Back Pain; Causes, Symptoms, Diagnosis, Treatment









User Review


5
(6 votes)


Back pain (LBP) is a common disorder involving the muscles, nerves, and bones of the back. Pain can vary from a dull constant ache to a sudden sharp feeling. Low back pain may be classified by duration as acute (pain lasting less than 6 weeks), sub-chronic (6 to 12 weeks), or chronic (more than 12 weeks). The condition may be further classified by the underlying cause as either mechanical, non-mechanical, or referred pain. The symptoms of low back pain usually improve within a few weeks from the time they start, with 40-90% of people completely better by six weeks.

Types of Back Pain

Low back pain can be broadly classified into four main categories

In addition, symptoms of lower back pain are usually described by the type of onset and duration

  • Acute pain  This type of pain typically comes on suddenly and lasts for a few days or weeks, and is considered a normal response of the body to injury or tissue damage. The pain gradually subsides as the body heals.
  • Subacute low back pain  Lasting between 6 weeks and 3 months, this type of pain is usually mechanical in nature (such as a muscle strain or joint pain) but is prolonged. At this point, a medical workup may be considered and is advisable if the pain is severe and limits one’s ability to participate in activities of daily living, sleeping, and working.
  • Chronic back pain  Usually defined as lower back pain that lasts over 3 months, this type of pain is usually severe, does not respond to initial treatments, and requires a thorough medical workup to determine the exact source of the pain.

Causes of Back Pain

  • Bulging or herniated disc A disc may bulge outward. A herniated disc occurs when the soft interior matter escapes through a crack or ruptures through the disc’s protective outer layer. Both disc problems can cause nerve compression, inflammation, and pain.
  • Spinal stenosis  – develops when the spinal canal or a nerve passageway abnormally narrows.
  • Spinal arthritis – also called spinal osteoarthritis or spondylosis, is a common degenerative spine problem. It affects the spine’s facet joints and may contribute to the development of bone spurs.
  • Spondylolisthesis –  occurs when a lumbar (low back) vertebral body slips forward over the vertebra below it.
  • Vertebral fractures – (burst or compression types) are often caused by some type of trauma (eg, fall).
  • Osteomyelitis – is a bacterial infection that can develop in one of the spine’s bones.
  • Spinal tumors – are an abnormal growth of cells ( a mass) and are diagnosed as benign (non-cancerous) or malignant (cancer).
  • Sprains and strains –  account for most acute back pain. Sprains are caused by overstretching or tearing ligaments, and strains are tears in tendon or muscle. Both can occur from twisting or lifting something improperly, lifting something too heavy, or overstretching. Such movements may also trigger spasms in back muscles, which can also be painful.
  • Intervertebral disc degeneration is one of the most common mechanical causes of low back pain, and it occurs when the usually rubbery discs lose integrity as a normal process of aging. In a healthy back, intervertebral discs provide height and allow bending, flexion, and torsion of the lower back. As the discs deteriorate, they lose their cushioning ability.
  • Herniated or ruptured discs – can occur when the intervertebral discs become compressed and bulge outward (herniation) or rupture, causing low back pain.
  • Radiculopathy – is a condition caused by compression, inflammation and/or injury to a spinal nerve root. Pressure on the nerve root results in pain, numbness, or a tingling sensation that travels or radiates to other areas of the body that are served by that nerve. Radiculopathy may occur when spinal stenosis or a herniated or ruptured disc compresses the nerve root.
  • Sciatica  – is a form of radiculopathy caused by compression of the sciatic nerve, the large nerve that travels through the buttocks and extends down the back of the leg. This compression causes shock-like or burning low back pain combined with pain through the buttocks and down one leg, occasionally reaching the foot. In the most extreme cases, when the nerve is pinched between the disc and the adjacent bone, the symptoms may involve not only pain but numbness and muscle weakness in the leg because of interrupted nerve signaling.
  • A traumatic injury – such as from playing sports, car accidents, or a fall can injure tendons, ligaments or muscle resulting in low back pain. Traumatic injury may also cause the spine to become overly compressed, which in turn can cause an intervertebral disc to rupture or herniate, exerting pressure on any of the nerves rooted in the spinal cord.
  • Skeletal irregularities – include scoliosis, a curvature of the spine that does not usually cause pain until middle age; lordosis, an abnormally accentuated arch in the lower back; and other congenital anomalies of the spine.
  • Abdominal aortic aneurysms – occur when the large blood vessel that supplies blood to the abdomen, pelvis, and legs becomes abnormally enlarged. Back pain can be a sign that the aneurysm is becoming larger and that the risk of rupture should be assessed.
  • Kidney stones – can cause sharp pain in the lower back, usually on one side. Low back pain is rarely related to serious underlying conditions, but when these conditions do occur, they require immediate medical attention.
  • Infections – are not a common cause of back pain. However, infections can cause pain when they involve the vertebrae, a condition called osteomyelitis; the intervertebral discs, called discitis; or the sacroiliac joints connecting the lower spine to the pelvis, called sacroiliitis
  • Cauda equina syndrome – is a serious but rare complication of a ruptured disc. It occurs when disc material is pushed into the spinal canal and compresses the bundle of lumbar and sacral nerve roots, causing loss of bladder and bowel control. Permanent neurological damage may result if this syndrome is left untreated.

