Back pain is a common condition that affects most people at some point during their life. Most cases of back pain are associated with pain and stiffness in the lower back.
See also: Lumbar Supports – Back Pain
Types of back pain
Back pain is classified in two main ways:
- specific back pain – pain that is associated with an underlying health condition or damage to the spine
- non-specific back pain – where the pain is not caused by serious damage or disease, but by sprains, muscle strains, minor injuries or a pinched or irritated nerve
Causes of specific back pain include:
- sciatica – a condition caused by a nerve in the back (the sciatic nerve) being irritated or compressed
- slipped disc – where one of the discs of the spine (see box, left) splits and the gel inside leaks out
- ankylosing spondylitis – a condition where the joints at the base of the spine become inflamed
This article focuses on non-specific back pain.
Back pain can also be classified according to how long the symptoms last. For example:
- acute back pain – the pain does not last longer than six weeks
- chronic back pain – the pain lasts for more than six weeks
How common is back pain?
Back pain is a very common condition and can affect adults of all ages.
It is estimated that one in five people will visit their GP in any given year because of back pain. And 80% of adults will experience at least one episode of back pain at some point in their life.
Chronic back pain is less common than acute back pain, but it is still very widespread. In England, chronic back pain is the second most common cause of long-term disability (after arthritis). After stress, it is the leading cause of long-term work-related absence. A recent study found that one in every 10 people reported having some degree of chronic back pain.
The rates of reported cases of back pain in England have doubled over the past 40 years – a trend that is seen in almost all Western nations. There are a number of theories to explain the rise in the number of cases.
One theory is that the rates of obesity, depression and stress are now higher than they were in the past. These conditions are all risk factors for chronic back pain. Another theory is that people are now more willing to report symptoms of pain to their GP than they were in the past. See Back pain – causes for more information.
The outlook for back pain can vary considerably between individuals. Some people have minor episodes of acute back pain before making a full recovery.
Other people have long periods of mild to moderate back pain that are interrupted by periods of severe pain, which makes them unable to do their normal daily activities.
An Australian study which looked at people who visited their GP because of back pain found that:
- 40% were completely free of pain within six weeks
- 58% were pain-free within 12 weeks
- 73% were pain-free within one year
Psychological and social factors play an important role in the expected outlook for back pain, particularly for chronic back pain.
For example, people who have a positive frame of mind and report enjoying a good quality of life tend to make a faster recovery than those who report symptoms of depression and are unhappy with one or more aspects of their life.
Treatment options for back pain include painkillers, spinal manipulation, acupuncture and exercise classes. Some cases of chronic back pain may also benefit from additional psychological treatment for the reasons discussed above.
The structure of the back
The back is a complex structure that consists of:
- 24 small bones (vertebrae) that support the weight of your upper body and form a protective canal for the spinal cord
- shock-absorbing discs (intervertebral discs) that cushion the bones and allow the spine to bend
- ligaments that hold the vertebrae and discs together
- tendons that connect muscles to vertebrae
- the spinal cord, which carries nerve signals from the brain to the rest of the body
The lumbar region
The lumbar region is the lower part of the back. It is made up of five vertebrae: L1, L2, L3, L4 and L5. The lumbar region supports the entire weight of your upper body (plus any extra weight that you are carrying). It is under constant pressure, particularly when you are bending, twisting and lifting. This is why most cases of back pain develop in the lower back.
Symptoms of back pain
The symptom of lower back pain is a pain or ache anywhere on your back, in between the bottom of the ribs and the top of the legs. The majority of cases of back pain usually clear up quite quickly.
However, if you experience back pain together with any of the following symptoms, visit your GP as soon as possible:
- a fever,
- weight loss,
- inflammation or swelling on the back,
- constant back pain that doesn’t ease after lying down or resting,
- pain that travels to the chest or pain high up in your back,
- pain down the legs and below the knees,
- a recent trauma or injury to your back,
- loss of bladder control,
- inability to pass urine,
- loss of bowel control, or
- numbness around the genitals, buttocks or anus.
You should also seek medical advice if you’re experiencing back pain and:
- you’re under 20 years old or over 55 years,
- you have taken steroids for a few months,
- you are a drug abuser,
- you have or have had cancer, or
- you have a low immune system due to chemotherapy or another medical condition (for example, HIV/AIDS).
