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How do I know it is serious and should seek care?
Lower back pain is extremely common and nearly all people will experience it at some point in their lives,(1,2) however, it is rarely serious(2). Lower back pain is only an indication of a serious pathology in roughly 1-2% of cases(1,2,4). Lower back pain often improves on its own with time and without treatment(3,13). If you do experience any of the following it would be recommended to seek an opinion from a medical doctor.
High impact injury (e.g., car crash, fall from height). Especially for someone with Osteoporosis or a history of long-term corticosteroid use.
Fever, nausea, feeling generally unwell (especially if immunocompromised or if having undergone a recent surgery/invasive procedure)
History of cancer
Worsening or complete numbness and weakness in lower limbs and/or buttocks region
New bladder and/or bowel dysfunction
Unexpected weight loss
Pain at rest or at night (increase risk with cardiovascular conditions)
It is important to note that the above factors alone are quite common and not necessarily an indication of a serious pathology,(1,2) however, they may warrant further investigation to rule anything out. A medical doctor is well trained in identifying serious pathology and ordering the appropriate tests.
What is causing my back pain?
Once we have ruled out serious conditions/injuries the treatment/interventions will be individual based, not pathology/structure based! There are many structures in the lower back that can be the cause of pain for example, discs, ligaments, joints, muscles, and others,(1,2) however we do not currently have the technology available to accurately determine which of these structures is responsible for causing the lower back pain which an individual experiences (1,2). Findings on scans (e.g., bulging discs, spondylosis) are often incidental, meaning they might have been there before your pain started and are not actually correlated with your pain(1,2,5). These findings are often also seen in people without pain. In fact, changes on scans are seen in 90% of adults.
Our body can be predisposed to lower back pain by various factors that can affect our nervous system such as(6).
Sleep disturbances
Depressed mood
High anxiety
High stress levels
Other lifestyle factors and genetics also increase the risk of lower back pain (e.g., smoking or being less physically active)(2,4) lifting/handling weights that the body is not accustomed too(1,2).
Episodes of low back pain seem to happen more often when multiple risk factors are involved (e.g., high stress job, low mood, poor sleep, lifting heavy items that you are not used to lifting)(1).
It is important to know that lower back pain can occur without a physical trigger. A study found that ⅓ of low back pain episodes do not have a known trigger(1).
Will I need a scan?
No, as stated in the above paragraph, scans are often quite useless in low back pain if there is no indication for serious pathology (7,8). They can even be harmful to you and lead to worsened outcomes (2,4,7,8). Although the radiation from scans is low, having multiple scans over your lifetime adds up (8). Scans are also expensive for you and the general health care system, this money can be spent on far more important and useful things (7,8).
Lastly, and maybe most importantly scans can often create fear. Lower back scans majority of the time will find something, at any time of your life, if you're young or old, are active or not active, have pain or no pain. However, these changes are usually not related to your pain(1,8) and can sound quite scary (e.g., bulging disc, degenerative disc disease). You may feel that these are very serious and that you have to stop moving/exercising/enjoying your hobbies. However, in the long term this can be very detrimental to your recovery and the opposite of what your body/mind needs(1).
Below is a table of the % of “abnormalities” found in asymptomatic (people without pain) on scans
Taken from Hall et al.(8)
From this table we could probably conclude that these “abnormalities” are not necessarily abnormalities but normal age related changes(8). In a sense, they are similar to developing wrinkles or gray hair, but on the inside of the body instead of the outside(8).
Will the pain become persistent?
As mentioned previously, most lower back pain will resolve with time with or without treatment(3). However, for some people this does not happen. There are many factors that can cause persistent pain both biological, psychological and social(1).
Avoiding movement in general due to pain or the fear of pain is understandable (and potentially helpful in the first few days)(1) however, this can lead to increased pain sensitivity and disability in the long term.
Here are some links for screening tools that can assess if you are at higher risk of developing persistent lower back pain:
When should I seek help?
If you have any indication you have a serious pathology it is a good idea to seek help from a health professional. If you are not sure if your lower back pain is serious it is always good to seek assistance from an up-to-date health care professional. It may also be a good idea to seek help if you have scored high on the above screening tools for persistent pain or if you feel you could benefit from guidance/advice.