back-pain-posture

  • Inflammatory diseases of the joints such as arthritis, including osteoarthritis and rheumatoid arthritis as well as spondylitis, an inflammation of the vertebrae, can also cause low back pain. Spondylitis is also called spondyloarthritis or spondyloarthropathy.
  • Osteoporosis – is a metabolic bone disease marked by a progressive decrease in bone density and strength, which can lead to painful fractures of the vertebrae.
  • Endometriosis – is the buildup of uterine tissue in places outside the uterus.
  • Fibromyalgia, – a chronic pain syndrome involving widespread muscle pain and fatigue.

Red flag historic or physical exam features that, when present, should raise the provider’s suspicion for a process that may require imaging for proper diagnosis. These differ slightly from adults to children based on the incidence of diseases in these age groups:

Adults:

Cauda equina syndrome

  • History: Progressive motor/sensory loss, new urinary retention or incontinence, new fecal incontinence
  • Physical exam: Saddle anesthesia, anal sphincter atony, significant motor deficits of multiple myotomes

Fracture

  • History: Significant trauma (relative to age), Prolonged corticosteroid use, osteoporosis, and age greater than 70 years
  • Physical exam: Contusions, abrasions, tenderness to palpation over spinous processes

Infection

  • History: Spinal procedure within the last 12 months, Intravenous drug use, Immunosuppression, prior lumbar spine surgery
  • Physical exam: Fever, wound in spinal region, localized pain, and tenderness

Malignancy

  • History: History of metastatic cancer, unexplained weight loss
  • Physical exam: Focal tenderness to palpation in the setting of risk factors

Pediatric red flags are the same as adults with a few notable differences

Malignancy

  • History: age less than 4 years, nighttime pain

Infectious

  • History: age less than 4 years, nighttime pain, history of tuberculosis exposure

Inflammatory

  • History: age less than 4 years, morning stiffness for greater than 30min, improving with activity or hot showers

Fracture

  • History: activities with repetitive lumber hyperextension (sports such as cheerleading, gymnastics, wrestling, or football linemen)
  • Physical exam: Tenderness to palpation over spinous process, positive Stork test

Everyday activities or poor posture.

Back pain can also be the result of some everyday activity or poor posture. Examples include:

low-back pain

Adopting a very hunched sitting position when using computers can result in increased back and shoulder problems over time.
  • Bending awkwardly
  • Pushing something
  • Pulling something
  • Carrying something
  • Lifting something
  • Standing for long periods
  • Bending down for long periods
  • Twisting
  • Coughing
  • Sneezing
  • Muscle tension
  • Over-stretching
  • Straining the neck forward, such as when driving or using a computer
  • Long driving sessions without a break, even when not hunched

The Symptom of Back Pain

The main symptom of back pain is, as the name suggests, an ache or pain anywhere on

  • Pain in the back, and sometimes all the way down to the buttocks and legs. Some back issues can cause pain in other parts of the body, depending on the nerves affected.
  • In most cases, signs, and symptoms clear up on their own within a short period. If any of the following signs or symptoms accompany back pain, people should see their doctor:
  • Pain. It may be continuous, or only occur when you are in a certain position. The pain may be aggravated by coughing or sneezing, bending or twisting.
  • Patients who have been taking steroids for a few months
  • Drug abusers
  • Patients with cancer
  • Patients who have had cancer
  • Patients with depressed immune systems
  • Stiffness.

