What is Low Back Pain?

“Soreness or stiffness in the back, between the bottom of your rib cage and top of your legs.” (NICE 2019). The majority of the population will have an episode of low back pain at some point in their life. The vast majority of the time, there is no serious underlying problem, and there are things we can do to help ourselves to manage the symptoms better.

We have strong, flexible muscles and ligaments to support our spine. There are soft cushions which act as shock absorbers between our bones, called discs, along with nerves which come out of the holes in the vertebrae which branch out to your body (Ministry of Health, 2018).

Some people can have a nerve irritation, which would present as leg pain. This can be worse than the back pain. It usually resolves, but it is worth speaking to a doctor or physiotherapist regarding these symptoms. Nerve compression presents with weakness and numbness in one or both of the legs, which can resolve, but again, would benefit from speaking to a doctor or physiotherapist regarding these symptoms (Ministry of Health, 2018).

Episodes of low back pain are usually short term (acute), improve over a few weeks and settle further over a few months. It can take time. Back pain can last over 3 months (chronic). The majority of low back pain has no serious underlying problem or condition. It can be common to have further episodes of back pain in the future. (Ministry of Health, 2018).

Chronic low back pain can be associated with psychosocial barriers to recovery. They can increase time off work and disability (ACC, 2004). These can include extended bed rest, the belief that movement is harmful, social withdrawal, low in mood, problems at work, stress, problems with claim and compensation (ACC, 2004).

There are rare ‘red flags’ associated with low back pain, which would require assessment from a doctor urgently. One of these is known as cauda equina syndrome. The cauda equina is a bundle of nerves. Symptoms include:

• Loss of sensation in the saddle area
• Recent problem with bladder or bowel function, such as difficulty emptying your bladder, or incontinence
• Can be associated with severe low back pain, altered sensation or pain in one or both legs

Other red flags include significant trauma, swelling or deformity in the back, sudden unexplained weight loss, history of cancer, severe unremitting night pain, fever, use of IV drugs or steroids, bilateral neurological symptoms (ACC, 2004).

Do I need a scan?

The majority of the time, an X-ray or MRI scan is not required. In an asymptomatic population, MRI scans of the spine can show degenerative changes, mild scoliosis and disc prolapse, and these people have no pain. Usually MRIs or X-Rays are organised if there has been severe trauma, or someone has neurological deficit. MRI findings do not always correlate with your pain patterns, and if there has been a finding which may, or may not be relevant to your pain, it can increase disability (Jensen et al, 1994).

Management – advice for Patients

Health Professionals such as Physiotherapists and doctors can do an assessment of your symptoms and suggest management strategies that may be suitable for you.

Management advice for your pain can depend on what activities or positions make the symptoms feel better, or worse. Some people can feel worse in flexed positions e.g. cycling or rowing, and walking or swimming may feel better at this stage. It does not mean you will not be able to return to your previous hobbies, you may just need to adapt them for a short time.

Bed rest is not advised. Evidence gathered for low back pain management has supported keeping active as able, and returning to work as quickly as possible (Ministry of Health, 2018).

NICE (2018), have provided evidence-based suggestions for the management of low back pain and sciatica for ages 16 and over:

• They have suggested exercise, group exercise and possibly manual therapy as part of a treatment package
• Consideration of psychological therapy can be beneficial for managing low back pain.
• Speaking to a pharmacist or GP for pain relief if you need it e.g. difficulty mobilising or difficulty sleeping due to the pain.

Pace your activities – in the early stages of low back pain, you may be able to do more in the day if you do little and often rather than too much at once.

Exercises

These exercises should feel like they are working or stretching something, and can be a little uncomfortable but they shouldn’t be painful or worsen your pain (including that evening or next day). Some exercises you can try for acute low back pain:

Pelvic tilts – https://www.youtube.com/watch?v=KASF9rhl4z4 around 10 repetitions, a few times daily as comfortable.

Knee rolls – https://www.youtube.com/watch?v=s6KrZewKlSE around 10 repetitions, a few times daily as comfortable.

Side flexion – standing, reach one hand down the side of the thigh until you feel a stretch on the side of the back you are stretching away from. Hold for 10-20 seconds, repeat 3 times. Only to a stretch, not pain.

Cat cow – https://www.youtube.com/watch?v=QiAkSBhpKRs from this exercise you can lead on to the next exercise, Bird Dog.

Bird dog – in neutral position (where back is flat). Keeping this as still as possible, slowly extend one leg and the opposite arm. Try not to let the back rotate. 10 each side as comfortable.

Some people use heat or ice e.g. hot water bottle or a bag of frozen peas, wrapped in a layer and applied to the back for 10-15 minutes can give them short term relief.

Long term management of low back pain:

• Physiotherapists can give you advice for this as well, if your pain has become chronic
• There are pain management strategies which can help you achieve your goals
• Physiotherapists can also educate you to help you understand your symptoms, and come up with a goal setting programme to help you keep as active as possible, and let you do what makes you happy
• General exercise can help your symptoms. For example, pilates, yoga or outdoor activities. One type of exercise has not been found to be more beneficial than the other (Reference)
• Find something you enjoy, and what works for you. This is important, as it needs to be sustainable over time

A Physiotherapist can also give you advice for low back pain in pregnancy.

Management – advice for Health Professionals

Group exercise can also be beneficial, depending on the person’s preferences. Orthotics, acupuncture and electrotherapies such as ultrasound and traction are not recommended treatments of low back pain (NICE, 2018).

NICE (2018) also advised considering manual therapy as part of a treatment package which also includes exercise, or psychological therapy. Return to work and facilitating return to work is also advised.

There are also recommendations on pharmacological management, and more invasive treatments, or pathways for low back pain and sciatica on the NICE website.

References:

ACC (2004). Lower Back Pain Guide. [online]. [Accessed 6^th April 2019]. Available from: http://www.acc.co.nz

Jenson, M; Brant-Zawadzki, M; Obuchowski, N; Modic, M; Malkasian, D; Ross, J. 1994. Magnetic Resonance Imaging of the Lumbar Spine in People without Back Pain. N Engl J Med. 331 (2) pp69-73 [online]. [Accessed 18^th April 2019]. Available from: http://www.nejm.org

Ministry of Health (2018). Back Pain. [online]. [Accessed 6^th April 2019]. Available from: http://www.health.govt.nz

NICE (2019). Low Back Pain and Sciatica for ages 16 and Over. [online]. [Accessed 5^th April 2019]. Available from: http://www.nice.org.uk