Pain in the back
The article below appeared in the April 26 issue of Health with Perdana, a regular column in The Star by Perdana University faculty members. This week’s article is contributed by Assoc. Prof. Dr. Neelakanta Reddy, Associate Professor in Orthopaedics, Perdana University Graduate School of Medicine.
Lower back pain is one of the most common types of pain worldwide, but there are ways to prevent it.
Back pain is very common. It is the single biggest reason for absence of work, discomfort and disability. Its incidence is increasing due to prevailing sedentary lifestyle and bad postural habits. Globally low back pain disability has increased by 54% in the past 30 years. At some point during their lives 80% of adults will have lower back pain. With age, natural aging changes occur in the spine. As a result, chances of developing low back pain increases as people get older. Its peak incidence is in the middle age. More common in women than in men.
Low back pain can occur suddenly or gradually. It can be dull ache or sharp intense pain. Quite often pain radiates to the buttocks and legs on one side or both sides.
There may be no obvious cause for pain or there can be a serious underlying medical condition. Majority of cases it is due to minor trauma, strains or abuse.
Sources of pain
Strain and Sprains are overstretching or minor tears in the soft tissues in the spine like muscles, tendons and ligaments. It can occur due to overuse, unaccustomed work, lifting of heavy weights, lifting objects improperly, awkward twisting, bad postures at work and in leisure times and sports injuries. These pains will usually resolve in six weeks of natural period of healing. In some individual’s pain may persist for months or years and no specific cause can be found. They are labelled as nonspecific low back pain.
Disc degeneration is another important cause for low back pain. Disc is a soft rubbery cushioning structure in between the two vertebrae. It allows flexion and bending movement to the spine and hence subjected to wear and tear. Commonly affected discs are at the lower lumbar and lower cervical discs. Once the disc starts degenerating it loses its height leading to more biomechanical stresses on the soft tissues surrounding it, resulting in strain and minor tears in them. If it progresses may lead to prolapse of the disc material. When disc prolapse occurs it compresses the neurological structures and the patients will have associated neurological symptoms in the legs along with low back pain. Neurological symptoms may range from tingling, numbness, sciatic pain, weakness, paralysis, bladder and bowel dysfunction depending on the extent of neurological involvement. Further progression of disc degeneration leads to instability and osteoarthritis of facet joints of the spine which can be painful associated with stiffness.
Spondylo-arthritis is another cause for low back pain seen in patients who are diagnosed with Psoriasis, Ankylosing spondylitis, Lupus (SLE), Rheumatoid arthritis, and inflammatory bowel disorders. They are a group of systemic inflammatory disorders in which joints of spine are involved.
Osteoporosis also affects spine leading to thinning and weak vertebrae. These fragile vertebrae can collapse with trivial injury causing back pain.
Infections and tumours involving the spine are small percentage of illnesses causing back pain and they usually present with other associated symptoms related to the underlying cause apart from back pain. Even though they are less in number greater emphasis is required to diagnose them early and treat, to avoid serious permanent disabilities or even threat to life.
Sometimes low back pain can be due to conditions elsewhere that do not relate to the back, for example abdominal tumours, aortic aneurysms, kidney stones, or due to problems in the uterus or bladder.
Treating the pain
Around 85% of lower back pain is benign in nature. It is also sometimes not possible to detect the source of pain even with complex imaging techniques and advanced investigations. Research shows that about 40% disc degeneration detected via MRI (magnetic resonance imaging) do not present with any symptoms, not even lower back pain. Most of these low back pains resolve with nonsurgical treatments and by educating the patients to manage and keep the pain under control. According to the recent WHO bulletin there is worldwide prevalence of unnecessary care in the form of investigations and offer of surgical treatments for these non- specific low back pains. In future with advances in minimally invasive surgical procedures having robust evidences, we can look forward to mitigate these pains and discomforts through surgical means and improve the quality of life for the millions of people worldwide.
However, at present, surgical treatments are offered only in the following situations:
- Lower back pain that does not improve even after three months of non-surgical treatment.
- Increasing severity of pain and recurrent pain disturbing normal activities of daily living.
- Pain associated with symptoms of nerve compression, like sciatica, and numbness or weakness in the limbs.
- Pain associated with bladder and bowel dysfunction.
- Lower back pain associated with specific pathology like infection and tumours.
Apart from surgery some invasive procedures like facet joint injections or radiofrequency ablations are widely used to control pain. However, there is lack of supporting evidence for their use.
Best recommended approaches for non-surgical management of low back pain are:
1. Physical activity and regular routine
Those who have mild chronic symptoms need to be physically active and continue normal activities. To a certain degree patients need to be aware that it is a part of life and learn to manage stresses, coping techniques. Patient should understand the benign nature of it without any serious pathology and learn to self-manage.
2. Cognitive behavioural therapy
This will provide the patient with relaxation techniques and positive ways of thinking to help with their pain.
3. Regular exercise
Regular physical exercise will help build strength and maintain the tone of the back and abdominal muscles to help decrease the pain.
4. Limit pain medications
Painkillers can be prescribed for relief of inital acute pain and from any further episodes of acute pain. However, chronic pain care should be without medications. Opioid drugs are to be avoided in general.
5. Physical therapy
Certain physical therapy modalities like electrotherapy and hydrotherapy, can also help to relive the pain.
6. Complementary therapies
Such therapies that are evidence-based, can be useful to relieve the pain. It is important to seek for a well-qualified, registered therapist when considering complimentary treatments.
7. Quit smoking
This, along with a healthy life-style, will help reduce the pain.
8. A healthy diet
Adopting a healthy diet to help maintain or achieve good body weight and support a healthy lifestyle is essential.
9. Proper posture
Ensuring you have a proper posture while sitting, lying, working and carrying heavy objects or weights, will help prevent lower back pain to a large extent.
The following prevention tips are generalised. If you are worried about developing lower back pain, it is highly recommended to consult a physiotherapist or occupational therapist to get individualised advise, based on your body shape, and work habits.
While sleeping, the natural curves of the spine need to be supported and maintained. The mattress should be moderately firm and should not be too soft. Individuals can choose their own most comfortable position to sleep. For acute lower back pain caused by a prolapsed disc, sleeping on the back with a pillow under the knees, sleeping on the side with a pillow in between the knees, or a curled-up foetal position, is recommended.
Maintaining a proper posture while standing, sitting and driving is important to prevent back pain. Slouching should be avoided. An ergonomically optimised work space, as well as regular breaks from sitting are essential.
If possible, the lifting of heavy weights should be avoided. But if necessary, your back should be kept straight and your knees bent while lifting heavy objects.
Doing regular exercises to stretch and strengthen your back and abdominal muscles will help in preventing back pain. Do not that any new type of exercise should be done with caution and with the help of a trainer. There are various exercise regimes are available to help prevent or decrease lower back pain, but a physiotherapist or occupational therapist will be able to advice on a personalised exercise programme to improve posture, strength and movement.
In summary, the majority of lower back pains are due to natural aging changes in the spine, associated with poor postural and work habits. By maintaining proper body weight, staying active with regular exercises and paying attention to preventive measures, most chronic back pains and discomfort can be controlled and managed without the need for any major surgical procedures. However, a certain percentage of back pains do need active treatment, including surgeries, to address the causative factors. It is always advisable to seek for medical consultation to get a proper diagnosis early for this ailment.