Ask your GP for advice if your back pain has developed gradually and has got increasingly worse over several days or weeks.
Worrying unduly about your back can make the pain worse. Feeling tense can cause muscle spasms and increase the pain signals that are getting to your brain. Feeling worried about how serious a painful back is, when it’s going to get better and whether it’s going to hurt when you move, can be an additional stress.
Causes of back pain
Most cases of lower back pain are known as ‘non-specific’ because they are not caused by serious damage or disease, but by sprains, muscle strains, minor injuries or a pinched or irritated nerve.
Back pain can also be triggered by everyday activities at home or work, and by poor posture. For example, back pain may be triggered by:
- bending awkwardly,
- lifting, carrying, pushing or pulling incorrectly,
- slouching in chairs,
- standing or bending down for long periods,
- muscle tension,
- driving in hunched positions, or
- driving for long periods without taking a break.
Sometimes, you may wake up with back pain and have no idea what has caused it.
Some common causes of back pain include:
- gynaecological problems in women, such as pelvic inflammatory disease (PID),
- different types of arthritis, such as osteoarthritis,
- stress-related tension,
- viral infections,
- bone disorders,
- bladder and kidney infections,
- osteoporosis (weak and brittle bones),
- a trip or fall,
- a trauma or injury, such as a fracture,
- lack of exercise,
- obesity, and
- sleep disorders.
The bulging or rupture of one or more of the intervertebral discs can sometimes cause serious back pain. This results in the inner jelly-like material (nucleus pulposus) pressing on the spinal cord or nerve roots, which run next to the disc. This is commonly known as a ‘slipped disc’, but is more accurately described as a ‘prolapsed’ (bulging) or ‘herniated’ (ruptured) disc.
The pain will usually be in your lower back, but you may also experience pain in you buttocks, thigh, calves, feet and toes, due to irritation of the sciatic nerve, which runs down both legs. Occasionally, the pain is also accompanied by pins and needles, numbness and weakness.
Intervertebral discs tend to dry out and weaken with age, or following an injury. This results in the discs becoming less flexible, which means they do not cushion the vertebrae as well as they did before. This is a common cause of stiffness and pain, particularly in the elderly. It also tends to be worse early in the morning.
Persistent lower back pain can also be caused by a number of rare conditions, such as:
- congenital (inherited) spinal defects,
- bone diseases,
- shingles (an infection that affects the nerves),
- fibromyalgia, or
- cancer that has spread to the spine.
If you are look after someone who is ill or disabled, you are more likely to have back pain. Around half of all carers have backache, according to a survey by the charity Carers UK.
Diagnosing back pain
Your GP will be able to diagnose back pain by discussing your symptoms with you and conducting a physical examination.
Usually, there is no need for tests, such as X-rays or scans, when diagnosing back pain. If you have simple back pain, tests are not always helpful because they often do not show anything unusual.
You may be sent for tests if you have had an injury or blow to your back, if your GP suspects that there may be an underlying cause for your pain, or if the pain has lasted for an unusually long time.
For suspected disc problems, X-rays or a computerised tomography scan (CT scan) may be required. Your GP may suggest having a magnetic resonance imaging (MRI) scan, that uses a strong magnetic field and radio waves to produce detailed images of the inside of your body, in order to provide more accurate information about the soft tissues in your back.
In some cases, blood tests or a myelogram (a special kind of X-ray using an injected dye) may be needed.
Do I need a chiropractor, osteopath or physiotherapist?
Chiropractic treatment tends to involve a more ‘direct’ approach, with an emphasis on adjustments of the spinal joints. Chiropractors also rely on X-rays, blood and urine tests and MRI scans for diagnosis.
The osteopathic approach involves mobilisation (slow, rhythmic stretching), pressure or ‘indirect’ techniques and manipulations on the muscles and joints.
Physiotherapists are trained to diagnose problems in the joints and soft tissues of the body. Physiotherapy for back pain provides a wide range of treatments to relieve pain, promote relaxation and restore movement. They include manipulation, mobilisation and massage. Exercise may also be used to increase general fitness or to strengthen muscles that support the spine.