What treatments can assist in my recovery?
There have been major advances in technology and treatments for lower back pain over the years. However, these have not led to improved outcomes (3,9). It seems like the shinier, newer, more impressive tools and interventions are not always going to lead to better results(7,9) and the foundations (movement, sleep, stress management, etc.) are likely more important.
There are numerous treatments advertised to “assist” in lower back pain. Common ones are injections, manual therapy, exercise, medications. The following options may be explored in the absence of serious pathology.
Movement is very important at all stages of your recovery, the body and spine love movement and this gets you back to activities which are meaningful to you. A lack of movement and increased bed rest can ease pain in the short term but can lead to de-conditioning, increased pain sensitivity and disability in the long-term.
Exercises can be useful (but are not essential) in your recovery and can reduce pain, as above movement is key. For lower back pain there does not seem to be a ‘superior’ form of exercise, so choose what you enjoy e.g., walking, Pilates, strength exercise, swimming(1,9). It may be worth taking a gradual progressive approach, starting at lower duration/intensity then gradually building it up.
Manual therapy including manipulation, massage and other soft tissue mobilization can be useful in the short term(11). For many people these strategies can ease the pain and allow you to move more. It is important to note that these techniques don’t “fix” lower back pain/injuries.
Cognitive behavioral therapy and other psychological treatments can be very useful for people that are at moderate-high risk of developing chronic low back pain. This is not because pain is “all in your head” but, because negative emotions, mood and cognitive factors can increase pain and pain’s impact/interference. These treatment’s can also be helpful if the person is fear-avoidant which means the person is consciously or unconsciously avoiding activities that they feel may cause damage(1).
Medications. These should always be taken with care, even seemingly harmless medications such as Panadol and Nurofen can still have adverse effects. If possible, avoiding any medication is ideal(1). Medications which have shown to be effective for some people(1) and may be explored with a Doctor include:
Anti-inflammatories (NSAIDs)
Tramadol (2nd line)
Duloxetine (2nd line)
Ideally these would only be taken for a short period of time(1).
Steroid injections are very commonly done even with less than favorable outcomes. There are several negatives to getting an injection, firstly they don’t seem to work in the long-term, they cost money and have a risk for adverse effects (although very small). The effects of steroid injection on back pain are overall no better then carrying on with normal life(1).
Surgery. may be indicated in certain cases (e.g., serious pathology or radiculopathies) however, for lower back pain with an unknown origin (90-95%) it does not show to be effective(1,7). As with all surgeries it also comes with an obvious risk(1)
Will more physical activity lead to more wear and tear of the spinal structures?
This is again unlikely. In epidemiology data (large population studies) it shows that low back pain is most common between 40-69 years old. After this period the occurrence of low back pain becomes less common(1). If physical activity/exercise did cause increased wear and tear then the prevalence would be higher the older you are.
Top tips for when you have lower back pain
Once serious pathology or injuries are ruled out, the following tips can assist healing:
Try and stay active(1,4)
If possible continue working(1)
If possible continue with activities you enjoy(1)
Try and keep a positive mind frame
Use heat packs if needed
If possible delay the use of medication (even Panadol or Nurofen)(1)
What can Adapt Movement do for you?
If you do live in Geraldton and you are wanting guidance through your lower back pain recovery come and see us at Adapt Movement. We have exercise physiologists and a physiotherapist that can guide you through your recovery. We use a ‘psychology’ informed approach which means that we consider psychological and contextual factors that may be contributing to your pain experience. All our interventions and advice is based on the latest evidence. Why is this important? Because incorrect information and unnecessary treatments can lead to longer recoveries(12).
