11 Things You Should Know about Low Back Pain

by

Your back hurts. Maybe this is the first time or maybe it’s a recurring problem. All you know is you’re sick of it and it hurts. If you’ve been searching for a remedy online you may have already noticed how many “experts” are out there and even more “cures.” What do all of these cures have in common? They are too expensive, take too much time and aren’t as effective as many people claim.

I am not here to offer another cure or sell you anything! I see a lot of confusion and misinformation surrounding low back pain and the purpose of this article is to try to provide some clarity. I will discuss what I believe are the 11 most important issues related to low back pain. All of the research used to write this article is provided for anyone wishing to dive further into their learning.

1.  What to Expect

Low back pain is commonly labeled a self-limiting condition because most people get better without treatment. Let’s go over some data to get a handle on what this means: Studies show about 84% of people will experience lower back pain at some point in their lives1. Without receiving any treatment about 50% of people improve within two weeks, 70% within a month and 90% in three to four months2. The remaining 10% develop what is known as chronic pain, or pain lasting longer than three months1. 50% of these individuals will still have some pain a year later but be doing fairly well and the other half will have a harder time.

There is a problem labeling low back pain as a self-limiting condition: research shows many people will have another episode of low back pain, usually within the first six months of the first. The best available estimate for recurrence is 33%3. This information isn’t meant to scare you. It’s meant to reinforce the idea that it’s not abnormal for back pain to reoccur, and if it does, it doesn’t necessarily mean something more serious is happening.

2. When to Worry

In most cases, low back pain isn’t caused by a serious underlying condition or even a spine abnormality. In fact, a diagnosis of non-specific low back pain accounts for over 90% of patients who go to their primary care physician for treatment4. So, what are the signs for concern? Let’s review what are known as red flags––signs of concern that may indicate a more serious problem than just pain and may require more investigation.

The first red flag is a concern for a spine fracture: Recent trauma––like a hard fall or car accident and decreased bone density due to older age, osteoporosis or long-term steroid drug can raise this suspicion.

The second red flag is a concern for infection: A sustained fever, IV drug use or a weakened immune system can increase this concern.

The third red flag is a concern for cancer: Warning signs can include a history of cancer, unexplained weight loss, constant pain that is worse at night or unrelieved by adjusting your body position.

The fourth red flag is a concern about spinal nerves being compromised: Sudden changes in bowel or bladder control, such as difficulty urinating, numbness around the groin or rectal area or a severe or progressing weakness in your legs may indicate this is occurring.

3. Pain Doesn’t Equal Damage!

Back to the pain. There are a large number of studies showing the amount of pain––even the kind that can be severe––isn’t related to spine damage. This is one of the most confusing topics surrounding low back pain. There is a reason the most common type of low back pain is known as non-specific low back pain: In this case the pain isn’t commonly attributed to a specific anatomical problem. A recent study reviewed 33 articles reporting imaging findings for 3,110 individuals. They found 37% of people in their twenties and 96% of people in their eighties had evidence of spine degeneration5. The most interesting finding: These individuals had no symptoms! We now know that features like disc degeneration, herniated discs and bulging discs are likely a normal aging process and not necessarily associated with pain5.

4. Overuse of Imaging for Low Back Pain

We just reviewed strong evidence that what we see on imaging isn’t well associated with low back pain. So, what’s the harm in getting an image anyway? There are few things to consider. One is the significant cost of some of these images: MRI’s have an average cost of about $2,500 in the United States. Another consideration is unnecessary exposure to radiation. One study, published in the Archives of Internal Medicine, estimated approximately 29,000 future cancers could be related to the number of CT scans performed in the US in 20076. This is not new information. There is no shortage of studies that show routine imaging for low back pain yields little to no benefit7,8,9. The takeaway message: Imaging may be very important for some people with low back pain but people should speak with their healthcare team to decide if imaging is the proper course of action.     