According to the British National Health Service (NHS), the following groups of people should seek medical advice if they experience back pain:

  • Weight loss
  • Elevated body temperature (fever)
  • Inflammation (swelling) on the back
  • Persistent back pain – lying down or resting does not help
  • Pain down the legs
  • Pain reaches below the knees
  • A recent injury, blow or trauma to your back
  • Urinary incontinence – you pee unintentionally (even small amounts)
  • Difficulty urinating – passing urine is hard
  • Fecal incontinence – you lose your bowel control (you poo unintentionally)
  • Numbness around the genitals
  • Numbness around the anus
  • Numbness around the buttocks
  • Dull ache,
  • Numbness,
  • Tingling,
  • Sharp pain,
  • Pulsating pain,
  • Pain with movement of the spine,
  • Pins and needles sensation,
  • Muscle spasm,
  • Tenderness,
  • Sciatica with shooting pain down one or both lower extremities
  • People aged less than 20 and more than 55 years
  • Additionally, people who experience pain symptoms after a major trauma (such as a car accident) are advised to see a doctor. If low back pain interferes with daily activities, mobility, sleep, or if there are other troubling symptoms, medical attention should be sought.

Risk increases with

  • Biomechanical risk factors.
  • Sedentary occupations.
  • Gardening and other yard work.
  • Sports and exercise participation, especially if infrequent.
  • Obesity.

Preventive measures

  • Exercises to strengthen lower back muscles.
  • Learn how to lift heavy objects.
  • Sit properly.
  • Back support in bed.
  • Lose weight, if obese.
  • Choose proper footwear.
  • Wear special back support devices.

Red flag conditions indicating possible underlying spinal pathology or nerve root problemsw9

Red flags

  • Onset age < 20 or > 55 years
  • Non-mechanical pain (unrelated to time or activity)
  • Thoracic pain
  • Previous history of carcinoma, steroids, HIV
  • Feeling unwell
  • Weight loss
  • Widespread neurological symptoms
  • Structural spinal deformity

Indicators for nerve root problems

  • Unilateral leg pain > low back pain
  • Radiates to foot or toes
  • Numbness and paraesthesia in the same distribution
  • Straight leg raising test induces more leg pain
  • Localized neurology (limited to one nerve root)

Diagnosis of Back Pain

Suspected disk, nerve, tendon, and other problems – X-rays or some other imaging scan, such as a CT (computerized tomography) or MRI (magnetic resonance imaging) scan may be used to get a better view of the state of the soft tissues in the patient’s back.

  • Blood tests – CBC ,ESR,Hb, RBS,CRP, Serum Creatinine,Serum Electrolyte,
  • Myelograms
  • Discography.
  • Electrodiagnostics
  • Bone scans
  • Ultrasound imaging
  • X-rays – can show the alignment of the bones and whether the patient has arthritis or broken bones. They are not ideal for detecting problems with muscles, the spinal cord, nerves or disks.
  • MRI or CT scans – these are good for revealing herniated disks or problems with tissue, tendons, nerves, ligaments, blood vessels, muscles, and bones.
  • Bone scan – a bone scan may be used for detecting bone tumors or compression fractures caused by brittle bones (osteoporosis). The patient receives an injection of a tracer (a radioactive substance) into a vein. The tracer collects in the bones and helps the doctor detect bone problems with the aid of a special camera.
  • Electromyography or EMG – the electrical impulses produced by nerves in response to muscles is measured. This study can confirm nerve compression which may occur with a herniated disk or spinal stenosis (narrowing of the spinal canal).
Types of low back pain associated with physical findings of no clear pathoanatomical significance
SyndromeFindingsAssessment/Plan
Facet syndromeHistory and physical examination:

  • local and pseudoradicular symptoms and signs
  • pain on movement
  • facet tenderness
  • pain on reclination
  • positive injection test
  • joint dysfunction on manual diagnosis

Radiological findings (not indicated on initial evaluation):

  • differentiation from high-grade or activated spondylarthrosis (possibly, juxtaforaminal cyst) or
  • axial spondylarthritis
Differential diagnosis:

  • major joint dysfunction (blockage)
  • activated spondylarthrosis

Treatment:
analgesics (1–3 days), muscle stabilization,
manual medicine, facet injection if indicated

Sacro-iliac joint syndromeHistory and physical examination:

  • Sacro-iliac joint symptoms, a positive provocation test
  • functional leg length discrepancy
  • injection test

Radiological findings (not indicated on initial evaluation):

  • differential diagnosis: inflammation (sacroiliitis in seronegative spondylarthritis)
Functional disturbance:
muscular imbalance
Treatment:
stabilizing exercises, analgesics (1–3 days) if needed, manual medicine, sacroiliac joint injection if indicated
Myofascial pain syndromeHistory and physical examination:

  • muscle trigger points: local pain with peripheral radiation
  • peripheral and central sensitization

Radiological and histological findings:

  • not indicated
  • no clear evidence from MRI or biopsy
  • pathogenesis and definitive diagnosis still unclear
  • (low intra- and interrater reliability)

Local treatment:
active physiotherapy, manual therapy, infiltration, acupuncture

Functional instabilityHistory and physical examination:

  • “snapping” feeling
  • generalized deconditioning
  • pain on movement, possibly accompanied by ‧sensory and motor deficits (reversible)
  • impaired proprioception

Radiological findings:

  • no direct evidence
  • unclear pathogenesis and definition
  • treatment with manual medicine
  • physiotherapeutic stabilization program
  • caveat: surgery, differential diagnosis, structural instability

 

Treatment of Back Pain

Not all treatments work for all conditions or for all individuals with the same condition, and many find that they need to try several treatment options to determine what works best for them. The present stage of the condition (acute or chronic) is also a determining factor in the choice of treatment. Only a minority of people with back pain (most estimates are 1% – 10%) require surgery.

Non-medical

Treatment for back pain generally depends on how long your pain lasts

Acute (short-term) back pain – usually gets better on its own. Exercises or surgery are usually not recommended for this type of pain. There are some things you may try while you wait for your pain to get better:

  • Acetaminophen, aspirin, or ibuprofen will help ease the pain.
  • Get up and move around to ease stiffness, relieve pain, and have you back doing your regular activities sooner.

Chronic (long-term) back pain – is typically treated with nonsurgical options before surgery is recommended.

Nonsurgical Treatments

  • Pain relievers – that are taken by mouth or applied to the skin. Examples include acetaminophen and aspirin. Your doctor may suggest steroid or numbing shots lessen your pain. Involves using pulleys and weights to stretch the back, which may allow a bulging disk to slip back into place. Your pain may be relieved while in traction, although pain returns once you aren’t in traction.
  • Practice healthy habits – such as exercise, relaxation, regular sleep, proper diet, and quitting smoking.
  • Manipulation – Professionals use their hands to adjust or massage the spine or nearby tissues.
  • Acupuncture This Chinese practice uses thin needles to relieve pain and restore health. Acupuncture may be effective when used as a part of a comprehensive treatment plan for low back pain.
  • Acupressure A therapist applies pressure to certain places in the body to relieve pain. Acupressure has not been well studied for back pain. Move your body properly while you do daily activities, especially those involving heavy lifting, pushing, or pulling. Back pain is generally treated with non-pharmacological therapy first, as it typically resolves without the use of medication. Superficial heat and massage, acupuncture, and spinal manipulation therapy may be recommended.
  • Heat therapy –  is useful for back spasms or other conditions. A review concluded that heat therapy can reduce symptoms of acute and sub-acute low-back pain.
  • Regular activity and gentle stretching exercises – is encouraged in uncomplicated back pain, and is associated with better long-term outcomes. Physical therapy to strengthen the muscles in the abdomen and around the spine may also be recommended.
  • These exercises  – are associated with better patient satisfaction, although it has not been shown to provide functional improvement. However, one study found that exercise is effective for chronic back pain, but not for acute pain. If used, they should be performed under the supervision of a licensed health professional.
  • Massage therapy – may give short-term pain relief, but not functional improvement, for those with acute lower back pain. It may also give short-term pain relief and functional improvement for those with long-term (chronic) and sub-acute lower pack pain, but this benefit does not appear to be sustained after 6 months of treatment. There does not appear to be any serious adverse effects associated with massage.
  • Acupuncture – may provide some relief for back pain. However, further research with stronger evidence needs to be done.
  • Spinal manipulation is a widely-used method of treating back pain, although there is no evidence of long-term benefits.
  • Back school – is an intervention that consists of both education and physical exercises. A 2016 Cochrane review found the evidence concerning back school to be very low quality and was not able to make generalizations as to whether back school is effective or not.