References
Vlaeyen, J. W. S., Maher, C. G., Wiech, K., Van Zundert, J., Meloto, C. B., Diatchenko, L., Battié, M. C., Goossens, M., Koes, B., & Linton, S. J. (2018). Low back pain. Nature Reviews Disease Primers, 4(1). https://doi.org/10.1038/s41572-018-0052-1
Hartvigsen, J., Hancock, M. J., Kongsted, A., Louw, Q., Ferreira, M. L., Genevay, S., Hoy, D., Karppinen, J., Pransky, G., Sieper, J., Smeets, R. J., Underwood, M., Buchbinder, R., Hartvigsen, J., Cherkin, D., Foster, N. E., Maher, C. G., Underwood, M., van Tulder, M., & Anema, J. R. (2018). What low back pain is and why we need to pay attention. The Lancet, 391(10137), 2356–2367. https://doi.org/10.1016/s0140-6736(18)30480-x
de Campos, T. F., da Silva, T. M., Maher, C. G., Pocovi, N. C., & Hancock, M. J. (2023). Prognosis of a new episode of low‐back pain in a community inception cohort. European Journal of Pain. https://doi.org/10.1002/ejp.2083
Haldeman, S., Kopansky-Giles, D., Hurwitz, E. L., Hoy, D., Mark Erwin, W., Dagenais, S., Kawchuk, G., Strömqvist, B., & Walsh, N. (2012). Advancements in the Management of Spine Disorders. Best Practice & Research Clinical Rheumatology, 26(2), 263–280. https://doi.org/10.1016/j.berh.2012.03.006
McCullough, B. J., Johnson, G. R., Martin, B. I., & Jarvik, J. G. (2012). Lumbar MR Imaging and Reporting Epidemiology: Do Epidemiologic Data in Reports Affect Clinical Management? Radiology, 262(3), 941–946. https://doi.org/10.1148/radiol.11110618
Gatchel, R. J., Peng, Y. B., Peters, M. L., Fuchs, P. N., & Turk, D. C. (2007). The biopsychosocial approach to chronic pain: Scientific advances and future directions. Psychological Bulletin, 133(4), 581–624. https://doi.org/10.1037/0033-2909.133.4.581
Mafi, J. N., McCarthy, E. P., Davis, R. B., & Landon, B. E. (2013). Worsening Trends in the Management and Treatment of Back Pain. JAMA Internal Medicine, 173(17), 1573. https://doi.org/10.1001/jamainternmed.2013.8992
Hall, A. M., Aubrey-Bassler, K., Thorne, B., & Maher, C. G. (2021). Do not routinely offer imaging for uncomplicated low back pain. BMJ, n291. https://doi.org/10.1136/bmj.n291
Deyo, R. A., Mirza, S. K., Turner, J. A., & Martin, B. I. (2009). Overtreating Chronic Back Pain: Time to Back Off? The Journal of the American Board of Family Medicine, 22(1), 62–68. https://doi.org/10.3122/jabfm.2009.01.080102
Artus, M., van der Windt, D. A., Jordan, K. P., & Hay, E. M. (2010). Low back pain symptoms show a similar pattern of improvement following a wide range of primary care treatments: a systematic review of randomized clinical trials. Rheumatology, 49(12), 2346–2356. https://doi.org/10.1093/rheumatology/keq245
George, S. Z., Fritz, J. M., Silfies, S. P., Schneider, M. J., Beneciuk, J. M., Lentz, T. A., Gilliam, J. R., Hendren, S., & Norman, K. S. (2021). Interventions for the Management of Acute and Chronic Low Back Pain: Revision 2021. Journal of Orthopaedic & Sports Physical Therapy, 51(11), CPG1–CPG60. https://doi.org/10.2519/jospt.2021.0304
Fieke) Linskens, F. G., van der Scheer, E. S., Stortenbeker, I., Das, E., Staal, J. B., & van Lankveld, W. (2023). Negative language use of the physiotherapist in low back pain education impacts anxiety and illness beliefs: A randomised controlled trial in healthy respondents. Patient Education and Counseling, 110, 107649. https://doi.org/10.1016/j.pec.2023.107649
de Campos, T. F., da Silva, T. M., Maher, C. G., Pocovi, N. C., & Hancock, M. J. (2023). Prognosis of a new episode of low-back pain in a community inception cohort. European journal of pain (London, England), 27(5), 602–610. https://doi.org/10.1002/ejp.2083
This blog was written by Samuel Bulten
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