Low back pain / Lower Back Pain
Low back pain is very common. It is estimated that 60% to 80% of the general population will experience an episode of low back pain in his or her lifetime. Everything from the mattress you sleep on, to the job you do can have a cumulative effect on the different areas of the spine. Whether you are doing a lot of heavy lifting, or sitting still for long periods of time, you may be unwittingly putting unnecessary stress on your back. Low back pain is one of the top reasons why an individual may decide to come and visit an osteopath or physical therapist.
What Makes Up the Low Back?
The lumbar spine, or low back is made up of 5 spinal bones known as vertebrae, they are referred to as L1-L5. The low back supports much of the weight of the upper body and has a natural inward curve known as a lordosis.
The vertebrae in the low back are supported by a variety of different soft tissue structures including muscles, ligaments, intervertebral discs and nerves. The muscles in the low back aid in supporting the spine during twisting and bending motions as well as flexing and rotating the hip enabling you to walk. The ligaments in the spine create a strong supporting structure around the vertebrae and vertebral joints, to stabilize the spine during movements.The intervertebral discs in the low back provide a cushioning and act as a shock absorber for the low back. The nerves in the low back innovate the muscles and supply sensation to the pelvis, thigh, leg and feet.
Most low back pain has an acute onset and can last anywhere from a couple of days to a few weeks. Back pain that has lasted for around 6 weeks to 3 months is classed as subacute and back pain that has lasted for more than 3 months is classed as chronic back pain.
Most acute low back pain is a result of there being injury to the muscles, ligaments, disc or joints in the low back. With injury there can also be the presence of inflammation as this is a by-product of the body’s response to healing. Inflammation can cause severe pain.
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What are the Common Types of Low Back Pain?
There are many different ways to categorize low back pain, as mentioned above, the time period of back pain is one way. Other ways of categorizing low back pain is by the type of pain an individual is experiencing:
Mechanical pain: this is the most common type of low back pain. Mechanical pain is pain that arises primarily as a result from injury to the muscles, ligaments, joints or bones within the lumbar spine. The presentation of this type of pain tends to be localised to the low back, buttocks and occasionally to the thighs. It is usually made worse by certain movements of the spine, including flexing forwards, twisting, going from sitting to standing, walking and lying down.
Radicular pain: this type of pain refers to pain caused by irritation of the nerve roots as they exit the lumbar vertebrae. This may be because the nerves have become trapped, impinged or inflamed. Radicular pain usually follows a certain pattern, this is known as a dermatome. Your physical therapist will be able to understand which nerve is irritated based on the location of the pain down in your lower extremity. Radicular pain usually feels very sharp and can create a burning sensation as well as pins and needles. It can also be associated with muscle weakness and a feeling of numbness in the buttock, thighs, legs or feet. This is normally only felt on one side of the body. However there are some conditions that can cause you to have these types of symptoms down both sides of your body.
Other categories for low back pain are:
Pain from inflammatory conditions: such as ankylosing spondylitis and rheumatoid arthritis. With these types of conditions pain is usually worse when at rest and is generally relieved by activity. It is a chronic type pain that is accompanied with morning stiffness lasting for more than one hour. It is normally relieved by non-steroidal inflammatory medications such as ibuprofen and naproxen.
Referred pain: this is when the pain originates from another part of the body. Common examples of referred pain in the low back are kidney stones, ulcerative colitis, cystitis or bladder infections, fibroids and pelvic inflammatory disease.
What Are The Common Causes Of Low Back Pain?
There are many different causes for low back pain. The most common causes are mechanical in nature, this means that there is a disruption to the normal functioning of the anatomical components of the low back. The list below includes some of the most common mechanical causes of low back pain as well as some non-mechanical causes.
Bones, Muscles and Joints
Muscle Strain – when a muscle is stretched beyond its normal limits. This can sometimes cause the muscle to tear, damaging the muscle. A muscle strain is usually a result of overuse, fatigue or improper use of a muscle. It can happen suddenly or it can develop slowly over time.
Ligament Sprain – ligaments are strong supportive tissues that are located around joints. They act as a supportive structure around a joint, that aid in improving stability of the joint. A sprain occurs when the ligament is overstretched. Sometimes tearing can occur, this is known as a ligament rupture.
Facet Joint Dysfunction – the spinal column is made up of 33 spinal vertebrae that are connected together by facet joints. The joints have cartilage between the bones and are supported by an abundance of ligaments, including a capsular ligament. Within the capsular ligament there is a fluid known as synovial fluid which aids in the smooth moving of the joint. The capsule, ligaments and joints are highly innervated. Through injury, trauma, poor posture and many other reasons these joints can be affected and cause pain, on their own or in conjunction with the intervertebral discs.
Spondylolithesis – when one of the vertebrae in the low back, moves out of its normal position, usually slipping forwards. This causes instability within the spine. If the bone slips too much it may compress onto the surrounding nerves causing pain and neurological symptoms down the legs.
