Back pain particularly lowerback Pain

 If you have low back pain, you may have tension, soreness or stiffness in your lower back area. This pain is often referred to as 'non-specific' back pain and usually improves on its own within a few days.
Back pain may be called either 'acute' or 'chronic' depending on how long your symptoms last. You may have: acute back pain - lasting less than six weeks, sub-acute back pain - lasting six weeks to three months, chronic back pain - lasting longer than three months

 

If in doubt don't live with back pain get it checked by a professional, its what they do!

 

 

We are going to look at :

Types of backpain

Anatomy of the spine

Causes of back pain

 

A note of caution, contact your doctor as soon as possible if with your back pain you also have;

 

• a fever (high temperature)
• redness or swelling on your back
• pain down your legs and below your knees
• numbness or weakness in one or both legs or around your buttocks
• loss of bladder or bowel control (incontinence)
• constant pain, particularly at night
• pain that is getting much worse and is spreading up your spine

 

These symptoms are known as red flags. It's important to seek medical help for these symptoms to ensure you don't have a more serious, underlying cause for your back pain.

Back pain is a common condition that affects most people at some point during their life. Most cases of back pain are associated with pain and stiffness in the lower back, if in doubt check it out.

 

Types of back pain

Back pain can classified in two main ways:

• specific back pain – pain that is associated with an underlying health condition or damage to the spine
• non-specific back pain – where the pain is not caused by serious damage or disease, but by sprains, muscle strains, minor injuries or a pinched or irritated nerve.

Causes of specific back pain include:

• sciatica – a condition caused by a nerve in the back (the sciatic nerve) being irritated or compressed
• slipped disc – where one of the discs of the spine (see box, left) splits and the gel inside leaks out
• ankylosing spondylitis – a condition where the joints at the base of the spine become inflamed

 

How common is back pain?

Unfortunately Back pain, whether its lowerback pain or neck pain it is remarkably common;

1. early half the adult population of the UK (49%) report low back pain lasting for at least 24 hours at some time in the year.(1)
2. It is estimated 80% of all adults will experience back pain at some stage in their life.(2)

1. The National Health Service spends more than £1 billion per year on back pain related costs, this includes:  hospital costs, GP consultations and physiotherapy.
2. The private healthcare sector spends £565 million on back pain every year.(2)
3. The total healthcare costs for back pain is £1.6 billion per year.(2)

1. Palmer KT, Walsh K, et al. Back pain in Britain: comparison of two prevalence surveys at an interval of 10 years BMJ 2000;320:1577-1578.

2. Maniadakis A, Gray A. The economic burden of back pain in the UK. Pain 2000;84:95-103

 

What does the future hold when you experience backpain

The outlook for back pain can vary considerably between individuals. Some people have minor episodes of acute back pain before making a full recovery.
Other people have long periods of mild to moderate back pain that are interrupted by periods of severe pain, which makes them unable to do their normal daily activities.
Psychological and social factors play an important role in the expected outlook for back pain, particularly for chronic back pain.
For example, people who have a positive frame of mind and report enjoying a good quality of life tend to make a faster recovery than those who report symptoms of depression and are unhappy with one or more aspects of their life.
Treatment options for back pain include painkillers, spinal manipulation, acupuncture and exercise classes. Some cases of chronic back pain may also benefit from additional psychological treatment for the reasons discussed above.
The symptom of lower back pain is a pain or ache anywhere on your back, in between the bottom of the ribs and the top of the legs. The majority of cases of back pain usually clear up quite quickly.
However, if you experience back pain together with any of the following symptoms, visit your GP as soon as possible:

• a fever,
• weight loss,
• inflammation or swelling on the back,
• constant back pain that doesn't ease after lying down or resting,
• pain that travels to the chest or pain high up in your back,
• pain down the legs and below the knees,
• a recent trauma or injury to your back,
• loss of bladder control,
• inability to pass urine,
• loss of bowel control, or
• numbness around the genitals, buttocks or anus.

You should also seek medical advice if you're experiencing back pain and:

• you're under 20 years old or over 55 years,
• you have taken steroids for a few months,
• you are a drug abuser,
• you have or have had cancer, or
• you have a low immune system due to chemotherapy or another medical condition (for example, HIV/AIDS).

Ask your GP for advice if your back pain has developed gradually and has got increasingly worse over several days or weeks.