5. The Spine is Stable!

Let’s quickly review the anatomy of the spine: It’s important to know the spine is an inherently stable structure and designed to handle large forces throughout our lifespan. In fact, bending forward to lift a 10kg or 22lb object from the ground results in forces up to 1650 newtons in the spine 33. That’s equivalent to approximately 168 kilograms or 371 pounds; that’s a lot of weight and your spine is designed to handle this! I bring this up because a lot of people have the idea that they are unstable, or that their back or sacroiliac (SI) joint “slips out” and needs to be put “back in.” This is terrible misinformation because it makes people believe they can’t trust their back. True spine instability, like an unstable spondylolisthesis, is one thing. This can be very serious and require surgery. A few millimeters of extra motion in a joint is quite another thing. There have been a number of studies on the topic of SI joint pain and dysfunction. The best available evidence on this topic not only shows less than 4 millimeters of rotation and 1.6mm of translation31,32 in the SI joint, it shows no evidence of a joint slipping out of place. Additionally, there is no evidence of people with SI joint pain having more motion than people without30.

6.  Types of Low Back Pain

In simple terms, back pain usually presents itself in two patterns. The first pattern is back dominant pain. This pain commonly refers to the back, buttocks or around the hips. Some people feel this pain in their thighs, generally above the knees, but the back is the dominant pain location. Specific positions like bending forward, backward or to the side can usually affect this type of back pain. This pain typically comes and goes and sometimes causes spasms during movement. While this can be intense, it’s a good pain because there aren’t signs that damage is occurring.

The other common pattern of low back pain is leg dominant pain and there are two common presentations: The first is when nerves are being irritated. This is generally called sciatica or radiculopathy. This pain is most commonly in one leg and can be more dominant in the leg than the back. There can also be numbness or tingling felt in the lower extremity. These symptoms often increase with sitting, bending forward or positions like hamstring stretching. They commonly decrease while lying flat, standing, walking or positions where your spine is more vertical. Sciatica often resolves on its own and most people do well but it’s a good idea to speak with a healthcare team because specific advice may be helpful for recovery.

The other common presentation with leg dominant pain is when the pain is felt in both legs. This is often described as heaviness, aching or numbness and tingling in the legs that is increased by walking and standing and relieved by bending forward or sitting. This type of low back pain typically happens in people over the age of 50. Spinal stenosis, or a narrowing of the spinal canal, is commonly a cause for this type of back pain. When stenosis is severe it can decrease the ability to perform day-to-day activities and it’s good to get ahead of this by speaking to a healthcare team.

7. Recovery’s Greatest Enemy: Fear

Viewing low back pain as a threat or a catastrophe can lead to maladaptive coping strategies. People who avoid activity because they are afraid it may cause pain or damage can develop a fear avoidance behavior. Fear avoidance is a big deal because it is associated with disability and lower levels of function10,11,12. Studies have shown people who rest and wait for their pain to get better don’t do as well as those who remain active throughout their pain episode13,14. People experiencing low back pain should develop a plan that includes finding movements that can reduce pain and gradually building their activity each day. Movement can often help back pain because the spine is designed for movement, not prolonged rest. The spine’s joints, muscles, discs and cartilage all depend on movement and stress to maintain and improve their health. This is not a new concept but it’s often forgotten when people have pain. There is overwhelming evidence that immobility and prolonged rest can have detrimental effects on the human body28.

8. Treatment Choices Can Influence Your Outcome

This is a great topic to review because treating low back pain can become very expensive. There are two treatment categories: active and passive. Research has shown remaining active throughout a back pain episode can improve your outcome. Walking, exercises for mobility, muscle balance, strength and endurance, Yoga, Pilates, Tai chi, active coping strategies like breathing exercises or meditation can all result in substantial improvements15,17,18,19,20,21,26. Research shows there is no single best exercise for low back pain. People should consider incorporating lower back exercises into activities they enjoy because this can improve their chance of sticking with a program. Staying active can provide benefit for short term and long-term pain relief as well as functional ability. The combination here is important because short term pain relief is what most low back pain treatments provide.

Research has shown support for passive treatments like spine manipulation22,23,24,27, hot packs25,26, transcutaneous electrical nerve stimulation (TENS) for chronic back pain26, low level laser therapy (LLLT)26, massage26, acupuncture26, epidural steroid injections33,34,35, radiofrequency ablation37, and traction.  These options can be beneficial for short-term pain relief but not long-term pain relief or an improvement in function. Given their short-term effect, these procedures should not be the focus for treatment. They should not be regarded as a cure for low back pain and should be used judiciously. Passive treatments should support activity, not substitute it. Chasing temporary pain relief often leads to lost time, wasted money and underwhelming results.

