Back pain will affect most of us, but it's usually a short-lived episode with no serious consequences. Most cases are managed without seeing your doctor if you can avoid strenuous activity and treat yourself with gentle stretches, hot or cold compresses, plus painkillers if needed.
Back pain is a significant burden both to those suffering and to the workforce and economy, and it affects particularly those aged 40 to 60 years old.
The back is a complex structure comprising the bones of the spine (vertebrae) stacked on top of each other, enveloping the spinal cord, which is a bundle of nerves. The spine flexes side to side and front to back, and it has 4 natural curves, named the cervical (neck), thoracic (upper), lumbar (lower), and sacral (lowest) regions. Movement comes from ligaments, tendons and surrounding muscles. Intervertebral disks provide a cushion between each vertebra and your rib cage encloses the lungs from front to back, where it attaches to the vertebrae.
The lower back is the part most vulnerable to injury, as it carries most of a heavy load if we're lifting something. Injury is usually to the muscles here, and doctors call this mechanical back pain or musculoskeletal back pain. But anywhere in the back – upper, middle, or lower – can become injured and painful, and it may only affect one side.
Referred pain from surrounding organs and structures can be felt in the back, such as kidney pain on either side of your flanks, lung conditions, pain from the heart or major blood vessels in the chest, and injury or illness referred from the shoulders, neck, or pelvis.
There are certain cases where we, as doctors, worry about what's causing back pain, and these can relate to your age, how long you've been suffering, specific symptoms, and any underlying health conditions or lifestyle risk factors. Let's take you through worrisome symptoms and signs of backache and ways to help heal a back injury.
There are multiple causes of back pain, which can be categorized differently. We’ve found it easiest to consider this by which part of the anatomy is affected.
This is the most common cause of back pain, especially low back pain, often called mechanical back pain. It usually relates to a sprain or strain on a muscle or ligament, and it aches or spasms in certain movements. It usually starts to improve after 3 to 4 days but may take a bit longer.
You may be able to recall an injury that triggered your back pain, perhaps a move where you were lifting boxes and furniture, or it might have been a sporting injury or awkward weight lift at the gym. It can even occur from tripping on a curb or missing a step in a flight of stairs. Your job may involve lifting or twisting, such as delivery drivers, clerical staff, or nurses, and poor technique or a load that’s too heavy is often responsible for these injuries.
Coughing fits can cause you to strain the muscles either around your spine or between the ribs – the intercostal muscles. Obesity and a sedentary job or inactive lifestyle are other common risk factors for muscle injury due to additional load and lack of supportive muscles in the back and core.
Pinched nerves are common and usually get better on their own. Sciatica is a condition where the sciatic nerve gets inflamed and pinched as it passes from the lower spine, through the pelvis, to each leg. Symptoms include low back ache and burning or shooting pain across one buttock, down the back of the thigh, and possibly to the outside of the lower leg or foot. It might cause a temporary numbness in the leg. It’s worse on bending the leg, and most people are better at standing than sitting. It’s worst when it first starts when it can cause spasms of pain.
There’s often no underlying cause of sciatica, the nerve may become inflamed after injury or overuse, and some people seem more vulnerable to it. It can sometimes be the result of a compressed nerve from a slipped disk, a bone spur (notch of bone on one of the vertebrae), or spinal stenosis, where the space for the spinal cord to fit within one of the vertebrae narrows.
Cauda equina syndrome is a serious nerve problem where all of the nerves in the lower spine are compressed, leading to worsening weakness and numbness in the legs, sciatica in both legs, possibly a lack of sensation around the buttocks and rectum, and loss of control of the bladder or bowel. It’s an emergency requiring urgent medical attention to prevent permanent disability.
It’s common for the soft cushion between every two vertebrae to get compressed, causing it to bulge to one side. This can reduce cushioning, causing pain in itself, and compress nerves coming from the spinal cord, causing painful conditions like sciatica. Your cushioning reduces with age, so this is one risk factor, and obesity is another, as additional weight puts more strain on the disks.
Ankylosing spondylitis is an autoimmune condition that causes lower back pain and typically starts in the late teens to early 30s. It’s lifelong and can run in families. You might notice morning stiffness, where it takes 30 minutes or more before you can get out of bed and start the day, and loss of lower back flexibility over time. Care needs to be taken with regular stretching and possibly prescribed medication to avoid long-term problems such as the fusing of the lower spine.
Rheumatoid arthritis is another long-term inflammatory condition that can affect the spine, especially around the neck.