Treating back pain
Acute back pain
Most cases of acute back pain can be treated by using a combination of medication and self-care techniques. These are discussed below.
The painkiller paracetamol is usually recommended as the first treatment to try for acute backache.
If paracetamol does not control your pain, non-steroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, can be used instead.
Common side effects of NSAIDs include:
- stomach ulcer (a sore in the lining of the stomach)
In some people, particularly those who are 45 years or older, NSAIDs have been known to cause bleeding inside the stomach.
If you are thought to have an increased risk of stomach bleeding, your GP may also prescribe an additional medication known as a proton pump inhibitor (PPI), which is designed to protect your stomach from the adverse effects of NSAIDs.
PPIs help to prevent stomach ulcers and internal bleeding by reducing the production of stomach acid. See Stomach ulcer – treatment for more information about PPIs.
Alternatively, you may be given a special type of NSAID known as a COX-2 inhibitor. It is specifically designed to have a less harmful effect on the stomach.
Common side effects of COX-2 inhibitors include:
COX-2 inhibitors are not suitable for pregnant women or those with a history of heart problems.
If a stronger painkiller is required then a mild opiate-based painkiller, such as codeine or tramadol, can be used. Common side effects of these types of painkillers include:
- dry mouth
If you have dizziness or drowsiness, do not drive or operate complex or heavy machinery.
Also remember that even mild opiates like Tramadol can be addictive, and that taking too much of it might necessitate entry into an inpatient tramadol rehab program later on.
Stronger opiates, such as morphine, are usually required only in the most severe cases of acute back pain. Due to their potential for addiction, they are only prescribed for the shortest time possible.
Common side effects of morphine include:
Due to these side effects, you may also be prescribed additional anti-emetics (medicine used to treat nausea and vomiting) and laxatives (used to treat constipation).
If you are also experiencing symptoms of muscle spasms, you may be prescribed a short course of a muscle relaxant, such as diazepam. Common side effects of diazepam include:
- loss of co-ordination
Do not drive or operate complex or heavy machinery when taking diazepam. Long-term use (more than five days) of muscle relaxants, such as diazepam, is not recommended because they can be addictive.
While acute back pain can be frustrating to live with, try to remain as positive as possible. There is a lot of research to suggest that people with a positive mental attitude tend to have quicker recovery times and are much less likely to progress from acute to chronic back pain.
If you have acute back pain, it is important to remain as active as possible. If you find it too painful to return to your normal daily activities immediately, pace yourself by carrying out your daily activities at a reduced level or a slower rate. Aim to do a little more each day.
There is also no need to wait until you are completely pain-free before returning to work. Going back to work will help you to return to a normal pattern of activity, and it can often distract you from your symptoms of pain.
Many people with back pain find that using either hot or cold compression packs helps to reduce pain. You can make your own cold compression pack by wrapping a bag of frozen food in a towel. Hot compression packs are often available from larger pharmacies. You may find it useful to use one type of pack after the other.
Placing a small firm cushion beneath your knees when you are sleeping on your side, or using several firm pillows to prop up your knees when lying on your back, may help to ease your symptoms.
Chronic back pain
Your treatment plan
In 2009, the National Institute for Health and Clinical Excellence (NICE) issued guidelines about what treatments should be provided to people with chronic back pain. However, a number of back pain experts do not agree with NICE’s recommendations
NICE recommended that chronic back pain should be treated using painkilling medication and one of the following treatment options:
- acupuncture – fine needles are inserted into your skin at certain points on the body
- exercise classes – aerobic exercise, muscle strengthening and stretching
- manual therapy – your back is massaged or manipulated
If the treatments listed above prove to be ineffective, you may be referred for a combined programme of exercise and psychological treatment.
There is also a type of surgery called spinal fusion. However, it is usually regarded as a ‘treatment of last resort’ for people who fail to respond to treatment and who feel that chronic pain is making their life intolerable.
The various treatment options are discussed in more detail below.
As with acute back pain, a step-wise approach to pain management is recommended for chronic back pain. You will first be given a mild painkiller and only ‘step up’ to a stronger painkiller if it proves to be ineffective.