 

 

Anatomy of the spine

Anatomy – how the spine is put together
There are 33 bones in the spine with discs in between to act as shock absorbers; altogether they make up the spinal column.
There spinal column is divided into sections, cervical, thoracic, lumbar, sacral, coccyx.
Cervical            7 bones in the neck
Thoracic           12 bones in the spine where most of the ribs attach
Lumbar            5 bones in the lower back
Sacral               5 bones called the sacrum (these are fused together)
Coccyx            4 bones (referred to as the tail bone and are fused)
The vertebrae have different shapes and although they are connected do provide different actions, i.e. the cervical spine gives great flexibility, movement and support for the head where as the lumbar vertebrae are larger as these support pretty much most of your upper body.
The vertebrae have a small gap (called the ‘foramen’) through which the spinal nerves run. The spinal nerves run all the way from the base of your brain to the bottom of the spinal column. The nerves exit the spinal column at the level where they need to be, for example the nerves that go to your hands, exit the spinal column in the neck area (cervical), and the nerves going to your legs exit much lower and run along the whole length of the spinal column.
Intervertebral discs (bits between the bones offering shock absorbency and allow mobility) consist of a nucleus centre (soft jelly like substance) and an annulus which is a very tough, elastic and fibrous casing.
The spinal column is supported by muscles, tendons and ligaments, providing strength and stability to the ‘chain’ of vertebrae and discs. The muscles are connected to your bones with tendons; the whole skeletal system has to withstand all the forces placed on it through our activities such as work, sports and activities giving strength, flexibility and function allowing to get on with life.
Our spines are not straight and resemble an ‘S’ shape though this varies considerably with many variations such as exaggerated lumbar curve like a hollow at the base of the spine, lordosis is an excessive curvature in the lumbar spine.

 

 

How it work ; The Physiology of the spine

Anatomy is the parts of the spine now we need to look at how it can do its job.
The nervous system orchestrates what’s happening in and around the body and your, nerves pass on messages from your body to your brain and back
One type of nerves passes messages from your brain to the rest of your body and a second type ensures that information from the various body parts is fed back to your brain. This messaging service is however slightly more complicated because before a message from let’s say your lower spine reaches your brain, there can be many factors that can either suppress or re-enforce the original message.
This is of particular interest for a pain message because it provides the option to alter a pain message and by doing so turn down the volume of the pain signal. Unfortunately your body is also able to ‘increase’ the volume of the pain signal and this is targeted in many treatments for chronic pain. Researchers still find new factors that can alter pain messages.

 

The body requires oxygen and nutrients to function and this is circulated around the body via the blood, which also provides a waste removal service.
Restricting blood flow in any way can alter the body’s ability to perform its function, i.e. muscles require energy, if it’s limited they can fatigue or fail, If metabolic waste is not eliminated and taken away you can get cramp, not good if your an athlete or at work.
Excessive pressure onto the discs which have a very minimum blood flow can further any damage and restrict recovery, contributing to backpain.
One of the factors that may restrict the blood flow is smoking and research has now shown that smoking can indeed be one of the factors that contribute to back pain. [1] [2].

[1] Shiri et al. The association between smoking and low back pain: a meta-analysis. Am J Med. 2010 Jan;123(1):87.e7-35. DOI: 10.1016/j.amjmed.2009.05.028
View Abstract

[2] Scott et al. The association between cigarette smoking and back pain in adults. Spine 1999 Jun 1;24(11):1090-8.
View Abstract

 

 

Causes of back pain? 

Most cases of lower back pain are known as 'non-specific' because they are not caused by serious damage or disease, but by sprains, muscle strains, minor injuries or a pinched or irritated nerve.
Back pain can also be triggered by everyday activities at home or work, and by poor posture. For example, back pain may be triggered by:

• bending awkwardly,
• lifting, carrying, pushing or pulling incorrectly,
• slouching in chairs,
• standing or bending down for long periods,
• twisting,
• coughing,
• sneezing,
• muscle tension,
• over-stretching,
• driving in hunched positions, or
• driving for long periods without taking a break.

Sometimes, you may wake up with back pain and have no idea what has caused it.

Looking at the above you may get the impression back pain is mainly mechanical in origination, however a more complete picture would look something like this;

 

~ Exercise; type,lack of or commonly repetitive/excessive exercise.

