Are you suffering from low back pain?

Low back pain is widespread and is the leading cause of years lived with disability in 126 countries and worldwide productivity loss.² Low back pain prevalence is around 1.4% and 20%, increasing significantly with age.¹ The economic burden has an annual expenditure estimated to exceed 100 billion dollars in the USA.³ There has been an increase in back pain reports and a global trend in sedentary behavior.

It is likely that you may have already had back pain or will have it at some point. In the United States in 2013, about 1 in 4 people visited their doctor for back pain. Usually, the acute back pain resolves over a few weeks with proper attention. A guiding principle is how we shape our perspective: we can view back pain as a limiting factor or as an opportunity to understand the body’s message about our posture (here is an article on posture), body habitus, muscle tone, and activity status.

Addressing the source is crucial and offers future benefits in preventing chronic pain. Reports of people who take pain medication like opiates for their back showed lower quality of life scores, more side effects, and more significant disability.

Types of low back pain

There are three major types of lower back pain. Nociceptive pain comes after a specific stimulus, such as a burn, trauma, or muscle sprain. Neuropathic, or radicular pain, is the pain that starts in the lower back and travels down the legs and often gives sensations of electricity, tingling, and numbness. Nociplastic or non-specific low back pain originates without a clear cause and may stem from the brain overamplifying certain stimuli.¹

Very often, these types of pain overlap with low back pain. Furthermore, biological, psychological, and social factors contribute to chronic low back pain. ⁴ The following are risk factors for progressing from acute to chronic low back pain.

• Genetics: Heritability contributes 26% to the prevalence of low back pain.
• Gender: Increased in females
• Lifestyle: Sedentary lifestyle, obesity, smoking
• Psychosocial: Poor social support, anxiety, depression
• Inadequate coping mechanisms: Fear-avoidance behavior
• Traumatic injuries
• Occupational hazards: construction work, other types of manual labor, poor job satisfaction, and hostile work environment.⁵

Causes of low back pain

The lumbar spine consists of muscles, fascia, ligaments, tendons, facet joints, neurovascular elements, vertebrae, and intervertebral discs; all these parts can suffer biochemical, degenerative, and traumatic stressors.⁶

Myofascial pain

Myofascial pain is the most common cause of back pain and overlaps with the other categories. The erector spinae muscles can atrophy and signal pain with increased myoelectric activity. It often manifests as non-specific low back pain resulting from overuse, acute stretch injuries or tears, and diffuse or localized muscle spasms. ^{10, 15-16}

Herniation and Spinal Stenosis

The two major causes of neuropathic pain are herniation of the nucleus pulposus and spinal stenosis, but having these conditions does not always lead to low back pain.

Herniation of the inner nucleus pulposus can lead to back pain. It may cause mechanical compression of nerves giving a dermatomal distribution (following a specific pain pattern). Spontaneous regression of herniation can occur in more than 90% of sequestered discs, 70% of herniated discs, and more than 40% of protruded discs.¹³

Spinal stenosis is a progressive anatomical condition that results from age-related degenerative changes. There is an increase in bony deposition and degenerative disc disease, which encroaches upon the spinal cord and can cause axonal or nerve root injury.¹⁴  A person with spinal stenosis may present with neurogenic claudication, a sensation of (usually) bilateral leg pain and weakness.

Disc degeneration

The intervertebral discs have an outer layer (annulus fibrosus) and an inner nucleus pulposus. They allow spinal movement and distribute and absorb forces. These may be damaged, and sensory nerves can penetrate the nucleus pulposus, leading to mechanical and chemical sensations during healing.⁷ An MRI study may detect a herniation, but it does not always mean that it is the cause of the pain or warrants surgery if present. For example, there are many asymptomatic patients with disc degeneration.⁸ 

Facet arthropathy

Facet joints connect adjacent vertebrae and limit spine movements. The joints can suffer osteoarthritis or other degenerative changes.⁹

People with this condition may present with pain after sitting upright, standing up, or getting up after sleep, rest, or inactivity.

Sacroiliac joint pain

Most pain occurs in the buttock, but two-thirds of individuals have lumbar pain. The pain can radiate down the leg, referred to as sciatica. It can be due to traumatic causes, especially in younger people, and degeneration of the joint in older people.^10-11 

Spondyloarthropathies

Spondyloarthropathies are a group of inflammatory and rheumatic diseases (ankylosing spondylitis, psoriatic arthritis, rheumatoid arthritis). They are systemic entities and affect multiple joints, especially the low back. Other symptoms may be present such as enthesis and auto-fusion of the vertebrae.¹² 

Why is it essential to identify the cause of back pain and listen for red flags?

As said before, most episodes of lower back pain resolve. Also, the most common causes of chronic low back pain are postural and positional behavior-related. Multiple social and psychological factors intensify it. A physician measures the history and physical with the potential considerations, listening for potential red flags, and should not diminish a person’s concerns. Based on the initial work-up, the doctor will decide if additional studies are necessary, such as vascular studies (for differential diagnosis) and image studies.¹⁷ Diagnosing rare causes of low back pain due to severe pathology is crucial and requires a specific, professional, and unbiased approach.

