Everything You Need To Know About Low Back Pain
According to the National Institute of Neurological Disorders and Stroke, approximately 80% of adults will experience low back pain at one point in their lives and it often tends to recur¹. Moreover, low back pain is not only the leading cause of activity limitation and work absence, but is also associated with significant economic burden². This may all seem daunting, but I am here to reassure you that after reading this article, you’ll have a better understanding of what low back pain is and how to properly manage it.
First and foremost, a large proportion of low back pain episodes are non-specific, which means that they are not attributable to a specific, known pathology such as an infection, tumor, fracture, inflammatory disorder, cauda equina syndrome, radicular syndrome, etc. This essentially means that most episodes of low back pain are self-limiting and are not related to serious diseases³. That being said, that does not mean that a medical consultation is unnecessary. On the contrary, it is extremely important that a health professional such as a doctor or physiotherapist perform a comprehensive evaluation to identify the small portion of patients who could potentially have a more serious underlying condition. In addition, a medical consultation will also provide you with the necessary tools to better manage your pain (i.e. a doctor would prescribe pain medication and a physiotherapist would treat your low back pain, as well as prescribe certain exercises/stretches to help manage the condition). Before we take a look at common causes of low back pain, let’s go over the anatomy of the low back, also known as the lumbar spine.
Anatomy of the Lumbar Spine
The low back is composed of 5 segments or vertebra (L1 to L5). Between each vertebra are intervertebral discs. The intervertebral discs consist of an inner gelatinous fluid, referred to as the annulus pulposus, which is responsible for attenuating shock. This is facilitated by the outer fibrous layer, referred to as the annulus fibrosis⁴.
Causes of Non-Specific Low Back Pain
Once any serious spinal pathology and specific causes of back pain have been ruled out, the patient is classified as having non-specific low back pain. Any innervated structure in the lumbar spine (i.e. muscles, ligaments, dura mater, nerve roots, zygapophyseal joints, annulus fibrosis, thoracolumbar fascia, vertebrae, etc.) can cause symptoms of low back and referred pain into the extremity or extremities. According to previous research and international guidelines, it is not necessary, nor is it possible, to identify the specific tissue source of pain in order to effectively manage patients with non-specific low back pain because as the name suggests, there is no identifiable pathoanatomical source⁵ ⁶ ⁷.
Specific Causes of Low Back Pain
Some episodes of low back pain can be attributed to an injury and/or pathology. One common cause of more specific low back pain is a disc herniation. This occurs when the fluid part of the disc that can be found between two vertebrae gets pushed outward, compressing the spinal cord or nerve root, which can cause pain that radiates down into the leg⁴. This can be caused by repetitive bending and twisting movements. Similarly, narrowing of the joint spaces between vertebrae or the spinal itself canal, also termed spinal stenosis, can also lead to compression of the spinal cord or a nerve root⁸.
Another common cause of low back pain is a lumbar sprain or strain, characterized as an overstretching of the muscles and/or ligaments of the lower back. The latter can occur with a sudden intense movement such as lifting a heavy object or repetitive flexing and twisting movements. Lastly, with age, the disc can degenerate, losing its capacity to act as a “shock absorber”. This degeneration also leads to a decrease in height between two vertebrae, which can compress neural structures around the spinal cord and cause further degeneration⁹.
That being said, it is crucial to understand that the above conditions CAN be causes of low back pain. However, this does not necessarily mean that you will have pain if a disc degeneration or a bulging disc are present. We have to move away from a “pain = injury” mindset. This is often not the case. For instance, a recent systematic review of 33 articles examining the prevalence of imaging findings (CT or MR imaging) in asymptomatic individuals (patients who do not report any pain) demonstrated that imaging findings of spine degeneration are present in high proportions of asymptomatic individuals. More specifically, the prevalence was 37% in 20 year-old individuals, and increased up to 96% in 80 year-old individuals. Moreover, disc bulges ranged from 30% in people 20 years of age, to 84% in people 80 years of age. Lastly, disc protrusion prevalence increased from 29% in individuals who were 20 years old, to 43% in individuals who were 80 years old. I must re-iterate that these prevalence numbers are taken from people who are asymptomatic, which means they do not report any pain whatsoever¹⁰. Therefore, positive imaging findings must be taken with a grain of salt. They can be the source of your pain, but they can also be completely unrelated. The evidence suggests that certain imaging-based degenerative features are likely part of normal aging and unassociated with pain.
