Back Pain: Facts, Causes, Treatment, Prevention

September 12, 2017 Mom MD Hawaii

This article is about one of the most common medical problems that almost every person has experienced at sometime. Or, if you have been fortunate enough not to have suffered back pain yet, then chances are you will at some point in your life. Back pain is often a chronic, remitting issue that can severely affect quality of life. As a sports medicine physician I hate back pain; mostly because there is not a lot that I can do to make it go away instantly. In truth, a lot of what I can provide doesn’t matter in the long run as patients get better with or without me. What the patient does and if they see a physical therapist is actually much more helpful and valuable.

In this article I will give you some basic back pain information and general guidelines about what to do to treat back pain. I’ll list some important red-flag signs and symptoms to look out for. The goal is especially on prevention, so the most important information will be on preventing back pain in the first place.

Back Pain Facts

Back pain is the most common musculoskeletal reason to seek medical care
It is most common in the low back
Low back pain costs at least $16 billion each year
Disables 5.4 million Americans
Aggressive rehabilitation (Physical Therapy) for chronic low back pain improves outcomes
First episodes are usually between 20-40 years of age
Psychological and Social factors predict long-term disability

Causes of Most Back Pain

Bad posture
Bad biomechanics (the way your body moves)
Weakness
Compensation for weaknesses

I personally have experienced acute back pain and it really sucks. It occurred when I was breastfeeding and I know it was from being in a hunched over, poor posture position for hours a day. Most back pain is from poor biomechanics and posture that over time lead to weaknesses and improper ability to compensate for these faults. My husband also gets back pain likely due to a slipping vertebrae. For the most part he works out to stabilize his back and prevent his abnormal spine bone movement, but when he gets an acute episode he can usually pinpoint the inciting incident back to one or more of the causes above.

Example Causes of Back Pain

The best illustrative example about the cause of back pain I can provide is when you sit most (if not all) of the day for your job. Sitting causes your core (deep abdominal) muscles to slacken, weaken and stop working. Because they are in a flexed position your back muscles takeover and do all the work of holding your spine and your trunk upright. Over time your back muscles on the sides of your spine (paraspinal muscles) get overused and get tired. At some point just a small abnormal movement, like twisting, bending, or lifting a box, will cause an acute spasm and strain of these muscles that are already overused. This results in an acute, and often severe, back pain and spasm.

You or someone you love has acute low back pain, oh no, now what? The first and most important thing is to see if you have any red flag signs and symptoms. This would indicate that you should seek a medical evaluation. I encourage reading up and learning about your symptoms or disease via credible sources, like the American Academy of Family Physicians and Up To Date, to stimulate discussion with your Primary Care Provider (PCP). I would also recommend that you always see a health care professional if you have any questions or concerns about any medical issue. Dr Google and Dr Up-to-Date are NOT a replacement for a one-on-one relationship with your doctor.

Red Flag Signs and Symptoms

Recent significant trauma
Mildler trauma if age >50 years (actually any kind of trauma would count for a older person)
Unexplained weight loss
Recent infection
Unexplained fever
Immunosuppression
Previous recurrent cancer
Intravenous drug use
Osteoporosis
Chronic Corticosteroid (steroid) use
Age greater than 70 years old
Focal neurologic deficit
Unable to control bowel or bladder
Saddle anesthesia
Duration greater than 6 weeks

If you have red flag symptoms or risk factors as listed above please see a physician or primary care provider. Please remember that even with red flag signs and symptoms you may still just have an acute muscle strain and imaging is usually NOT indicated.

If you do NOT have these RED FLAG signs and symptoms then feel reassured that you can proceed to treatment as listed below.

Treatment

MOVE!
Keep MOVING!
Don’t stop MOVING!
Tylenol (Yes, plain old tylenol works very well in Double blinded placebo controlled studies)
Nonsteroidal anti-inflammatory drugs ( NSAIDs)
- Naproxen, Celebrex, and Mobic are my favorite because they have daily or twice a day dosing
- Ibuprofen needs to be taken 4 times a day in order to reach a good steady state in your bloodstream to really help the inflammation
- Indocin and Toradol are the stronger anti-inflammatories I prescribe for really severe acute back pain
Muscle Relaxants
- I prescribe flexeril and robaxin and stay away from benzodiazepines due to side effects
Physical therapy
- Spine stabilization PT is preventative and decreases pain, disability, and recurrence
- MacKenzie method has been shown to decrease the need for healthcare services, but has no long term benefit like spine stabilization (core strengthening)
Gentle stretching – I love to prescribe yoga and pilates (gentle exercises) as tolerated
No Bed Rest – Just laying there is very bad idea
Avoid Opioids/narcotics, especially long term use
- They have no benefit over Tylenol and NSAIDs in all studies, and can be harmful
- I personally do not prescribe any opioid, narcotic, or benzodiazepine (any controlled medication) prescriptions for low back pain
Heat is beneficial in the first 5 days for the muscle spasm, but ice and heat have the same pain reducing properties
Be conscious of your posture, don’t slouch, hunch, or tilt

Move, Move, Move!