~ Posture; work such as workstaion, home such as slouching or having your legs tucked under.

~ Your hydration, fluid intake; not simply about water but the quality or lack of quality you put in.

~ Diet & Nutrition

~ Menta l& Emotional state; if talking about a phobia can bring on the symtoms of an episode it lets you know how powerful the body physiology and mental/emotional states are so integrated.

 

 

Common causes of back pain? 

Some common causes of back pain include:

• pregnancy,
• gynaecological problems in women, such as pelvic inflammatory disease (PID),
• different types of arthritis, such as osteoarthritis,
• stress-related tension,
• viral infections,
• bone disorders,
• bladder and kidney infections,
• osteoporosis (weak and brittle bones),
• a trip or fall,
• a trauma or injury, such as a fracture,
• lack of exercise,
• obesity, and
• sleep disorders.

 

Serious back pain

The bulging or rupture of one or more of the intervertebral discs can sometimes cause serious back pain. This results in the inner jelly-like material (nucleus pulposus) pressing on the spinal cord or nerve roots, which run next to the disc. This is commonly known as a 'slipped disc', but is more accurately described as a 'prolapsed' (bulging) or 'herniated' (ruptured) disc.
The pain will usually be in your lower back, but you may also experience pain in you buttocks, thigh, calves, feet and toes, due to irritation of the sciatic nerve, which runs down both legs. Occasionally, the pain is also accompanied by pins and needles, numbness and weakness.
Intervertebral discs tend to dry out and weaken with age, or following an injury. This results in the discs becoming less flexible, which means they do not cushion the vertebrae as well as they did before. This is a common cause of stiffness and pain, particularly in the elderly. It also tends to be worse early in the morning.
Persistent lower back pain can also be caused by a number of rare conditions, such as:

• congenital (inherited) spinal defects,
• bone diseases,
• shingles (an infection that affects the nerves),
• fibromyalgia, or
• cancer that has spread to the spine.

 

Diagnosing back pain 

Your GP will be able to diagnose back pain by discussing your symptoms with you and conducting a physical examination.
Usually, there is no need for tests, such as X-rays or scans, when diagnosing back pain. If you have simple back pain, tests are not always helpful because they often do not show anything unusual.
You may be sent for tests if you have had an injury or blow to your back, if your GP suspects that there may be an underlying cause for your pain, or if the pain has lasted for an unusually long time.
For suspected disc problems, X-rays or a computerised tomography scan (CT scan) may be required. Your GP may suggest having a magnetic resonance imaging (MRI) scan, that uses a strong magnetic field and radio waves to produce detailed images of the inside of your body, in order to provide more accurate information about the soft tissues in your back.
In some cases, blood tests or a myelogram (a special kind of X-ray using an injected dye) may be needed.

 

A chiropractor, osteopath or physiotherapist?

Chiropractic and osteopathy are similar disciplines. Both osteopaths and chiropractors can diagnose by visual inspection, bio-mechanical assessment with many similiar to orthopeadic tests and palpation (feeling by hand). 
Chiropractic treatment tends to involve a more ‘direct’ approach, with an emphasis on adjustments of the spinal joints. Chiropractors also rely on X-rays, blood and urine tests and MRI scans for diagnosis. 
The osteopathic approach involves mobilisation (slow, rhythmic stretching), pressure or ‘indirect’ techniques and manipulations on the muscles and joints.
Physiotherapists are trained to diagnose problems in the joints and soft tissues of the body. Physiotherapy for back pain provides a wide range of treatments to relieve pain, promote relaxation and restore movement. They include manipulation, mobilisation and massage. Exercise may also be used to increase general fitness or to strengthen muscles that support the spine. 

These professionals help you understand what you present, its then in your hands. A common presentation is sciatica with lots of self help available but very diificult to really self help without some help and a correct diagnosis.

Acute back pain

Most cases of acute back pain can be treated by using a combination of medication and self-care techniques. These are discussed below.

Medication

The information is not for diagnosis or prescription purposes, If you have any questions about your medication talk to your doctor or pharmacist.

 

The painkiller paracetamol is usually recommended as the first treatment to try for acute backache.