The Medication of Back Pain

If non-pharmacological measures are not effective, medications may be tried.

  • Muscle relaxants – and some antidepressants may be prescribed for some types of chronic back pain.
  • Transcutaneous electrical nerve stimulation (TENS) – A small box over the painful area sends mild electrical pulses to nerves. TENS treatments are not always effective for reducing pain.
  • Non-steroidal anti-inflammatory drugs (NSAIDs) – are typically tried first. NSAIDs have been shown to be more effective than placebo, and are usually more effective than paracetamol (acetaminophen).
  • In severe back pain not relieved by NSAIDs  – or acetaminophen, opioids may be used. However, long-term use of opioids has not been proven to be effective at treating back pain. Opioids have not always been shown to be better than placebo for chronic back pain when the risks and benefits are considered.
  • Skeletal muscle relaxers – may also be used. Their short term use has been shown to be effective in the relief of acute back pain. However, the evidence of this effect has been disputed, and these medications do have negative side-effects.
  • In people with nerve root pain and acute radiculopathy – there is evidence that a single dose of steroids, such as dexamethasone, may provide pain relief.
  • Epidural corticosteroid injection – (ESI) is a procedure in which steroid medications are injected into the epidural space. The steroid medications reduce inflammation and thus decrease pain and improve function. ESI has long been used to both diagnose and treat back pain, although recent studies have shown a lack of efficacy in treating low back pain.
  • Carisoprodol – This muscle relaxant was investigated in two high-quality studies on acute low back pain. The first study compared carisoprodol with diazepam [. Carisoprodol was superior in performance on all the outcome parameters measured. A comparison of carisoprodol with cyclobenzaprine‐hydrochloride in the second study revealed no statistically significant differences between the two treatments [.
  • Chlorzoxazone – This muscle relaxant was compared with tizanidine in one high-quality study in a very small sample of patients with degenerative lumbar disc disease [. No differences were found between the treatments.
  • Cyclobenzaprine‐hydrochloride – Cyclobenzaprine was compared with diazepam in a low-quality trial on chronic low back pain, but no significant differences between the treatments were identified [. There was also no significant difference between cyclobenzaprine and carisoprodol in one high-quality study on acute low back pain [.
  • Diazepam – In comparison with carisoprodol, diazepam was found to be inferior in performance on muscle spasm, global efficacy and functional status in a high-quality trial on acute low back pain [. In a very small high-quality trial (30 people) comparing diazepam with tizanidine, there were no differences in pain, functional status and muscle spasm after seven days [.
  • Tizanidine – This muscle relaxant was compared with chlorzoxazone and diazepam in two very small high quality [. Both trials did not find any differences in pain, functional status and muscle spasm after 7 days.
  • Pridinol mesylate – One low-quality trial showed no differences between this muscle relaxant and thiocolchicoside on pain relief and global efficacy.

Surgery of Back Pain

  • Surgery for back pain is typically used as a last resort when the serious neurological deficit is evident. A 2009 systematic review of back surgery studies found that, for certain diagnoses, surgery is moderately better than other common treatments, but the benefits of surgery often decline in the long term.
  • Surgery may sometimes be appropriate for people with severe myelopathy or cauda equina syndrome. Causes of neurological deficits can include spinal disc herniation, spinal stenosis, degenerative disc disease, tumor, infection, and spinal hematomas, all of which can impinge on the nerve roots around the spinal cord. There are multiple surgical options to treat back pain, and these options vary depending on the cause of the pain.