The vertebrae are vulnerable to breakdown, where the structure of the bone becomes less dense and strong. This occurs in a condition called osteoporosisand puts you at risk of compression fractures. A lack of calcium and vitamin D over a lifetime can contribute to reduced bone density, along with being both overweight and underweight, long-term alcohol excess, smoking, and age. Medications can also reduce bone health, such as long-term corticosteroid use.
Spinal osteoarthritis is a wear and tear arthritis that can affect the cartilage cushions in your spine and neck and put you at risk of spinal stenosis.
Vertebral bones are the most common place for cancers to spread (metastases), causing severe back pain that won’t improve and it may wake you at night. You may be more aware of this if you have already been diagnosed with cancer, but it may also be the first sign. Night sweats, immense fatigue, and unintentional weight loss are all added characteristics to getting this checked out.
Lung, breast, and gastrointestinal cancers are the most common to spread there. Smokers are at high risk of lung cancer, and therefore spinal deposits of cancer, and the elderly are also at the highest risk of cancer overall, and therefore spine metastases.
Significant injuries such as from impact sports or a traffic collision can cause vertebral fractures. Pathological fractures relate to either very mild injury or no particular injury at all. They occur because of poor bone health and alert a doctor to an underlying problem that needs investigating, such as cancer. Compression fractures usually occur as a consequence of spinal osteoporosis, where the bone loses density and becomes more brittle, making it vulnerable to fractures.
Kidneys come in pairs and sit by the flank on either side of the back. A kidney infection called pyelonephritis can cause kidney pain, where you may also have blood in your urine, passing it with more urgency or frequency, and a fever. Kidney stones can also cause a searing back and abdominal pain, usually leaving you doubled over in spasms, and they can cause blood in the urine.
Much less commonly, a spinal abscess from bacteria or tuberculosis (TB) can cause back pain and a reluctance to move the back, possibly with a fever.
People describe this as a searing or ripping pain in their back and across to their chest. It’s where a layer in the lining of your aorta, the biggest blood vessel in your body, comes apart, and blood that should be transported from the heart to the rest of the body starts leaking out. This is a medical emergency and requires immediate hospital treatment.
General principles apply for back pain when it should be something you discuss with your doctor. If there is severe pain or weakness, or the pain is associated with concerning symptoms such as fever, unintentional weight loss, night sweats, a traumatic injury (such as falling from a chair height), or pain that feels out of proportion with an injury or suspected diagnosis, then you should see your doctor for review urgently.
Pain and stiffness can often occur shortly after a muscle injury to the back. Acetaminophen is a safe and sensible place to start when reaching for back pain relief, with relatively few risks or side effects if taken as instructed. It’s well-tolerated and may be sufficient for occasional mild pain that occurs for just a brief time. It’s also safe in pregnancy. It should be avoided by those with a known liver condition who have been told not to use it.
Nonsteroidal anti-inflammatory drugs (NSAIDs) can help to relieve the swelling and inflammation that causes back pain and loss of function, especially in musculoskeletal injuries. NSAIDs include ibuprofen, naproxen, and aspirin, and stronger versions are available on prescription. Taken regularly for a week or so, NSAIDs can be very effective. They should be taken with food to minimize any irritation to the stomach lining or increasing reflux issues. The anti-inflammatory element of NSAID medications increases throughout the first week so will continue to give added benefit with regular usage.
NSAIDs should be avoided in pregnancy and in those with NSAID-sensitive asthma, a long-term kidney condition, on certain medications, or those with stomach ulcers. Aspirin is not suitable for those under 16.
A proton pump inhibitor (PPI) may be recommended by your doctor or pharmacist to protect the stomach lining if using regular NSAID medications. These are available on prescription or to buy at the pharmacy, such as Nexium (which contains esomeprazole) or Prilosec (which contains omeprazole).
First things first, we’d recommend starting with some good old-fashioned stretching if musculoskeletal back pain is present. For the majority of mild back pains, this may be all that is needed. Even if you need other techniques or medication, moving and stretching are essential throughout your road to recovery.
Moving and stretching is encouraged in all with musculoskeletal back pain. Try to move a little and often, with gentle stretches for the back, neck, shoulders, waist, and legs, to avoid further stiffness, pain, and difficulty recovering. You should avoid complete bed rest with back pain, as it stiffens muscles and it can set up new problems in surrounding joints.
A cold compress is a good idea in the first few days after a flare-up or injury. A bag of frozen peas wrapped in a towel will help to reduce the initial wave of inflammation and swelling that can add to the pain. You should only use a cold compress for a maximum of 20 minutes at a time. Any cream or gel containing menthol can be applied to the injured area to have the same effect.