When is Low Back Pain An Emergency?
If you have a history of any of the following, please consult a doctor immediately¹¹:
- Recent trauma
- Prolonged use of steroids
- Previous history of cancer or current cancer
If you are experiencing any of the following symptoms, please consult a doctor immediately¹¹:
- Numbness/loss or sensation between the thighs and around the
- Bladder/bowel dysfunction (incontinence)
- Sudden/severe weakness in one or both legs
- Erectile dysfunction
- Pain that is increased or not relieved by rest
- Unexplained sudden and significant weight loss
How To Manage Your Low Back Pain Right Now
Stay Active: Limit bed rest and begin a gradual return to your daily activities. However, refrain from activities that increase your pain. Avoid prolonged sitting, as well as repetitive bending, lifting and twisting movements.
Cold packs/ice: Place a cold pack on your lower back for 15–20 minutes at a time, every 2 hours, as needed. The cold pack will help relieve your pain, reduce muscle spasms and reduce any inflammation caused by the injury. Avoid heat within the first 48 hours after injury.
Proper posture: Modify your sleeping, sitting and standing postures to minimize the stress on your low back.
Consult your doctor: Please consult your doctor to inquire about any medications you can take to help relieve your low back pain, as well as to inquire whether any further medical investigation is required for your low back pain.
Consult a physiotherapist: Physiotherapists are highly trained health professionals who can perform a comprehensive evaluation to determine whether or not there is an underlying serious pathology present. In addition, a physiotherapist can treat your low back pain through the use of various techniques such as manual therapy and myofascial release, and will provide you with a home exercise program comprised of strengthening and stretching exercises.
How To Prevent Low Back Pain
A systematic review and meta-analysis of 41 studies published by Taylor et al. in 2014 examined the incidence of low back pain and risk factors associated with either first-time low back pain or transition to low back pain from a baseline of a pain-free state¹².
RISK FACTORS FOR A FIRST OCCURRENCE OF LOW BACK PAIN
Examples of risk factors identified for a first occurrence of low back pain include standing or walking > 2 hours per day, frequent moving or lifting > 25 lbs, increased driving time, poor Mental Health Composite Scale Short Survey-12 score (i.e. higher anxiety, depression ,etc.) and obesity, among others¹². How can we interpret this information? Staying in certain positions for long periods of time (i.e. standing or walking for 2 hours, sitting while driving for prolonged periods, etc.) are not so well tolerated, especially if you have poor posture. If you have poor posture, the muscles, ligaments and vertebrae of your lower back have to work harder to support the forces that are being transmitted through the spine, increasing unnecessary compression at the spine and tiring the muscles. Consequently, this will increase the risk of an injury. The key to having proper posture is a neutral spine. A neutral spine ensures that the stresses experienced by the spine and the surrounding structures are minimal. To ensure that your spine is in a neutral position in standing, it should be exactly mid-way between having a fully rounded and a fully arched back. To ensure that you have proper posture while standing, you should be able to trace a line from your ears down to the front of your shoulders, through the mid-way point of your hips, down to the back of your knees and to the front of your ankles.
Moreover, repetitive movements soliciting the spine (i.e. bending forward to pick up objects repeatedly) are also not well tolerated. Proper posture when performing daily activities and/or work is crucial for the prevention of low back injuries. For instance, when lifting heavy objects, keep them close to you, bend your knees and hips, and avoid twisting movements and most importantly, don’t forget to take breaks. In addition, psychosocial risk factors such as depression or increased anxiety are sources of mental distress and play an important role. These are crucial to address, as they can often be involved in the persistence of low back pain. Lastly, obesity an important risk factor for developing low back pain. Did you know that being overweight and obesity have the strongest association with seeking care for low back pain and chronic low back pain¹³? This is why it is so important to address this early on.