Sacroiliac Joint (SIJ) Dysfunction – the sacroiliac joint is located at the base of the spine, where the spine meets each side of the pelvis. It is a very strong joint that absorbs a lot of force created from the upper and lower body. The SIJ doesn’t have much range of motion and can become painful if there is too much motion or too little motion. It can also become painful if it becomes inflamed, this is known as sacroiliitis.
Age Related Changes
Spondylosis – is another term to describe osteoarthritis of the spine. It is the age related changes that occur to the spinal column, including the discs and facet joint. As these changes occur they can cause pain, inflammation and instability within the joint. In some cases it can cause stenosis. This is when there is a narrowing of the spinal canal.
Degenerative Disc Disease – this is an age related condition in which one or more of the intervertebral discs within the spinal column lose their ability to act as a cushioning for the spine. As a consequence they become weaker and develop tears. In some cases it can also cause stenosis, this is when there is a narrowing of the spinal canal.
Osteoporosis – this is a condition in which there is weakening of the bones due to a reduction in bone density. It is more common in the elderly but can also be a result of some endocrine and metabolic diseases. Due to the reduction in bone density compression fractures are common which can sometimes cause pain. However, pain is more likely to be caused due to there being compression onto neurological structures as a result of the compression fracture.
Nerve and Spinal Cord Problems
Lumbar Herniated Disc – intervertebral discs act as a cushion, aiding (along with muscles and ligaments) in holding the spinal vertebrae together. The discs prevent the vertebrae from rubbing together and consists of a gel filled inner layer surrounded by a hard fibrous outer layer. Sometimes a person can injure or strain their discs causing part of the gel filled nucleus to herniate out of the fibrous outer casing. This is known as a herniated disc, prolapsed disc or a slipped disc. When the disc herniation occurs in the low back it may compress onto the sciatic nerve causing symptoms into the buttock, thigh, leg and/ or foot.
Spinal Stenosis – this is a condition in which there is narrowing of the spinal canal. There are many different causes of spinal stenosis, such as injury, trauma and degenerative changes.
Less Common Causes of Low Back Pain
Infection – spinal infection is very rare, but can cause severe pain and can be lifethreathning if it is left untreated. Also known as osteomyelitis it can be caused by; bacteria in the bloodstream, infectious disease that spreads to the bone, infection from recent surgery or injection in or around a bone.
Tumors – Tumours in the spine are not very common, however if they do appear they usually start elsewhere in the body and metastasize to the spine. The most common tumours that metastasize to the spine start from cancers in the prostate, kidney, lung, breast and thyroid.
Autoimmune diseases – back pain is a common symptom in individuals suffering from autoimmune conditions such as ankylosing spondylitis, rheumatoid arthritis, lupus and crohn’s disease.
How Is Low Back Pain Diagnosed?
You don’t always have to see your GP to have low back pain diagnosed. Physical therapists such as osteopaths are able to diagnose some causes of low back pain. During your consultation a precise case history taking of your symptoms and thorough physical examination will be taken to help to diagnose and understand the cause of the low back pain.
During the case history the practitioner may ask you questions such as;
- When did the pain and symptoms start?
- Were you doing anything when the pain started?
- What is the nature and duration of the pain?
- Have you had any injury to the back or hip area?
- Have you noticed any decrease in strength of the leg or foot?
- Have you got any other symptoms?
During the physical assessment the practitioner may carry out a series of tests including; a postural assessment, orthopedic tests, testing of your reflexes, testing the strength of your muscles and nerve stretch tests.
In some cases further testing may be required, this may include:
X-ray imaging – this can show if there is any disruption to the normal alignment of the bones in the spine. It also shows fractures in the bones. This may be requested if there is a chance of spondylolisthesis, boney fracture or osteoarthritis in the spine.
Magnetic resonance imaging (MRI) – this type of imaging is best at showing up any abnormalities within the soft tissues of the body. For example the muscles, ligaments, intervertebral discs, nerves and spinal cord. This type of test may be requested if a lumbar spine disc herniation is suspected.
Electromyography (EMG) – this test assesses the electrical activity in a muscle. It can detect whether or not the weakness in a muscle is a result of reduced or poor nerve conduction. This would suggest that there is a problem with the nerves. This type of test may be requested if somebody is experiencing weakness into their legs.
Bone scan – also known as a DEXA scan, this type of test can detect and monitor bone density. This type of test would be requested if osteoporosis was suspected.
Blood tests – this type of test is not routinely used to diagnose low back pain. However it might be requested to look for any signs of increased inflammation, infection or autoimmune diseases.
What Are The Treatment Options For Low Back Pain?
The length of treatment required and type of treatment needed depends on the cause of the low back pain.