The usual steps are:
- NSAID or COX-2 inhibitors, possibly in combination with paracetamol
- mild opiate-based painkillers, such as codeine or tramadol
If you need to take NSAIDs on a long-term basis, you will probably also be prescribed a proton pump inhibitor (PPI) to protect against stomach bleeding.
If painkillers are not effective, you will probably be prescribed an additional medication called tricyclic antidepressants (TCAs). TCAs were originally designed to treat depression, but they have subsequently proved to be effective at treating some cases of chronic pain.
Amitriptyline is a widely used TCA that is used to treat chronic back pain. You will usually be prescribed the lowest possible dose to control your symptoms. If the medication is ineffective, your dose can be gradually increased. This approach will help to lower the risk of side effects.
Common side effects of amitriptyline include:
- dry mouth
- problems passing urine
- slight blurring of vision
If you experience drowsiness or blurred vision, avoid driving or operating heavy machinery.
The side effects should ease after seven to 10 days as your body gets used to the medication. However, tell your GP if the side effects continue or become troublesome. It may be possible for you to switch to a different TCA that will suit you better.
There have been reports of people suddenly having suicidal thoughts when taking amitriptyline. If this happens to you, contact your GP or go to your nearest hospital immediately.
It may be helpful to tell a close friend or relative that you are taking amitriptyline and ask them to let you know if they notice any changes in your behaviour or they are worried about the way you are acting.
Avoid drinking alcohol while you are taking amitriptyline as the combined effects can make you feel very drowsy.
Acupuncture is a form of ancient Chinese medicine where fine needles are inserted into your skin at certain points on your body.
Acupuncture is based on the belief that an energy or ‘life force’ flows through the body in channels called meridians. This life force is known as Qi (pronounced ‘chee’). ‘Blockages’ in Qi can result in illness and pain. Placing needles at certain points around your body is thought to ‘unblock’ Qi and help relieve symptoms such as back pain.
However, many experts believe that the beneficial effects of acupuncture on chronic back pain (for which there is a reasonably good body of evidence) are actually due to the needles stimulating nerves and muscles while encouraging your body to release naturally occurring painkillers, called endorphins.
This view is backed up by a number of studies, which found that sticking needles in random locations around the body (sham acupuncture), rather than following the principles of traditional acupuncture, still had beneficial effects.
Ten sessions of acupuncture is recommended over a 12-week period. Side effects are usually mild and occur in about one in 10 cases. They include:
- pain where the needles puncture the skin
- bleeding or bruising where the needles puncture the skin
- worsening of pre-existing symptoms
Some primary care trusts offer acupuncture on the NHS, but provision can be sometimes patchy. Therefore, many people pay for private treatment. The cost of acupuncture varies widely between practitioners. Initial sessions usually cost between £35 and £60. Further sessions cost £25-50.
When choosing an acupuncturist (someone who practises acupuncture), make sure that they are registered with a recognised and reputable acupuncture organisation, such as the British Acupuncture Council or The British Medical Acupuncture Society.
If exercise classes are recommended to help treat your back pain, you will be offered eight sessions over a 12-week period. The classes usually take the form of group exercises, i.e. around 10 people under the supervision of a qualified exercise instructor.
You will take part in a range of exercises that are designed to strengthen your muscles and improve your posture. The exercises may include:
- aerobic activity – exercises designed to strengthen your heart and lower your blood pressure, such as jogging or swimming
- muscle strengthening
There are three main types of manual therapy:
- spinal mobilisation – force is applied to move one or more of your spinal joints within its normal range of position
- spinal manipulation – force is applied to move one or more of your spinal joints out of its normal range of position
- massage – the muscles around your spine are manipulated
Three main methods of treatment involve the use of manual therapy. These are:
- physiotherapy – a treatment designed to restore movement and function after injury or illness
- osteopathy – a treatment that focuses on detecting and treating problems with the muscles, nerves and joints
- chiropractic – similar to osteopathy; focuses on disorders of the bones, muscles and joints
Both osteopathy and chiropractic are complementary or alternative medicines (CAM). CAM differs in important ways from conventional western medicines. Unlike conventional treatments, CAMs are not always based on scientific evidence.