RISK FACTORS FOR A RECURRENCE OF LOW BACK PAIN
Examples of risk factors identified for a recurrent episode of low back pain include sitting, standing or walking >2 hours per day, frequent moving or lifting >25 lbs, strength <50%, poor back endurance, obesity, poor health, prior low back pain frequent moving or lifting >25 lbs, manual jobs, awkward posture & mental distress¹². Do any of these look familiar? That’s because the majority of these risk factors were identical, if not similar, to the risk factors identified for a first time occurrence of low back pain. If the previously mentioned risk factors are properly addressed, the risk of first-time or recurring low back pain can drastically decrease.
If you have any questions or concerns regarding your low back pain, please consult your doctor and/or physiotherapist.
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DISCLAIMER: This blog is not meant for diagnostic or treatment purposes. It should not substitute for professional diagnosis and treatment. The information contained on this blog is a resource for information. This blog was created to inform the population about different musculoskeletal injuries with the ultimate goal of better informing them concerning their condition and to provide the necessary tools to better manage their pain and impairments. For any further questions or concerns regarding low back pain, please consult your doctor and/or physiotherapist.
References
1. National Institute of Neurological Disorders and Stroke. (2014). Low Back Pain. National Institutes of Health. Retrieved from: http://www.ninds.nih.gov/disorders/backpain/low-back-pain-brochure.pdf
2. DeLitto, A., George, S. Z., Van Dillen, L., Whitman, J. M., Sowa, G., Shekelle,…Godges, J. J. (2012). Low Back Pain: Clinical Practice Guidelines Linked to the International Classification of Functioning, Disability, and Health from the Orthopaedic Section of the American Physical Therapy Association. J Orthop Sports Phys Ther, 42(4):1–57.
3. Balagué, F., Mannion, A. F., Pellisé, F., & Cedraschi, C. (2012). Non-specific low back pain. Lancet, 379(9814): 482–491.
4. OrthoInfo. (2012). Herniated Disk in the Lower Back. American Academy of Orthopaedic Surgeons. Retrieved from: http://orthoinfo.aaos.org/topic.cfm?topic=a00534
5. Hancock, M.J., Maher, C.G., & Latimer, J., Spindler, M. H., McAuley, J. H., Laslett, M., & Bogduk, N. (2007. Systematic review of tests to identify the disc, SIJ or facet joint as the source of low back pain. European Spine Journal, 16(10): 1539–1550.
6. Koes, B.W., van Tulder, M., Lin, C. W. C., Macedo, L. G., McAuley, J., & Maher, C. (2010). An updated overview of clinical guidelines for the management of non-specific low back pain in primary care. European Spine Journal, 19(12): 2075–2094.
7. van Tulder, M., Becker, A., Bekkering, T., Breen, A., del Real, M. T., Hutchinson, A., Koes, B., Laerum, E., & Malmivaara, M. (2006). Chapter 3. European guidelines for the management of acute nonspecific low back pain in primary care. European Spine Journal, 15(Suppl 2):S169–191.
8. National Institute of Arthritis and Musculoskeletal and Skin Diseases. (2016). Spinal Stenosis. National Institutes of Health. Retrieved from: https://www.niams.nih.gov/health_info/spinal_stenosis/
9. McGill, S. (2009). Ultimate back fitness and performance (4th ed.). Waterloo, Ontario: Backfitpro Inc.
10. Brinjikji, W., Luetmer, P. H., Comstock, B., Bresnahan, B. W., Chen, L. E., Deyo, R. A., Halabi, S., Turner, J. A., Avins, A. L., James, K., Wald, J. T., Kallmes, D. F., & Jarvik, J. G. (2015). Systematic Literature Review of Imaging Features of Spinal Degeneration in Asymptomatic Populations. AJNR Am J Neuroradiol, 36(4): 811–816.
11. Bratton, R. L. (1999). Assessment and Management of Acute Low Back Pain. Am Fam Physician, 60(8): 2299–2306. Retrieved from: http://www.aafp.org/afp/1999/1115/p2299.html
12. Taylor, J. B., Goode, A. P., George, S. Z., & Cook, C. E. (2014). Incidence and risk factors for first-time incident low back pain: a systematic review and meta-analysis. The Spine Journal, 14(10): 2299–2319.
13. Shiri , R., Karppinen, J., Leino-Arjas, P., Solovieva, S., & Viikari-Juntura, E. (2010). The association between obesity and low back pain: a meta-analysis. American Journal of Epidemiology; 171(2): 135–154.