Imaging studies are not routine. Most people have disc degeneration by the age of 40 years, but there is a high prevalence of abnormalities in images in asymptomatic people, so there is a poor correlation between symptoms and pathology found in the image.¹⁸

Several red flags in lower back pain prompt the need for imaging studies. These include severe or progressive neurological deficits in acute lower back pain. For chronic low back pain, imaging studies assist in the referral process and in clarifying the diagnosis and treatment in patients with specific risk factors or alerts in their history.

Non-pharmacological treatment of Low Back Pain

The medical, surgical, and pain management approaches to low back pain are beyond the scope of this article. The literature repeatedly supports the use of some medications, such as NSAIDs and newer antidepressants (duloxetine), in treating chronic back pain. As for opioids, a study of 202 patients with chronic low back pain demonstrated that pain relief was no better than nonsteroidal medications (PRECISION Pain Research Registry). Furthermore, back surgery may be necessary when there is a rapid loss of function or other neurosurgical emergencies.

Pain is not only a nervous nociception but also context-dependent emotional, cognitive, and behavioral elements. ²⁰ That is why there is a poor correlation between patients’ symptoms and the pathology and why interventions such as psychological therapies or acupuncture positively affect pain and quality of life.²¹ Also, there has been proof that psychologically traumatic events could precipitate or reinforce low back pain.²² Chronic pain is also related to brain structural reorganization seen on MRIs, which reverse with treatment.²³ Here is a Your Health Forum on the non-pharmacologic management of chronic pain.

Most pain management options address where the pain may be emanating as a single cause, but chronic low back, with its multifactorial background, needs a multimodal and interdisciplinary approach. The first-line treatments for low back pain are exercise and self-guided physical therapy.

Movement exercises

When we talk about an ounce of prevention being better than a pound of cure, exercise is an effective primary prevention strategy for low back pain.²⁹  I find it useful to coach patients about the bias we have in detecting pain and challenges sometimes to appreciate a benefit in something that reduces it. Another bias is how we place a greater value on prescriptions than a thorough exam and recommendation for stretching.

With a back pain flair-up, there is a risk of changing behaviors to avoid pain, such as reducing activity. People who suffer from chronic pain may develop a fear of movement or Kinesiophobia. The general recommendation is to face acute pain by stretching it out as tolerated. Eleven out of twelve guidelines recommend against bed rest for acute low back pain, promoting normal activities in acute low back pain.²⁴

Physical exercises are designed to stretch and strengthen muscles, alleviate pain, and improve spinal posture. There was a positive effect of controlled movement exercises on disability immediately after treatment and after 12 months.

Massage and Manual Medicine

Manual therapy to reduce muscle spasms and increase joint mobility. There is an immediate benefit for non-specific low back pain versus no treatment or bed rest. The most beneficial use of massage is when it supplements exercise and education

Superficial Heat and Cold

increases cutaneous blood flow and causes a cooling reaction; can be done with moist hot packs, fluid therapy, or paraffin. It may relieve muscle spasms, joint contractures, and decreased range of motion for short-term (4 days) pain reduction. It may provide additional benefits to exercise and therapy. There is insufficient evidence for chronic low back pain.

Psychological therapies (Cognitive Behavioral Therapy and operant therapy)

Therapy and counseling help manage pain by modifying maladaptive beliefs and behaviors through education and methods to manage symptoms. Operant therapy involves learning through positive reinforcement of health-promoting behaviors. These methods show superior short-term post-treatment pain improvement, but there is no therapeutic difference at six months

Yoga

Physical, mental, and spiritual exercises that improve bodily posture and emotional and physical well-being. Yoga is superior to non-yoga exercise for pain and function in chronic low back pain (more than 12 weeks)

Tai chi

The ancient Chinese martial art of Tai chi is a graceful series of slow and focused movements accompanied by deep breathing. Alone or add-on therapy can improve pain and function.

Acupuncture

Acupuncture employs manual needle insertion into points of different anatomical plains to reduce pain. Evidence from randomized controlled trials calls to question the benefit. However, there are inherent difficulties in testing the benefit of a procedure through trials. Acupuncture, in addition to medication, is more effective for pain relief and function versus medication alone.^25-28

Conclusions

The body is the manifestation of the brain state. Disease and dysfunction are a part of life and lifestyle. But the first thought when someone has back pain is not always self-exploration. Nevertheless, an experience of discomfort can be instructional to us, as it is useful to evaluate the habits, behaviors, and self-care practices that make up our lives. Rather than reaching for the pill bottle for lower back pain – or relying on them around the clock, we can start with stretching and other non-medication modalities.

The article was written by Daniela Dominguez and Christopher M. Cirino, DO MPH

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