However, it should be stressed that there is evidence that both osteopathy and chiropractic can be effective in treating some cases of back pain.
Physiotherapy is not a CAM because it is based on the principles of conventional western medicine.
If you decide to use manual therapy, eight sessions a week for 12 weeks will usually be recommended.
Combined therapy that includes exercise and psychological therapy may be recommended if:
- you fail to respond to one or more of the treatments discussed above
- back pain is causing you considerable distress and/or is seriously affecting your ability to work and carry out your daily activities
While back pain is mainly a physical condition, how you think and feel about your condition can have a significant impact on your symptoms and on your outlook.
Cognitive behavioural therapy (CBT) is a type of psychological therapy that is widely used for people with chronic back pain. It is based on the principle that the way you feel partly depends on the way that you think.
Studies have shown that people who train themselves to react differently to pain by using relaxation techniques and maintaining a positive attitude reported lower levels of pain. They were also more likely to remain active and take regular exercise, further reducing the severity of their symptoms.
Spinal fusion surgery
Spinal fusion surgery is usually only recommended as a possible treatment option in a small number of cases where:
- you have already tried combination therapy
- your back pain is persistent and severe
- you are willing to accept the potential risks of complications and side effects associated with spinal fusion surgery (see below)
If you are thought to be a potential candidate for spinal fusion surgery, you will be referred for a MRI scan to see whether you will benefit from treatment.
Spinal fusion surgery is usually only recommended when your back pain is associated with:
- progressive damage and ‘wear and tear’ to the discs inside your spine (known as degenerative disc disease)
- narrowing of your spine that places pressure on your spinal cord (known as spinal stenosis)
- tumours (cancerous growths)
The aim of spinal fusion surgery is to improve the stability of your spine. During the procedure, two or more damaged vertebrae are fused into a single bone.
Bone is a living tissue, which makes it possible to join two or more vertebrae together by placing an additional section of bone in the space between the vertebrae. This will help prevent the damaged vertebrae from irritating or compressing nearby nerves, muscles and ligaments, and reduce the symptoms of pain.
However, spinal fusion surgery is not a ‘magic cure’ or a substitute for having a healthy, functioning spine. And, despite the best efforts of your surgical team, you may still experience some degree of pain and loss of movement after surgery.
There are two ways that a bone graft can fuse the vertebrae together:
- bone autograft – a section of bone is taken from your hip and used to graft the vertebrae
- bone allograft – a section of bone is taken from a donor who is usually deceased
There are also a number of artificial materials that can be used to graft bone. These include:
- demineralised bone matrices (DBMs) – a type of sticky, putty-like material obtained from the calcium of bones provided by a donor
- bone morphogenetic proteins (BMPs) – genetically engineered substances that stimulate new bone growth
The two most common complications of spinal fusion surgery are:
- failure to achieve a significant reduction in the symptoms of pain; this occurs in around one in five cases
- the vertebrae fail to fuse together; this occurs in an estimated 5-10% of cases
Less common complications of spinal fusion surgery include:
- infection – occurs in an estimated one in 50 cases
- blood clots – occur in an estimated one in 100 cases
- retrograde ejaculation – sperm travels backwards into the bladder when you ejaculate rather than out of your penis; this is a result of nerve damage and occurs in an estimated one in 100 cases
More serious nerve damage can result in the loss of bladder or bowel function, and cause urinary and bowel incontinence. But this type of complication is very rare.
A number of treatments are sometimes used to treat chronic back pain, but they are not recommended by NICE due to a lack of evidence about their effectiveness. They include:
- low level laser therapy – low energy lasers are focused on your back to try to reduce inflammation and encourage tissue repair
- interferential therapy (IFT) – a device is used to pass an electrical current through your back to try to accelerate healing while stimulating the production of endorphins (the body’s natural painkillers)
- therapeutic ultrasound – ultrasound waves are directed at your back to accelerate healing and encourage tissue repair
transcutaneous electrical nerve stimulation (TENS) – a machine delivers small electrical pulses to the back via electrodes that are placed on the skin; the pulses stimulate endorphin production and prevent pain signals travelling from your spine to your brain
- lumbar supports – cushions, pillows and braces are used to support your spine
- traction – a pulling force is applied to your spine
- injections – painkilling medication is injected directly into your back
Preventing back pain
To avoid back pain, you must reduce excess stresses and strains on your back and ensure that your back is strong and supple.