Lower back pain exercises

https://www.rxharun.com/low-back-pain-exercise

A series of exercise routines you can do to help reduce any lower back pain (occasionally referred to as low back pain), including tension, stiffness, and soreness. These exercises from physiotherapists and BackCare expert Nick Sinfield help to stretch, strengthen and mobilize the lower back. When starting out, go gently to get used to the movements and work out how far you can go into each position without feeling pain.

Aim to do this routine at least once a day if the pain allows. You can complement this routine with walking, cycling and water-based activities. You are advised to seek medical advice before starting these back pain exercises and to stop immediately if you feel any pain.

Bottom to heels stretch

Stretches and mobilizes the spine

exercise-low-back-pain

Start position: Kneel on all fours, with your knees under hips and hands under shoulders. Don’t over-arch your lower back. Keep your neck long, your shoulders back and don’t lock your elbows.

Action: Slowly take your bottom backward, maintaining the natural curve in the spine. Hold the stretch for one deep breath and return to the starting position.

Repeat 8 to 10 times.

Tips:

  • Avoid sitting back on your heels if you have a knee problem.
  • Ensure correct positioning with the help of a mirror.
  • Only stretch as far as feels comfortable.

Knee rolls

Stretches and mobilizes the spine

backpain-knee-roll

Start position: Lie on your back. Place a small flat cushion or book under your head. Keep your knees bent and together. Keep your upper body relaxed and your chin gently tucked in.

Action: Roll your knees to one side, followed by your pelvis, keeping both shoulders on the floor. Hold the stretch for one deep breath and return to the starting position.

Repeat 8 to 10 times, alternating sides.

Tips:

  • Only move as far as feels comfortable.
  • Place a pillow between your knees for comfort.

Back extensions

Stretches and mobilizes the spine backward

backpain-exercise/Back extensions

Start position: Lie on your stomach, and prop yourself on your elbows, lengthening your spine. Keep your shoulders back and neck long.

Action: Keeping your neck long, arch your back up by pushing down on your hands. You should feel a gentle stretch in the stomach muscles as you arch backward. Breathe and hold for 5 to 10 seconds. Return to the starting position.

Repeat 8 to 10 times.

Tips:

  • Don’t bend your neck backward.
  • Keep your hips grounded.

Deep abdominal strengthening

Strengthens the deep supporting muscles around the spine

https://www.rxharun.com/Deep abdominal strengthening

Start position: Lie on your back. Place a small, flat cushion or book under your head. Bend your knees and keep your feet straight and hip-width apart. Keep your upper body relaxed and your chin gently tucked in.

Action: As you breathe out, draw up the muscles of your pelvis and lower abdominals, as though you were doing up an imaginary zip along your stomach. Hold this gentle contraction while breathing from your abdomen for 5 to 10 breaths, and relax.

Repeat 5 times.

Tips:

  • This is a slow, gentle tightening of the lower abdominal region. Don’t pull these muscles in using more than 25% of your maximum strength.
  • Make sure you don’t tense up through the neck, shoulders or legs.

Pelvic tilts

Stretches and strengthens the lower back

backpain-exercise-Pelvic tilts

Start position: Lie on your back. Place a small, flat cushion or book under your head. Bend your knees and keep your feet straight and hip-width apart. Keep your upper body relaxed and your chin gently tucked in.

Action: Gently flatten your low back into the floor and contract your stomach muscles. Now tilt your pelvis towards your heels until you feel a gentle arch in your lower back, feeling your back muscles contracting and return to the starting position.

Repeat 10 to 15 times, tilting your pelvis back and forth in a slow rocking motion.

Tips:

  • Keep your deep abdominals working throughout.
  • Don’t press down through the neck, shoulders or feet.

Modification
Place one hand on your stomach and the other under your lower back to feel the correct muscles working

References

Back Pain

Print Friendly, PDF & Email

Sharing to Spread to the World

Leave a Reply

Your email address will not be published.