9. Arm Yourself with Evidence

Research on spine manipulation and mobilization supports a low number of treatments27 and there is no evidence to support a tier program where you have to taper off your sessions. You should know that a high number of these treatments can be very expensive and likely won’t provide any added benefit. Interestingly, some people find they can perform spine mobility exercises on their own and find this may have a similar effect18. To try this, visit my YouTube channel and search “AI Physio spine mobility exercises.” We mentioned earlier than TENS and hot packs can provide temporary pain relief and this can be valuable. The best thing about these products: you can buy them online for a low cost and this is less expensive that paying someone else to provide this for you. To clarify, TENS has evidence to reduce chronic low back pain and is not as helpful for acute pain. Massage can also be helpful for short-term pain relief.  You can also try performing self-massage as many people find this helpful. Low level lasers do have some evidence that they provide short term pain relief but this is also very expensive.  If people can get pain relief from less expensive options like a TENS unit or simple exercises, they may not want to incur this added expense.

Another commonly used treatment is lumbar traction and this is an interesting topic. While some research shows it may be beneficial for people with sciatica, radiculopathy or nerve root compression, it seems like researchers are having a hard time agreeing on this. Dr. Anne Thackeray and her colleagues performed a research trial comparing lumbar traction combined with spine extension exercises to spine extension exercises alone. They found no added benefit from traction36. What does this mean? Well, if traction can be very expensive and isn’t beating spine extension exercise, this may be an avoidable expense.

Epidural steroid injections(ESI) and radiofrequency denervation(RFD) are used by physicians to help provide low back pain relief. Evidence does support these treatments for short term pain but they aren’t shown to be very effective for long term pain relief or improving function33,34,35,37. A recent study reviewed RFD’s effect on relieving pain in facet joints, sacroiliac joints, or a combination of facet joints, sacroiliac joints, or intervertebral disks. The authors found RFD combined with exercise resulted in either no improvement or no clinically important improvement in chronic low back pain compared with exercise alone38. The best available evidence does not support these procedures as curative or a stand-alone solution for low back pain.

10. Medication to Help, Not Cure!

Medication can be helpful in the recovery process when the pain is severe. This should not be regarded as a cure for low back pain, but rather a means to get moving again so you can focus on activity. A few medications supported by research and best practice recommendations for a recent onset of low back pain include nonsteroidal anti-inflammatory drugs (NSAIDS) and skeletal muscle relaxants26. People should always discuss medication options with their care team. One final note, but certainly not least important, is opioid medication for low back pain. These medications are now being considered as a last resort and they have been associated with a risk for drug abuse and addiction39,40.

11. Understand the Whole Picture

If people want to understand treatments for low back pain they must be able to appreciate the whole picture. It can be overwhelming to look at all the options out there and frustrating to hear that everyone has a different opinion. A very important fact to remember: There is no miracle cure or magic treatment for low back pain and any claim to the contrary is not support by legitimate evidence. The best way to view all of the available treatments is to understand their purpose: temporarily reduce pain to allow people to tolerate building their activity level. As it turns out, how well people do may largely depend on their attitude about pain. Active coping skills, developing a plan to increase activity and tracking your progress are all very important when managing low back pain. Staying informed empowers people and helps them make the best decisions about their care.

I hope you find this information helpful. I’ve also made some YouTube videos to demonstrate exercises commonly used by people with low back pain. Please visit the AI Physio channel to view these. Subscribe to my blog if you want more information about common musculoskeletal conditions, injury prevention, treatment options and exercise programs. Thank you for reading!