If paracetamol does not control your pain, non-steroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, can be used instead.
Common side effects of NSAIDs include:

• indigestion
• stomach ulcer (a sore in the lining of the stomach)

In some people, particularly those who are 45 years or older, NSAIDs have been known to cause bleeding inside the stomach.
If you are thought to have an increased risk of stomach bleeding, your GP may also prescribe an additional medication known as a proton pump inhibitor (PPI), which is designed to protect your stomach from the adverse effects of NSAIDs.
PPIs help to prevent stomach ulcers and internal bleeding by reducing the production of stomach acid.
Alternatively, you may be given a special type of NSAID known as a COX-2 inhibitor. It is specifically designed to have a less harmful effect on the stomach.
Common side effects of COX-2 inhibitors include:

• weakness
• fatigue
• dizziness
• headache
• nausea
• indigestion

COX-2 inhibitors are not suitable for pregnant women or those with a history of heart problems.
If a stronger painkiller is required then a mild opiate-based painkiller, such as codeine or tramadol, can be used. Common side effects of these types of painkillers include:

• nausea
• dizziness
• drowsiness
• dry mouth
• vomiting

If you have dizziness or drowsiness, do not drive or operate complex or heavy machinery.
Stronger opiates, such as morphine, are usually required only in the most severe cases of acute back pain. Due to their potential for addiction, they are only prescribed for the shortest time possible.
Common side effects of morphine include:

• constipation
• nausea
• vomiting

Due to these side effects, you may also be prescribed additional anti-emetics (medicine used to treat nausea and vomiting) and laxatives (used to treat constipation).
If you are also experiencing symptoms of muscle spasms, you may be prescribed a short course of a muscle relaxant, such as diazepam. Common side effects of diazepam include:

• drowsiness
• dizziness
• loss of co-ordination

Do not drive or operate complex or heavy machinery when taking diazepam. Long-term use (more than five days) of muscle relaxants, such as diazepam, is not recommended because they can be addictive.

 

If you have any questions about your medication talk to your doctor or pharmacist.

 

Self-care for back pain

While acute back pain can be frustrating to live with, try to remain as positive as possible. There is a lot of research to suggest that people with a positive mental attitude tend to have quicker recovery times and are much less likely to progress from acute to chronic back pain.
If you have acute back pain, it is important to remain as active as possible. If you find it too painful to return to your normal daily activities immediately, pace yourself by carrying out your daily activities at a reduced level or a slower rate. Aim to do a little more each day, ie a graded response.
There is also no need to wait until you are completely pain-free before returning to work. Going back to work will help you to return to a normal pattern of activity, and it can often distract you from your symptoms of pain.
Many people with back pain find that using either hot or cold compression packs helps to reduce pain. You can make your own cold compression pack by wrapping a bag of frozen food in a towel. Hot compression packs are often available from larger pharmacies. You may find it useful to use one type of pack after the other.
Placing a small firm cushion beneath your knees when you are sleeping on your side, or using several firm pillows to prop up your knees when lying on your back, may help to ease your symptoms.

 

Chronic back pain, Your treatment plan

In 2009, the National Institute for Health and Clinical Excellence (NICE) issued guidelines about what treatments should be provided to people with chronic back pain. However, a number of back pain experts do not agree with NICE’s recommendations
NICE recommended that chronic back pain should be treated using painkilling medication and one of the following treatment options:

• acupuncture – fine needles are inserted into your skin at certain points on the body
• exercise classes – aerobic exercise, muscle strengthening and stretching
• manual therapy – your back is massaged or manipulated

If the treatments listed above prove to be ineffective, you may be referred for a combined programme of exercise and psychological treatment.
There is also a type of surgery called spinal fusion. However, it is usually regarded as a ‘treatment of last resort’ for people who fail to respond to treatment and who feel that chronic pain is making their life intolerable.
The various treatment options are discussed in more detail below.

Painkillers

As with acute back pain, a step-wise approach to pain management is recommended for chronic back pain. You will first be given a mild painkiller and only ‘step up’ to a stronger painkiller if it proves to be ineffective.
The usual steps are:

• paracetamol
• NSAID or COX-2 inhibitors, possibly in combination with paracetamol
• mild opiate-based painkillers, such as codeine or tramadol

If you need to take NSAIDs on a long-term basis, you will probably also be prescribed a proton pump inhibitor (PPI) to protect against stomach bleeding.

