain (without sciatica type symptoms)

Clinical Knowledge Summary – Low back pain (with sciatica type symptoms)

 




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