A warm compress is helpful once the inflammation has subsided, after the first few days, as it helps the muscles relax, prevents stiffness, and eases pain. A hot water bottle does the job well – use a towel to avoid causing a skin rash – or certain creams and gels can cause a local heat, such as Deep Heat heat patches.
A professional massage or manipulation can help ease aches and pains in the back and improve movement. This is best done by a professional who understands anatomy and injury. A sports therapist, physiotherapist, chiropractor, or osteopath are all highly trained, with the latter two working specifically with back problems and alignment. They can also advise on stretches to alleviate pain and rehabilitate, and exercises to prevent future back pain or injury.
With sciatica symptoms, once you’re over the initial spasms of pain, stretching out the hamstring muscles at the back of your thighs helps to ease the sciatica with time, and can prevent it in the future.
A TENS machine (transcutaneous electrical nerve stimulation) can help relieve pain by providing small electrical impulses to the lower back area, giving a mild tingling sensation and reducing pain signals to the brain. It’s a good idea to try if you have long-term back pain.
Acupuncture has evidence to back its role in the short-term relief of chronic back pain, and it may allow a little more movement to encourage further rehabilitation and repair. Tiny needles are inserted into the skin and muscles, which is thought to release natural painkillers in the body called endorphins.
CBT and mindfulness may help to treat the brain’s interpretation of pain if your back pain lasts several weeks or months. Sometimes our bodies malfunction to continue making us think we’re in pain, even after we’ve recovered from the initial injury. So, CBT (Cognitive Behavioral Therapy) or mindfulness can be beneficial in reducing your sensitization to chronic pain and thereby dampening its impact.
Taking care of your mental health is essential with injuries that are slow to heal, as chronic back pain can take its toll. Consider what you enjoy and what helps you relax – music, reading, catching up with friends – and work on releasing those natural painkillers, the endorphins. Be aware that low mood, anxiety, and depression can sometimes set in with chronic pain. See your doctor if you think your condition is affecting your mental well-being.
Core strength and conditioning can help with longer-term back pain and help to prevent future injuries. Pilates, yoga, and weight training can all help to build up core muscles, including the paraspinal muscles that hug the spine, and flexibility to keep the spine supple. They also improve posture, which helps if you sit at a desk for long periods or have a physical job requiring lots of lifting.
Most cases of back pain are nothing to worry about and will improve within a few days or weeks. There are certain circumstances when you should seek medical attention, and you may need this urgently:
If your doctor thinks there is a serious or life-threatening condition, they will refer you directly to a hospital. Otherwise, they will examine you and discuss the next steps for your road to recovery. Most commonly, your doctor will refer you to a physiotherapist for more specialized management, as this is one of the best ways to improve your back pain and muscle strength and prevent further injury.
If your back pain has been intermittent over a long period or short term but has no other concerning features, if it’s interfering with your job, hobbies, or everyday activities, you should see your doctor. They will listen to your symptoms and what you’ve tried already, ask further questions, and they will have a look at how you move, what brings the pain on, and where the specific pain is.
Only rarely does your low back pain require referral to a specialist for further investigation and treatment. If they need specialist input, they may refer you to an orthopedic or spinal surgeon who deals with surgical bone and nerve problems or a rheumatologist, who deals with medical inflammatory conditions and joint problems.
Strengthening your core muscles through conditioning training is the best thing you can do for your back. It doesn’t just give you an abdominal six-pack (who doesn’t want that?), it strengthens the paraspinal muscles that hug the spine and the deep abdominal muscles you can’t see, which supports your spine while it’s under the stress of everyday life. Your posture will improve, too, leaving you standing taller and straighter. Pilates is particularly good for this, or specific core exercise programs and weight training.
Keeping muscles stretched and flexible also keeps them in good health. Yoga and swimming are very good for this, and making sure you take time to warm up and down after any exercise session or period where you expect the back to be put to work. Even a spinal stretch after you get up can help – all vertebrates, including your cat or dog, take time for a good morning stretch.
Learning the proper lifting techniques can help protect your back – in a nutshell, it’s keeping a wide stance, straight back, and bending at the knees, to keep an even distribution. And no twisting while you lift.
Adjusting your workplace set-up may improve posture to protect your back, such as keeping your computer screen at eye level, forearms and hands at waist height and rested on the desk, and hips, knees, and ankles at right angles, with feet flat on the floor.
Good bone health is a lifelong commitment of a calcium and vitamin D-rich diet or supplements, especially vitamin D in the winter, and regular exercise. Alternate cardiovascular activity that gets you out of breath with weight bearing exercise, such as strength or weighted exercise that improves bone density.
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