Exercise classes

If exercise classes are recommended to help treat your back pain, you will be offered eight sessions over a 12-week period. The classes usually take the form of group exercises, i.e. around 10 people under the supervision of a qualified exercise instructor.
You will take part in a range of exercises that are designed to strengthen your muscles and improve your posture. The exercises may include:

• aerobic activity – exercises designed to strengthen your heart and lower your blood pressure, such as jogging or swimming
• muscle strengthening
• stretching

 

Manual therapy

There are three main types of manual therapy:

• spinal mobilisation – force is applied to move one or more of your spinal joints within its normal range of position
• spinal manipulation – force is applied to move one or more of your spinal joints out of its normal range of position
• massage – the muscles around your spine are manipulated

Three main methods of treatment involve the use of manual therapy. These are:

• physiotherapy – a treatment designed to restore movement and function after injury or illness
• osteopathy – a treatment that focuses on detecting and treating problems with the muscles, nerves and joints
• chiropractic – similar to osteopathy; focuses on disorders of the bones, muscles and joints

More serious nerve damage can result in the loss of bladder or bowel function, and cause urinary and bowel incontinence. But this type of complication is very rare.
To avoid back pain, you must reduce excess stresses and strains on your back and ensure that your back is strong and supple.
If you have persistent, recurring bouts of back pain, the following advice may be useful:

• Lose any excess weight
• Practise the Alexander technique.
• Wear flat shoes with cushioned soles, as these can reduce the stress on your back.
• Avoid sudden movements or muscle strain.
• Try and reduce any stress, anxiety and tension.

Posture
How you sit, stand and lie down can have an important effect on your back. The following tips should help you maintain a good posture:

• Standing - you should stand upright, with your head facing forward and your back straight. Balance your weight evenly on both feet and keep your legs straight.
• Sitting - you should be able sit upright with support in the small of your back. Your knees and hips should be level and your feet should be flat on the floor (use a footstool if necessary). Some people find it useful to use a small cushion or rolled-up towel to support the small of the back. If you use a keyboard, make sure your forearms are horizontal and your elbows are at right angles.
• Driving - make sure your lower back is properly supported. Correctly positioning your wing mirrors will prevent you from having to twist around. Foot controls should be squarely in front of your feet. If driving long distances, take regular breaks so you can stretch your legs.
• Sleeping - your mattress should be firm enough to support your body while supporting the weight of your shoulders and buttocks, keeping your spine straight. If your mattress is too soft, place a firm board - ideally 2cm thick - on top of the base of your bed and under the mattress. Support your head with a pillow, but make sure your neck isn't forced up at a steep angle.

Exercise
Exercise is both an excellent way of preventing back pain and reducing any back pain you might have. However, if you have chronic back pain (back pain that has lasted more than three months), you should consult your GP before starting any exercise programme.
Exercises like walking or swimming strengthen the muscles that support your back without putting any strain on it, or subjecting it to a sudden jolt.
Activities like yoga or pilates can help improve the flexibility and the strength of your back muscles. It is important that you carry out these activities under the guidance of a properly qualified instructor.
There are also a number of simple exercises you can do in your own home to help prevent or relieve back pain:
Lifting and handling
One of the biggest causes of back injury, especially at work, is lifting or handling objects incorrectly. Learning and following the correct method for lifting and handling objects can help prevent back pain.

• Think before you lift - can you manage the lift? Are there any handling aids you can use? Where is the load going?
• Start in a good position - your feet should be apart with one leg slightly forward to maintain balance. When lifting, let your legs take the strain - bend your back, knees and hips slightly but don't stoop or squat. Tighten your stomach muscles to pull your pelvis in. Don't straighten your legs before lifting as you may strain your back on the way up.
• Keep the load close to your waist - keep the load as close to your body for as long as possible with the heaviest end nearest to you.
• Avoid twisting your back or leaning sideways - especially when your back is bent. Your shoulders should be level and facing in the same direction as your hips. Turning by moving your feet is better than lifting and twisting at the same time.
• Keep your head up - once your have the load secure, look ahead, not down at the load.
• Know your limits - there is a big difference between what you can lift and what you can safely lift. If in doubt, get help.
• Push, don't pull - if you have to move a heavy object across the floor, it is better to push it rather than pull it.
• Distribute the weight evenly - if you are carrying shopping bags or luggage, try to distribute the weight evenly on both sides of your body.