Low back pain is one of the most common causes for doctor’s visits. It is estimated that four out of five adults will experience low back pain at some point in their lives.
Some factors that will increase your risk of low back pain include:
Age over 30. The older you are the more likely you are to experience low back pain.
Obesity. Increased weight puts more pressure on joints and intervertebral discs.
Weak core. The core muscles help support the low back. Weakness of the core muscles increases stress on the low back.
Occupation and lifestyle. Jobs that involve much heavy lifting and bending increase risk. Alternatively, sedentary jobs such as desk work can also increase risk.
Structural issues like scoliosis or osteoarthritis can increase risk.
Smoking increases risk of low back pain by increasing inflammation which can hinder healing.
Mental health issues like depression and anxiety increase because depression lowers pain tolerance.
Low back pain can manifest itself in many ways. It can be mild with stiffness with position changes and just requiring movement for relief. It can cause pain with loss of movement in certain planes, or it can have severe muscle spasm causing total loss of function. If there is nerve entrapment, one can experience numbness, pain or weakness down one’s legs. In severe causes there may be loss of bowel or bladder control, which is a medical emergency.
There are many causes of low back pain. Over 90% of low back pain is due to strain or sprain, which has a very good prognosis. It does not take a lot to cause back strain. In my practice I see more patients with back strain from picking up something on the floor than from picking up something heavy. Chronic poor posture and poor bending and lifting techniques causes chronic strain on the low back such that at some point one more effort will throw the low back out, literally the straw that breaks the camel’s back.
Accidents can certainly lead to low back pain, either muscular due to strain/sprain or skeletal due to a fracture or disc injury. In elderly patients, osteoporotic fractures can occur with little to no trauma due to thinning of bones due to calcium loss.
Arthritis is a common cause of low back pain. Osteoarthritis, or degenerative joint disease is the most common form of arthritis. A rare form of back pain and stiffness is due to ankylosing spondylitis. This is very rare. I have seen about a half dozen patients in my career with ankylosing spondylitis.
Degenerative disc disease is another cause of back pain. The intervertebral disc can cause sciatic pain if the disc causes compression on a nerve root. It is a rare cause of pure back pain, however since the discs do not have any nerve endings. Many studies have shown that most people who have only degenerative discs with no nerve compression have no back pain or other symptoms.
Spondylolisthesis is a condition in which one vertebra slips forward onto the vertebra below it. This can cause chronic back issues.
Other diseases that can cause back pain are bone tumors or cancer that has spread to bones. A dissecting aortic aneurysm can cause sudden severe back pain and is a surgical emergency. Kidney stones can also cause back pain which is usually very severe and of sudden onset with no trauma. A rare cause of acute low back pain in younger people is spondylolysis, which is a stress fracture of part of the back. This can occur in gymnasts or lineman in football and is caused from extreme hyperextension of the back such as occurs with back bends or blocking someone coming at you at full speed.
If you were to develop low back pain, when should you go to see your doctor? First, remember that the vast majority of low back pain is self-limiting and will get better on its own. If it is mild to moderate pain and does not get better with one weeks’ worth of conservative treatment, I would recommend seeing your primary care doctor. Your primary internist or family physician is the best place to start with this because they know you and your history best.
If you have numbness, tingling, pain or weakness down your buttocks or legs I would recommend seeing your physician as this could be a sign of a pinched nerve. If you lose control of your bowel or bladder it is urgent that you see a physician as soon as possible because if this is not taken care of sooner rather than later permanent loss of function could result.
If you develop severe pain such that you cannot function or do your normal activities it is best to see your doctor.
If you develop fever, have weight loss, have blood in your urine or any other bladder issues or if you have a history of cancer you should go to your physician for an evaluation on the cause of your pain.
Just remember that under 1% of back pain is very serious, meaning infection or cancer. Under 10% is in the serious but less type, such as compression fractures, spinal stenosis or a pinched nerve. About 90% is in the not serious, usually self-limited type of back pain.