Non- surgical options include:
Osteopathy: visiting a physical therapist such as an osteopath can help with relieving your discomfort and pain that is a result of the low back pain. The treatment would include a range of different hands on techniques that aim to:
- Improve blood flow and circulation to the affected area which helps improve the body’s natural healing response.
- Release and stretch tight muscles to allow for improved movement and function.
- Release endorphins. These are hormones that circulate the body and act as natural pain relief.
- Strengthen the deep spinal stabilising muscles through a comprehensive exercise to lower back pain programme.
Your osteopath will also advise you about pain management techniques, including the use of hot and cold therapy along with advice about returning to activity.
Exercises for your low back pain may also be prescribed to you by your osteopath. These will be lower back pain exercises specific to improving the mobility and strength in your lower back and core muscles as well as improving your posture. The exercise programme will be controlled and progressive, tailored specifically to the underlying cause of your low back pain. Adherence to the lower back pain exercises plays a key part in preventing the return of low back pain.
Medication for low back pain: if you decide to visit your GP, depending on the severity of your pain they may prescribe you with some oral medications to help you with relieving your symptoms:
- Over the counter painkillers and anti inflammatory medications are prescribed as they can help with the pain and
- inflammation experienced due to low back pain.
- Prescription muscle relaxant medication such as diazepam may be prescribed to help with muscle spasms.
- If the pain is really severe then your GP may prescribe antidepressants or anticonvulsants as these can also help with nerve pain.
Epidural Steroid Injections (ESI): in some cases your GP may recommend a steroid injection to help you with your pain. ESI is a technique in which a corticosteroid and a local anesthetic is injected into a space around your spinal cord called the epidural space. The aim of ESI is to give you temporary relief from your low back pain, it does this by reducing the inflammatory response within the tissues of the low back.
Surgery may be considered for individuals who have not responded to other, no invasive forms of treatment. There are many different options for surgery which should be discussed in detail with your spinal surgeon. The type of surgery selected would depend on a few different factors:
- Cause of low back pain
- Age of the patient
- Mental health of the patient
- Ability to function in everyday life
Below are a few different types of spinal surgery:
Discectomy: this is a surgery in which part or all of a damaged intervertebral disc that is compressing a nerve is removed.
Laminectomy: this is a surgery in which the back part of one or more vertebrae in the lumbar spine (low back), known as the lamina is removed. This creates more space for the spinal nerves and reduces the likelihood of the nerve being compressed.
Spinal Fusion: this is a surgery in which the affected bone in the spine is joined together to the bone below to stabilise and strengthen the spine.
Balloon Kyphoplasty: this is a surgery that is commonly used for vertebral compression fracture. It is a minimally invasive technique where a small incision is made and tiny balloons are inflated within the fractured vertebrae. The inflated balloon restores vertebral height, and the cavity is then filled with bone cement to maintain the vertebral height.
Can Low Back Pain Be Prevented?
Not all types of low back pain can be prevented. However there are a few ways to reduce your risk and protect your low back from any further injury.
- Exercise: Having good strength in your spinal and abdominal muscles are key in providing stability to your spine. Exercises such as Pilates and Yoga are a great way of improving your spinal and abdominal strength and stability. Book in to one of our trial classes to see how Pilates of Yoga may help you and your lower back pains causes.
- Lifting techniques: ensuring that you have a good lifting technique is essential in reducing the risk of injuring your back. Whatever the weight of the object you are lifting ensure that you:
- Bend from your hips and knees, not from your back, and that you squat down to the object you are picking up.
- Keep the object close to your body and engage your abdominal muscles when straightening your legs to lift the object up.
- Avoid twisting or turning your back when you are lifting the object.
- Never lift a heavy object above the height of your shoulders.
- Posture: ensure that you have good posture when standing and sitting. Poor posture can lead to increased pressure of the joints, ligaments and muscles of the back.
- Maintain a healthy weight – excess abdominal weight increases pressure on the spine. This may increase the likelihood of degenerative changes or spondylolisthesis.
- Supportive mattress – Having a mattress that supports your spinal alignment is important, too squishy and it may have no support, too firm and it may create too much support. Testing your mattresses can be very helpful. Most companies now allow you to test mattresses for 100 days. This is really helpful as it gives you a better understanding about if the mattress is going to be suitable and supportive for your low back pain. There is no one size fits all when it comes down to pillow and mattress advice.
Do I Need to Go to The GP Or Visit My Local Hospital?
The NHS website suggests that you should go to your GP if you are experiencing any of the following symptoms.
- Have neurological symptoms in both of your legs.
- Have weakness or numbness in both legs that is severe or getting worse.
- Have numbness around or under your genitals, or around your anus.
- Find it hard to start peeing, cannot pee or cannot control when you pee – and this is not normal for you.
- Do not notice when you need to poo or cannot control when you poo – and this is not normal for you.
These could be symptoms of a more serious back problem. It is worthwhile going to visit your local GP or calling 101 to seek further medical advice on how to treat your symptoms.