The reason that move is listed as the first three treatment recommendations are because of how important it is. You should stay active (within pain limits), avoid aggravating movements, and return to normal activity as soon as possible. Returning to normal activities as soon as possible has been shown to reduce pain and get patients back to normal faster. Think about alternative activities at first like gentle stretching, yoga, and light swimming. It’s important to know that acute low back pain is usually benign and the prognosis is often good, with most cases resolving with little intervention.

Bed Rest is the WORST thing for back pain

Movement is GOOD, that means the opposite of movement, laying in bed, is BAD. Avoiding bed rest as much as possible is key. Bed rest is worse at reducing pain and has less functional improvement when compared with staying active. Prolonged bed rest can also cause harmful effects such as joint stiffness, muscle wasting, loss of bone mineral density, pressure ulcers, and blood clots (DVT). Bed rest is NOT recommended, but you should definitely avoid twisting and bending and any other aggravating motions.

Prevention

Physical Therapy
- Always choose PT where they do evaluations and treatments one-on-one with a dedicated PT who can individualize and adjust your program just for you, like my husband’s clinic Central Oahu PT Specialists
Spine/Core Stabilization
- I really like yoga and pilates, or even a combination to stabilize, strengthen, and stretch
- PT should provide a more focused program individualized and progressed for you
Work on your other muscular weaknesses, which likely are also contributing
- Everything is connected so weaknesses elsewhere can still show up as back pain, like weak glut (butt) muscles
Stretch out where you are tight
- You are likely compensating for your weaknesses with whatever muscles are tight and spasmed; usually hip flexors, IT band, back muscles
- Your whole body is connected in one big kinetic chain so everything can affect everything else
Lose weight (yes, I said it)
- The more weight you have the more your muscles, bones, and joints need to work to keep you moving and in balance
Work on your Zen
- Stress, poor quality of life, anxiety, inadequate coping skills, and psychiatric illness actually contribute to causing and worsens back pain
Good Posture
- My great-grandma used to cringe at my poor posture, but who knew that she was right; poor, slouchy, hunched over positions are more than just unattractive it sets you up for chronic back pain
- We’ve even bought a Lumo Lift Posture Coach, which is the latest high tech gear that you wear on your clothes and it vibrates when you’ve got poor posture
Learn how to lift properly, because lifting improperly can trigger an acute strain or spasm
Sleep, drive, and sit with good support
- Get a specially designed cervical pillow
- Side sleepers should place a pillow between their legs
- Use a lower back support when sitting/driving, or better yet don’t sit so much and get a standing desk
Exercise
- It will help you strengthen your weak muscles, reduce stress/anxiety, and lose weight

Lumo Lift

More on Prevention Strategies

Physical therapy has been shown to decrease back pain recurrence with spine stabilization. This includes core stabilization. Basically you need to strengthen your deep abdominal muscles that stop working when we sit on our butts all day. Not the rectus abdominus muscle (the six pack muscle), which everyone thinks is an indication of a strong core. Just because you have bricks doesn’t mean you have a strong core. You need to work more on the obliques and transversus abdominus muscles. These deeper muscles should always be working, contracting, and helping to stabilize you. If pain is higher up in your back then it’s often due to poor posture so work on sitting/standing upright, chin tucked, with your shoulders back. Check out your posture in a mirror. You can also set posture reminders on your smart phone or smart watch.

Summary

Back pain is extremely common and often caused by something that you’re doing on a chronic basis, like biomechanics faults or poor posture. It’s important to arm yourself with the knowledge about the likely cause, red-flags, treatment, and prevention of back pain because it will definitely affect you or a loved one. Being proactive with the information and strategies in this article could help prevent and treat a severely debilitating condition.

References:

Frymoyer JW. Back pain and sciatica. N Engl J Med. 1988;318(5):291–300.
Casazza, BA. Diagnosis and Treatment of Acute Low Back Pain. Am Fam Physician. 2012 Feb 15;85(4):343-350.

Back Examination

Low Back Pain Physical Examination Format

Red Flag Signs: Night pain, night sweats, history of cancer, TTP over spinous process at vertebral level. Associated fevers, weight loss, bowel/bladder retention

Inspection:

Stance/gait
Note deformities, atrophy, or spasms
Posture while standing & seated, note curvature of spine (lordosis, kyphosis, scoliosis)
Leg length discrepancy
Gross examination of entire kinetic chain (feet, ankle, knees, hips)

Palpation: Spinous processes, paraspinal muscles, SI joint

ROM: varies, usually say full, or limited by pain

Forward flexion
R/L lateral flexion
Extension/Hyperextension
R/L Rotation

Neurological

Sensory: Note myotome, dermatome, or nerve root distribution
Motor strength to MMT:
- Low Back: Hip flexion, Knee flexion, Knee extension, Ankle DF/PF, Great toe DF/PF
- Cervical Spine: Flexion, extension, R/L rotation, R/L lateral flexion
Deep tendon reflexes (normal 2+)

Special Testing:

Straight leg test
Seated strait leg test
Slump test
Rhomberg
Spurling’s
SI compression
Hoover test (malingering)
Axial loading

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