References

  1. Balagué F, Mannion AF, Pellisé F, Cedraschi C. Non-specific low back pain. Lancet. 2012;379(9814):482-91.
  2. Gatchel RJ, Polatin PB, Mayer TG. The dominant role of psychosocial risk factors in the development of chronic low back pain disability. Spine (Phila Pa 1976). 1995 Dec 15;20(24):2702-9.
  3. Da silva T, Mills K, Brown BT, Herbert RD, Maher CG, Hancock MJ. Risk of Recurrence of Low Back Pain: A Systematic Review. J Orthop Sports Phys Ther. 2017;47(5):305-313.
  4. Koes BW, Van tulder MW, Thomas S. Diagnosis and treatment of low back pain. BMJ. 2006;332(7555):1430-4.
  5. Brinjikji W, Luetmer PH, Comstock B, et al. Systematic literature review of imaging features of spinal degeneration in asymptomatic populations. AJNR Am J Neuroradiol. 2015;36(4):811-6.
  6. Berrington de gonzález A, Mahesh M, Kim KP, et al. Projected cancer risks from computed tomographic scans performed in the United States in 2007. Arch Intern Med. 2009;169(22):2071-7.
  7. Karel YH, Verkerk K, Endenburg S, Metselaar S, Verhagen AP. Effect of routine diagnostic imaging for patients with musculoskeletal disorders: A meta-analysis. Eur J Intern Med. 2015;26(8):585-95.
  8. Mafi JN, McCarthy EP, Davis RB, Landon BE. Worsening Trends in the Management and Treatment of Back Pain. JAMA Intern Med. 2013;173(17):1573–1581. doi:10.1001/jamainternmed.2013.8992.
  9. Flynn TW, Smith B, Chou R. Appropriate use of diagnostic imaging in low back pain: a reminder that unnecessary imaging may do as much harm as good. J Orthop Sports Phys Ther. 2011;41(11):838-46.
  10. Rainville J, Smeets RJ, Bendix T, Tveito TH, Poiraudeau S, Indahl AJ. Fear-avoidance beliefs and pain avoidance in low back pain–translating research into clinical practice. Spine J. 2011;11(9):895-903.
  11. Wertli MM, Rasmussen-barr E, Held U, Weiser S, Bachmann LM, Brunner F. Fear-avoidance beliefs-a moderator of treatment efficacy in patients with low back pain: a systematic review. Spine J. 2014;14(11):2658-78.
  12. Camacho-soto A, Sowa GA, Perera S, Weiner DK. Fear avoidance beliefs predict disability in older adults with chronic low back pain. PM R. 2012;4(7):493-7.
  13. Dahm KT, Brurberg KG, Jamtvedt G, Hagen KB. Advice to rest in bed versus advice to stay active for acute low-back pain and sciatica. Cochrane Database Syst Rev. 2010;(6):CD007612.
  14. Chou R, Qaseem A, Snow V, et al. Diagnosis and treatment of low back pain: a joint clinical practice guideline from the American College of Physicians and the American Pain Society. Ann Intern Med. 2007;147(7):478-91.
  15. Lawford BJ, Walters J, Ferrar K. Does walking improve disability status, function, or quality of life in adults with chronic low back pain? A systematic review. Clin Rehabil. 2016;30(6):523-36.
  16. Jauregui JJ, Cherian JJ, Gwam CU, et al. A Meta-Analysis of Transcutaneous Electrical Nerve Stimulation for Chronic Low Back Pain. Surg Technol Int. 2016;XXVIII
  17. Lawand P, Lombardi júnior I, Jones A, Sardim C, Ribeiro LH, Natour J. Effect of a muscle stretching program using the global postural reeducation method for patients with chronic low back pain: A randomized controlled trial. Joint Bone Spine. 2015;82(4):272-7.
  18. Shah SG, Kage V. Effect of Seven Sessions of Posterior-to-Anterior Spinal Mobilisation versus Prone Press-ups in Non-Specific Low Back Pain – Randomized Clinical Trial. J Clin Diagn Res. 2016;10(3):YC10-3.
  19. Gomes-neto M, Lopes JM, Conceição CS, et al. Stabilization exercise compared to general exercises or manual therapy for the management of low back pain: A systematic review and meta-analysis. Phys Ther Sport. 2016
  20. Geneen LJ, Moore RA, Clarke C, Martin D, Colvin LA, Smith BH. Physical activity and exercise for chronic pain in adults: an overview of Cochrane Reviews. Cochrane Database Syst Rev. 2017;4:CD011279.
