Lower back pain treatment, causes and symptoms

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. From the job you do to the bed mattress you sleep on, can have an effect on the spine in different areas. From just sitting still for longer periods, or lots of heavy lifting, you may be putting extra unnecessary stress on your spine and back. Low back pain can be commonly why an individual may decide to come and visit an osteopath or physical therapist.

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 low 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.

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: mechanical low back pain 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.

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.

There are many different low back pain causes. 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, sometimes this is known as non-specific low back pain. The list below includes some of the most common mechanical causes of low back pain as well as some non-mechanical causes.

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 aids 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.

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. Which is a reduction in size 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 narrowing of your spinal canal.

Osteoporosis – this is a condition in which there is weakening of the bones due to a reduction in bone density. More common in 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.

Lumbar Herniated Disc – intervertebral discs act as a cushion, assisting in holding the spinal vertebrae together. Discs prevent the vertebrae from contacting each other and consist of a gel filled inner layer surrounded by a hard fibrous outer layer. Individuals can injure or strain their discs causing the nucleus propulsus to herniate out of the fibrous outer shell. This can be diagnosed as either a herniated disc, prolapsed disc or a slipped disc. After a disc herniation occurs in the lumbar spine it may compress onto the sciatic nerve eliciting symptoms into the buttock, thigh, leg or foot. This type of very low back pain can also be known as discogenic low back pain. Check out or blog on sciatica to find out more. Disc prolapse can also be a common cause of low back pain in pregnancy.

Spinal Stenosis – this occurs when there is a narrowing of the spinal canal. There can many different real causes of spinal stenosis, such as injury, trauma and degenerative changes.

Infection – spinal infection is very rare, but can cause severe low back 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.

You do not have to present to your GP to have lower back pain diagnosed. A Physical therapists like an osteopath or a physiotherapist would be able to diagnose some causes of low back pain. During the osteopathy or physiotherapy consultation the precise case history would be taken of your symptoms and a detailed physical examination will be performed help to understand and diagnose the cause of your low back pain.

Questions which you may be asked during the case history by the Osteopath or Physiotherapist:

• What is the duration and nature of the pain?
• Do you remember what you doing anything when the lower back pain started?
• When did the lower back pain and symptoms start?
• Have you had any injury to the lumbar 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 osteopath or physiotherapist may perform testing which includes: postural assessment, orthopedic testing, a lower limb neurological exam which will involve muscle and nerve tests along with reflexes.

If your practitioner believes you may need further assessment, the may send you for:

X-ray imaging – this can show if there is any disruption to the normal alignment of the vertebrae in your 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. An EMG 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.

The length of treatment required and type of low back pain management needed depends on the cause of the low back pain. Low back pain treatment can include:

Non- surgical options include:

Osteopathy: 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.
• Muscular treatment aiming to release and stretch the affected area to allow for improved movement and function.
• Release endorphins. These are hormones that circulate the body and act as natural pain relief.
• Exercise programs which aim to increase strength in the deep spinal stabilising muscles.

Pain management techniques, including the use of hot and cold therapy along with advice about returning to activity will also be provided by your treating osteopath.

Lower back pain can be effectively treated and rehabilitated with the use of exercise. Your practitioner will aim to improve the mobility and strength in your lower back and core muscles as well as educate and encourage improved posture. It is essential that the exercise program is tailored to your needs and targets the specific underlying cause of your lower back pain. Adherence to the exercises is essential for long term relief from lower back pain.
Medication for low back pain: if you require strong pain relief from your back pain, your GP may prescribe you.

• Over the counter painkillers and anti inflammatory medications ..
• Muscle relaxant medication to reduce the spasms.
• Antidepressants or anticonvulsants in severe circumstances can be prescribed by your GP to assist with nerve pain.

Epidural Steroid Injections (ESI): in some instances a GP or sports doctor may recommend a steroid injection to reduce 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 ESI aims 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.

Surgical Options:

Surgery may be considered for individuals who have not responded to other, no invasive forms of treatment. Surgical options are varied and should be discussed in detail with a spinal surgeon. Many factors come into play when discussing surgical options:

• 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.

Some patients are predisposed to lower back pain, however some can be prevented. There are multiple ways to prevent, manage and nurture lower back pain.

Exercise: Strength in your spinal and abdominal muscles is key in providing stability to your spine. Exercise styles such as Pilates and Yoga are a great way to target these areas of your body.

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:

1. Bend from your hips and knees, not from your back, and that you squat down to the object you are picking up.
2. Keep the object close to your body and engage your abdominal muscles when straightening your legs to lift the object up.
3. Avoid twisting or turning your back when you are lifting the object.
4. Never lift a heavy object above the height of your shoulders.

Posture: Good posture is critical to reduce lower back pain over time. Poor posture whilst sitting or standing can lead to increased pressure of the joints, ligaments and muscles of the back. Depending on your posture it could lead to low back pain left side or low right back pain.

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.

Semi cobra. Lie on your stomach with your hands placed underneath your shoulders. Inhale and gently push up with your arms, maintaining a forward gaze. Gradually lift your chest off the floor. Hold for around 30 seconds. As you exhale gently lower your forehead and chest to the floor.

Knee hugs. Laying on your back with your knees bent. Raise the knees towards your chest as far as you can. Bring your hands around the knees and pull them gently towards you until you can feel your back stretching.

Glute bridge. Laying on your back with your knees bent. Lift yourself up until your thighs are about on a straight line with your torso. Hold this position for 1-2 seconds and then return to the starting position. Maintain a relaxed head on the floor at all times.

Pelvic tilt exercise for low back pain. Lie on your back with your knee bent. Slowly draw your lower back into the floor, you will notice that your pelvis tilts as you do this. Then tilt your pelvis into the opposite direction You will find that your low back arches slightly. Repeat this exercise 10-15 times.

*It is always recommended to having confirmation your GP, osteopath or physiotherapist before carrying out any of these exercises.

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 and are known as low back pain red flags. It is worthwhile going to visit your local GP or calling 101 to seek further medical advice on how to treat your symptoms.