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Low back pain?

Updated: Feb 10, 2019

Lower back pain (LBP) is considered the number one cause of disability Worldwide, however, LBP is a not a disease but a symptom.

LBP can affect the quality of life in men or women, the elderly, children, sedentary workers or elite athletes. Pain can range in intensity from a dull, constant ache to a sudden sharp sensation. Studies have found the incidence of low back pain is highest in the third decade of life and can increase with age until the 60-65-year age group and then gradually declines (Hoy et al., 2010). LBP does not equal tissue damage - many environmental and personal factors influence the onset and progression of low back pain, biological factors - muscle spasm, inflammation, etc, social factors - stress, quality of life, job satisfaction, social support etc. psychological - anxiety, depression, etc, creating the symptom of LBP. Non-specific LBP is where no specific cause is identified, furthermore, not all back pain is the same, so each person should be treated in an individual way.

According to Hoy, et al. (2010) the incidence of a first episode of low back pain range between 6.3% and 15.4%, and 24% - 80% of people who experience activity-limiting LBP go on to have recurrent episodes..

Spine anatomy

There are 24 individual vertebrae seven for the neck, 12 for the thoracic spine and five for the lumbar spine, sitting on top of five fused vertebrae of the sacrum and four fused vertebrae of the coccyx. The spine is made up of bones, ligaments, muscles, nerves and joints and is inherently strong and flexible. An intervertebral disc sits between each vertebra which acts like a cushion, the vertebrae and discs of the lower back are much larger than the neck.

The spinal cord threads through the middle of the spine, individual nerve roots exit between two vertebrae to form a nerve. The spinal cord fans out through the lower back forming the cauda equina. The nerve roots of the lower back feed the nerves of the pelvis and legs, the main nerve formed is the sciatic nerve. .

Causes and Associated Symptoms of Lower Back Pain

According to Hoy et al. (2010) acute lower back pain can be triggered by physical and/or psychosocial factors. People with conditions such as diabetes, asthma and headaches are more likely to report lower back pain (Eivazi and Abadi, 2012).It is not always possible to identify one specific cause of lower back pain (non-specific LBP) several elements may interact resulting in an individual feeling pain. Sudden onset low back pain can settle very quickly with the right advice and management.

Leg pain, commonly known as sciatica is usually caused by some irritation / inflammation around the nerve root. Generally, these symptoms include leg pain but not always, that is worse than back pain and can increase with sudden movement like bending, coughing or sneezing. In some cases, leg pain can co-exist with weakness, loss of sensation or changes in reflexes which are called radiculopathy.

Disc bulges and inflammation are a common cause of this, however, we know disc bulges are common in people with no pain and we also know that in people with pain, the bulge can resolve but pain may persist (Foster et al., 2018).

In extreme cases, the nerves at the bottom of your spinal cord (cauda equina) may be compressed, this is called cauda equina syndrome. If you experience any of the following, seek urgent medical attention:

  • Increasing difficulty when you try to urinate or difficulty when you try to stop or control your flow of urine

  • Leaking urine or recent need to use pads (incontinence)

  • Loss of feeling /pins and needles between your inner thighs or genitals

  • Numbness in or around you back passage or buttocks

  • Altered feeling when using toilet paper

  • Inability to stop bowel movement or leaking

  • Loss of sensation when you pass a bowel motion

  • Change in ability to achieve an erection or ejaculate

  • Loss of sensation in genitals during sexual intercourse

There are some rare conditions that are a cause of lower back pain, these should be cleared with everyone’s assessment when presenting with lower back pain. These include cancer, fractures, infections or inflammatory disorders. Some additional symptoms or red flags to look out for are:

  • Poor general health

  • Increased fatigue

  • Unexplained weight loss

  • Night sweating

  • Loss of coordination

  • Constant night pain worse than the day

  • Pain, redness, heat or swelling in other joints

  • Morning, back stiffness lasting more than 90 minutes.

Up to 80% of people with lower back pain will have one red flag despite less than 1% having one of those serious disorders. However, it is important to discuss any symptoms with a healthcare professional (Henschke et al., 2013).

Management of lower back pain:

Management of lower back pain will vary from individual to individual depending on the case. A multidisciplinary team approach should be used including a sport doctor, physiotherapist, soft tissue therapist, osteopath or chiropractor, Biokineticist, and Pilates instructor.

Not every patient will need to see all these therapists, but every professional can offer high-quality care within their scope of practice.

The main components of treatment and rehabilitation consist of:

Education - it is evident from the research that low back pain can be a complex problem with many elements contributing to why someone develops LBP. It is essential that people see healthcare professionals who understand and discuss the factors involved in each presentation. This should include a comprehensive management plan, so each patient knows how they are going to achieve their goals and what they need to do to help. Healthcare professionals should advise on activity levels to promote the fastest outcomes and answer any questions to help people manage their pain in-between sessions.

Heat – using heat i.e. hot bath, hot water bottle or heat rub on the lower back can give short-term pain relief and help relax tight muscles.

Medication – over the counter non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen can help relieve back pain, NSAIDs aren’t suitable for everyone so check with a pharmacist or GP for advice. Other medications are available such as codeine, but this should only be used for a short time. Paracetamol on its own is not recommended by NICE but can be used with codeine if advised by a doctor. If pain persists, the research shows that drugs like ibuprofen and codeine are ineffective and should not be used. Different medications for persistent pain can be prescribed by a doctor.

Manual and soft tissue therapy – soft tissue therapists can perform hands-on treatment designed to reduce pain and facilitate movement following injury. The treatments may include mobilisations and massage. This treatment in conjunction with exercise has been found to elicit the best response to recovery.

Corrective exercise and Pilates – practitioners can prescribe exercises to help facilitate a return to normal activities. Exercises can be used to progressively return to normal day to day activities and movement, improve flexibility and strengthen weak muscles. A prevention programme can be designed to avoid recurrence of lower back pain and promote a healthy lifestyle.

Psychological Support – due to the multifactorial nature of lower back pain, some patients may find speaking to a therapist beneficial.

Surgery - in most cases surgery is not indicated. Research has shown that there is minimal difference between long-term outcomes of conservative management and surgery in lower back pain patients. Surgery may be indicated in patients with radiculopathy if their symptoms are worsening or haven’t responded to conservative treatments.

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Eivazi, M. Abadi, L. (2012). Low Back Pain in Diabetes Mellitus and Importance of Preventive Approach, Health Promotion Perspectives, 2(1), pp. 80–88.

Foster, N. Anema, J. Cherkin, D. Chou, R. Cohen, S. Gross, D. Ferreira, P. Fritz, J. Koes, B. Peul, W. Turner, J. Maher, C. (2018). Prevention and treatment of low back pain: evidence, challenges, and promising directions, Lancet Low Back Pain Series, 391 (10137), pp. 2368-2383.

Henschke N, Maher CG, Ostelo RWJG, de Vet HCW, Macaskill P, Irwig L (2013). Red flags to screen for malignancy in patients with low-back pain (Review), The Cochrane library.

Hoy, D. Brooks, P. Blyth, F. Buchbinder, R (2010). The Epidemiology of low back pain, Best Practice & Research. Clinical Rheumatology, 24(6), pp. 769-81.



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