If you have persistent, recurring bouts of back pain, the following advice may be useful:
- Lose any excess weight
- Practise the Alexander technique.
- Wear flat shoes with cushioned soles, as these can reduce the stress on your back.
- Avoid sudden movements or muscle strain.
- Try and reduce any stress, anxiety and tension.
How you sit, stand and lie down can have an important effect on your back. The following tips should help you maintain a good posture:
- Standing – you should stand upright, with your head facing forward and your back straight. Balance your weight evenly on both feet and keep your legs straight.
- Sitting – you should be able sit upright with support in the small of your back. Your knees and hips should be level and your feet should be flat on the floor (use a footstool if necessary). Some people find it useful to use a small cushion or rolled-up towel to support the small of the back. If you use a keyboard, make sure your forearms are horizontal and your elbows are at right angles.
- Driving – make sure your lower back is properly supported. Correctly positioning your wing mirrors will prevent you from having to twist around. Foot controls should be squarely in front of your feet. If driving long distances, take regular breaks so you can stretch your legs.
- Sleeping – your mattress should be firm enough to support your body while supporting the weight of your shoulders and buttocks, keeping your spine straight. If your mattress is too soft, place a firm board – ideally 2cm thick – on top of the base of your bed and under the mattress. Support your head with a pillow, but make sure your neck isn’t forced up at a steep angle.
Exercise is both an excellent way of preventing back pain and reducing any back pain you might have. However, if you have chronic back pain (back pain that has lasted more than three months), you should consult your GP before starting any exercise programme.
Exercises like walking or swimming strengthen the muscles that support your back without putting any strain on it, or subjecting it to a sudden jolt.
Activities like yoga or pilates can help improve the flexibility and the strength of your back muscles. It is important that you carry out these activities under the guidance of a properly qualified instructor.
There are also a number of simple exercises you can do in your own home to help prevent or relieve back pain:
- Wall slides – stand with your back against a wall with your feet shoulder-width apart. Slide down into a crouch so your knees are bent to about 90 degrees. Count to five and then slide back up the wall. Repeat five times.
- Leg raises – lie flat on your back on the floor. Lift each heel in turn just off the floor while keeping your legs straight. Repeat five times.
- Bottom lifts – lie flat on your back on the floor. Bend your knees so your feet are flat on the floor. Then lift your bottom in the air by tightening your stomach muscles while keeping your back straight. Repeat five times.
At first you should do these exercises once or twice a day, and then gradually increase to doing them six times a day, as your back allows.
These exercises are also useful for ‘warming up’ your back. Many people injure their back when doing everyday chores at home or work, such as lifting, gardening or using a vacuum cleaner. ‘Warming up’ your back before you start these chores can help prevent injury.
Lifting and handling
One of the biggest causes of back injury, especially at work, is lifting or handling objects incorrectly. Learning and following the correct method for lifting and handling objects can help prevent back pain.
- Think before you lift – can you manage the lift? Are there any handling aids you can use? Where is the load going?
- Start in a good position – your feet should be apart with one leg slightly forward to maintain balance. When lifting, let your legs take the strain – bend your back, knees and hips slightly but don’t stoop or squat. Tighten your stomach muscles to pull your pelvis in. Don’t straighten your legs before lifting as you may strain your back on the way up.
- Keep the load close to your waist – keep the load as close to your body for as long as possible with the heaviest end nearest to you.
- Avoid twisting your back or leaning sideways – especially when your back is bent. Your shoulders should be level and facing in the same direction as your hips. Turning by moving your feet is better than lifting and twisting at the same time.
- Keep your head up – once your have the load secure, look ahead, not down at the load.
- Know your limits – there is a big difference between what you can lift and what you can safely lift. If in doubt, get help.
- Push, don’t pull – if you have to move a heavy object across the floor, it is better to push it rather than pull it.
- Distribute the weight evenly – if you are carrying shopping bags or luggage, try to distribute the weight evenly on both sides of your body.