So now you are at your doctor’s office. What should you expect? Your doctor should take a good history of the back pain, when it started, how it started, how severe the pain is, where is it located, does it radiate anywhere, are there any other symptoms, does anything make it better or worse, what have you tried for the pain.
After that he or she should examine you. They should look at where the pain is, look at your range of motion, see if they can reproduce the pain. They may check your reflexes if you have pain going down your leg. Depending on your history they may evaluate your abdomen also.
Most cases of back pain do not require lab tests. They may obtain them if they are suspicious for other causes such as kidney stones. Likewise, most cases of low back pain DO NOT require X-rays, CT imaging or MRIs, especially initially.
Unless there are things of concern in your history or physical, your doctor will most likely prescribe conservative therapy for your back pain. Relative rest and mild alterations of your activity level, heat, and Tylenol are sufficient for most. The Tylenol should be taken in a sufficient dose, such as two regular or extra strength tablets four times daily. Often when patients tell me Tylenol does not work, I ask them how much they are taking, and they respond one or two a day. That is not a sufficient dose to give adequate pain relief.
Bed rest is not recommended for treatment of low back pain. It will cause weakening of the muscles that support the back and long term will make the pain worse.
For most cases of acute low back pain physical therapy is not recommended. Most patients get better without it, and PT does not appear to hasten recovery. Massage, acupuncture or chiropractic or osteopathic manipulation all have been shown to help somewhat.
For more severe pain, short term non-steroidal anti-inflammatory agents and muscle relaxers can help give relief. Studies showing improvement with opioids are non-conclusive, especially considering the potential side effects and drug interactions associated with them. If given, they should only be given for a very short term (3-5 days) and use for chronic back pain is strongly discouraged and if done needs to be strongly monitored.
If there is no improvement in four weeks’ time, re-evaluation is recommended.
If you present with low back pain and sciatica an X-ray and MRI is still not recommended initially. Most patients (over 90%) will get better with physical therapy and non-steroidal anti-inflammatory agents. If after 4 weeks of the above treatment there is not resolution, an MRI would be indicated along with consideration of more aggressive therapy such as epidural steroid injections (shots in your back) or surgery.
If you have low back pain due to arthritis or strain due to poor lifting or bending techniques, it is important to get education on the proper way to lift and bend. The first thing to remember is to not bend your back when bending over or lifting. Hinge at the hips and keep your back flat. Lift with your legs and not with your back. When lifting, keep the weight close to your body, and do not twist when lifting. If sitting at a desk for long periods of time, make sure you sit up straight, do not slump in a chair. Have your feet pointed forward and pretend you are screwing your heels into the ground. This causes your gluteus muscles to contract slightly engaging your pelvic muscles while sitting. In addition, slightly contract your abdominal muscles, as if someone was going to punch you in the stomach. You don’t have to contract hard, just a 2-3 on a scale of 10. This posture should help with the stiffness you feel when getting up after sitting for a while.
I am now going to discuss exercises to help with low back pain. Since the majority of back pain is due to mechanical issues, that is what I am going to concentrate on. Even if pain is due to osteoarthritis, exercise can help. It may be uncomfortable at first and may even make the back pain worse for a while, but over the long term, exercise will help low back pain. It may not relieve it 100%, but it will improve it.
First, realize that almost all exercise will help improve back pain, whether you decide to walk, jog, bike, do yoga, Pilates, calisthenics, swimming or weightlifting. Studies comparing different forms of exercise do not show much difference between exercises, but all showed improvement in pain scores and function. I would recommend taking in person classes or getting a trainer at least initially, to make sure your form is good. Poor form doing exercises can have deleterious effects on your back pain.
I am going to give you a series of exercises that I have found to be beneficial in treating and preventing chronic back pain. These exercises are good for people with back pain due to arthritis or chronic strain from poor lifting, bending or people with desk jobs who develop back pain. Not all of the exercises done for low back pain involve the back. Other muscles can affect the back. Tight hamstrings, tight hips and tight hip flexor muscles from sitting a lot can affect the back, as can having a weak core. These exercises should be done daily, even multiple times daily to help treat and prevent low back pain.
