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)
- 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
- Previous recurrent cancer
- Intravenous drug use
- 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.
- 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.
- 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
- It will help you strengthen your weak muscles, reduce stress/anxiety, and lose weight
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.
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.
- 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.
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
- 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
- R/L Rotation
- 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+)
- Straight leg test
- Seated strait leg test
- Slump test
- SI compression
- Hoover test (malingering)
- Axial loading
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