  21. Airaksinen O, Brox JI, Cedraschi C, Hildebrandt J, Klaber-Moffett J, Kovacs F, Mannion AF, Reis S, Staal JB, Ursin H, Zanoli G. Chapter 4. European guidelines for the management of chronic nonspecific low back pain. Eur Spine J. 2006;15(Suppl 2):S192–S300. doi: 10.1007/s00586-006-1072-1.
  22. Goertz CM, Pohlman KA, Vining RD, Brantingham JW, Long CR. Patient-centered outcomes of high-velocity, low-amplitude spinal manipulation for low back pain: a systematic review. J Electromyogr Kinesiol. 2012;22(5):670-91.
  23. Bronfort G, Haas M, Evans RL, Bouter LM. Efficacy of spinal manipulation and mobilization for low back pain and neck pain: a systematic review and best evidence synthesis. Spine J. 2004;4(3):335-56.
  24. Paige NM, Miake-lye IM, Booth MS, et al. Association of Spinal Manipulative Therapy With Clinical Benefit and Harm for Acute Low Back Pain: Systematic Review and Meta-analysis. JAMA. 2017;317(14):1451-1460.
  25. French SD, Cameron M, Walker BF, Reggars JW, Esterman AJ. Superficial heat or cold for low back pain. Cochrane Database Syst Rev. 2006;(1):CD004750.
  26. Qaseem A, Wilt TJ, Mclean RM, Forciea MA. Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain: A Clinical Practice Guideline From the American College of Physicians. Ann Intern Med. 2017;166(7):514-530.
  27. Haas M, Vavrek D, Peterson D, Polissar N, Neradilek MB. Dose-response and efficacy of spinal manipulation for care of chronic low back pain: a randomized controlled trial. Spine J. 2014;14(7):1106-16.
  28. Parry SM, Puthucheary ZA. The impact of extended bed rest on the musculoskeletal system in the critical care environment. Extrem Physiol Med. 2015;4:16.
  29. Laslett M. Evidence-based diagnosis and treatment of the painful sacroiliac joint. J Man Manip Ther. 2008;16(3):142-52.
  30. Sturesson B. Load and movement of the sacroiliac joint. PhD thesis, Lund University, Malmo, Sweden,1999;29–35.
  31. Sturesson B, Selvik G, Uden A. Movements of the sacroiliac joints: A roentgnen stereophotogrammetric analysis. Spine. 1989;14:162–165.
  32. Sturesson B, Uden A, Vleeming A. A radiostereometric analysis of the movements of the sacroiliac joints in the reciprocal straddle position. Spine. 2000;25:214–217.
  33. Rohlmann A, Pohl D, Bender A, et al. Activities of everyday life with high spinal loads. PLoS ONE. 2014;9(5):e98510.
  34. Chou R, Hashimoto R, Friedly J, Fu R, Bougatsos C, Dana T, et al. Epidural Corticosteroid Injections for Radiculopathy and Spinal Stenosis: A Systematic Review and Meta-analysis. Ann Intern Med. 2015;163:373-381.
  35. Pinto RZ, Maher CG, Ferreira ML, et al. Epidural corticosteroid injections in the management of sciatica: a systematic review and meta-analysis. Ann Intern Med. 2012;157(12):865-77.
  36. Thackeray A, Fritz JM, Childs JD, Brennan GP. The Effectiveness of Mechanical Traction Among Subgroups of Patients With Low Back Pain and Leg Pain: A Randomized Trial. J Orthop Sports Phys Ther. 2016;46(3):144-54.
  37. Laura E Leggett, Lesley JJ Soril, Diane L Lorenzetti, et al., “Radiofrequency Ablation for Chronic Low Back Pain: A Systematic Review of Randomized Controlled Trials,” Pain Research and Management, vol. 19, no. 5, pp. e146-e153, 2014.
  38. Juch JNS, Maas ET, Ostelo RWJG, Groeneweg JG, Kallewaard J, Koes BW, Verhagen AP, van Dongen JM, Huygen FJPM, van Tulder MW. Effect of Radiofrequency Denervation on Pain Intensity Among Patients With Chronic Low Back Pain.The Mint Randomized Clinical Trials. JAMA. 2017;318(1):68–81.
  39. Ballantyne JC. Opioids for the Treatment of Chronic Pain: Mistakes Made, Lessons Learned, and Future Directions. Anesth Analg. 2017;125(5):1769-1778.
  40. Soelberg CD, Brown RE, Du vivier D, Meyer JE, Ramachandran BK. The US Opioid Crisis: Current Federal and State Legal Issues. Anesth Analg. 2017;125(5):1675-1681.

Leave a Comment