The first exercise can be done several ways. Sit on a sturdy chair or bench. Cross one foot over the other knee and hinge forward at the hip. Your back should not be bent but should be in a neutral position. The stretch should be felt in the hip , buttocks and low back on the side where the leg is crossed. Hold the stretch for 30 seconds. When you stretch, it should not be painful. Only stretch until you feel a mild stretch. As you breath, deepened the stretch as you exhale. Make sure you do both sides.
Alternatively, the exercise can be done lying on your back. With your feet on the floor, bend your knees and cross your right foot over your left leg. Reach through the opening to grab the back of your thigh or your shin and pull it towards your chest. Again, feel the stretch in your hip and buttocks. Hold it for 30 seconds and repeat on the other side.
The second stretch I like to call the couch stretch because it involves using a couch or chair. Kneel on one leg with the top of the foot on the top of a couch or chair. The other leg is in front of you. Now lean back. The stretch should be felt in the groin area. This is the hip flexor muscle which can tighten up if you sit a lot during the day. Tightness of the hip flexors Is a common cause of low back pain because the tightness alters your posture causing you to walk in a bent forward position. Again, do both sides and as you exhale gradually deepen the stretch over 30 seconds.
The next exercise is called cat/cow. You start off on your hands and knees. As the name suggest, you imitate the form of a cat by rounding your back when you exhale, and a cow by hyperextending your back when you inhale. Do this for 5-10 breaths.
Next is child’s pose. To start Childs pose get on your hands and knees, lean back onto your heels and hinge forward. You want to actively reach forward with your hands. You should feel a gentle stretch throughout your back. Next reach to your right side. You should feel a stretch from your elbows to your ribs on your left side. Now reach to your left side for a stretch on your right.
Bird dog is next. Again, start on all fours. Raise your left arm and your right leg, looking like a bird dog pointing. Hold for a few seconds and alternate the right arm and left leg. Do 10 repetitions on each side.
Now move into down dog, so named because of the way dogs stretch. Start off in a push-up position with your feet together hands at shoulder height just wider than your shoulders. Now push back with your hands and raise your hips up high. Keep your hands and arms strong, try to keep your heels as close to the ground as possible. You should feel a stretch from your shoulders, down your back, hamstrings and to your calf’s.
Next transition to up dog. Keep your hands and feet in the same positions, but rest on the top of your feet. Push your chest up with your arms and arch your back. If you can, lift your thighs off the ground so the only points of contact with the ground are your hands and the tops of your feet. Continue with slow deep breaths and hold for 30 seconds. Now alternate between up dog and down dog with a slow smooth motion
The next move is called Superman because you are in a posture like Superman flying. Lie down on your stomach and raise your chest and legs off the floor so the only point of contact with the floor is your stomach. You can either hold this position for 30 seconds or hold for 5 seconds, relax and do 10 repetitions.
Next get into the plank position. Lie on your stomach and raise yourself onto your forearms The only point of contact with the floor are your forearms and your feet. Tighten your abdominal muscles like someone is going to punch you. Also tighten your glutes (butt cheek muscles) and your quadriceps. (the muscles in front of your legs). Your body should be straight and rigid as a plank. Try to hold this position for 30-60 seconds.
Now do a side twist. You can sit in a chair or sit cross legged on the floor. Sit up straight and twist to your left. You can use the arm of the chair or push on your leg with the arm opposite the side you are twisting to help deepen the twist. Hold the twist for 30 seconds then do the other side.
Next is the forward fold. To do this hinge at the waist and reach as far as you can, stretching your hamstrings, the muscles in the back of your legs. You should also feel a mild stretch in your lower back. Do not bend your back. Your back should maintain a neutral position.
Lastly, bring your knees into your chest and give yourself a big hug for a job well done. For a video presentation of these exercises please check out my YouTube channel DocMike the exercise doc.