Back pain is a common condition and in the UK, it is the largest cause of work-related absence. Back pain can be very uncomfortable, but it is not usually serious.
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Back pain can affect anyone, regardless of age, but it is more common in people who are between 35 and 55 years of age.
In the majority of cases, the cause of back pain can be linked to the way that the bones, muscles and ligaments in the back work together.
The structure of the back
The back is a complex structure consisting 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 to connect muscles to vertebrae.
- A spinal cord, which carries nerve signals from the brain to the rest of the body.
The lower part of your back is known as the lumbar region, which is made up of five vertebrae, known as L1, L2, L3, L4 and L5. The lumbar supports the entire weight of your upper body (plus any extra weight that you are carrying), and it is under constant pressure, particularly when you are bending, twisting and lifting.
Lower back pain
Lower back pain, also known as lumbago, affects seven out of 10 people at some time in their lives. Lower back pain is a pain or ache on your back, in between the bottom of your ribs and the top of your legs.
Lower back pain can come on suddenly or gradually, and is sometimes the direct result of a fall or injury. The complex structure of your lower back means that even small amounts of damage to any part of the lumbar region can cause a lot of pain and discomfort.
Pain in your lower back is usually a symptom of stress or damage to your ligaments, muscles, tendons or discs. In some cases, if a nerve in your back is pinched or irritated, the pain can spread to your buttocks and thighs. This is known as sciatica (go to ‘Useful links’ for more information).
In most cases of back pain your back will heal itself, and staying active and continuing with your usual activities will normally promote healing. Back pain will usually last from a few days to a few weeks. Pain that lasts longer usually clears up after about six weeks.
However, in severe and persistent cases of back pain, it is important to seek medical advice so that a correct diagnosis can be reached and appropriate treatment given. Treatment for back pain will usually depend on the underlying cause of the condition. For example, pain that is caused by some types of arthritis may be treated using specific medicines.
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.
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.
Serious back pain
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.
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’ll only usually be sent for tests if your pain lasts for longer than six weeks, if you have had an injury or blow to your back, or if your GP suspects that there may be an underlying cause for your pain.
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.
A chiropractor, osteopath or physiotherapist?
Chiropractic and osteopathy are similar disciplines. Both osteopaths and chiropractors can diagnose by visual inspection and feeling by hand (palpation).
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
Advice from Pain Concern
Generally, back pain is categorised as:
- Acute - where your back pain occurs suddenly and lasts for less than three months, and
- Chronic - where your back pain develops gradually, over time, lasts for more than 12 weeks, and causes long-term problems.
However, most people with lower back pain experience mild pain and have occasional bouts of pain that are more severe. This can make it difficult to determine whether their back pain is acute or chronic.
Treating acute back pain
Most cases of acute back pain can be treated using self-help techniques. These are discussed below.
Over-the-counter (OTC) painkillers:
Paracetamol is usually recommended to treat acute lower back pain. If paracetamol proves ineffective, a non-steroidal anti-inflammatory drug (NSAID) such as ibuprofen may be used instead.
If your back pain symptoms are severe, your GP may prescribe a mild opiate-based painkiller, such as codeine, which can be taken in combination with paracetamol or a NSAID.
If your back pain symptoms are very severe, your GP may prescribe a muscle relaxant such as diazepam.
Diazepam can make you feel very sleepy, so do not drive if you have been prescribed this medication. After your course of diazepam has ended, you should wait at least 24 hours before driving. Diazepam will also make the effects of alcohol worse, so you should avoid alcohol while you are taking the medication.
Diazepam has the potential to be habit-forming, and can cause a number of unpleasant withdrawal symptoms when coming of the medication. To minimise these effects, your GP will not usually prescribe more than seven days worth of the medicine.
It’s important to remain as physically active as possible. While bed rest may provide some temporary relief from your symptoms, prolonged bed rest will make your symptoms worse.
Recommended exercises for back pain include walking and gentle stretching.
Your back pain may be so severe that you need to have some time off work. However, if this is the case, you should aim to return to work as soon as possible. While you may not feel any immediate benefit, research has shown the people who continue to work during an episode of back pain recover quicker than people who stay at home.
Many people with back pain find that using either hot or cold compression packs helps reduce pain. You can make you 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.
Treating chronic back pain
This will usually require a combination of self-help techniques and medical treatment. Treatment options are discussed below.
As with acute back pain, painkillers are usually the first method of treatment for chronic back pain. Initially, it is likely that paracetamol will be recommended, but if your back pain is severe, codeine may be prescribed.
Non-steroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, should only be used for long periods under the advice of your GP. If long-term treatment using NSAIDs is required, your GP may prescribe gastro-protective medicines, such as proton pump inhibitors (PPIs).
If your back pain is severe and does not improve with the use of painkillers, your GP may recommend a one-month trial of a medication called amitriptyline. Amitriptyline is usually used to treat depression, but it has also been found to be useful in treating nerve pain.
If you are prescribed a course of amitriptyline, you may experience some side effects including:
- dry mouth,
- blurred vision,
- constipation, and
- difficulty urinating.
You should not drive if you are taking amitriptyline and it is making you drowsy.
Amitriptyline should not be taken by people with a history of heart disease.
As with acute back pain, if you have chronic back pain, you should try to remain as physically active as possible because doing so will reduce the severity of your symptoms. It is also recommended that you continue working, or return to work as soon as possible.
Regular exercise will help to strengthen the muscles that support your back. Exercise also promotes the production of endorphins, which are natural painkilling chemicals. Ask your GP for advice about a suitable exercise plan for you.
Bending, twisting, or placing strain on your back can be painful. However, excessively protecting your back can delay return to normal activities. The trick is to be careful when making potentially painful movements, but to pace your return to full normal activity.
If you have chronic back pain, Your GP may refer you to a physiotherapist - a qualified specialist who will be able to help you to improve your range of movement.
A physiotherapist will be able to teach you exercises that strengthen the muscles that support your back, as well as improving the flexibility of your spine. They can also teach you how to improve your posture and reduce any future strain on your back.
Cognitive behavioural therapy (CBT):
Some studies have shown that a type of therapy called cognitive behavioural therapy (CBT) can help in the management of chronic back pain.
CBT is based on the principle that the way you feel is partly dependent on the way that you think about things. Studies have shown that people who train themselves to react differently to pain, by using relaxation techniques and maintaining a positive attitude, report that their levels of pain went down.
They were also more likely to remain active and take exercise, further reducing the severity of their symptoms.
Surgery may be an option to treat cases of chronic back pain when:
- there is an identifiable cause, such as a ruptured hernia,
- the symptoms have not responded to other forms of treatment, and
- the symptoms are getting progressively worse.
The type of surgery that will be recommended will depend on the cause of your back pain. Some surgical options are listed below.
- Discectomy - where the part of the herniated disc that is pressing on your nerve is removed.
- Fusion surgery - if a vertebra has slipped out of place, it may be possible to fuse it into place using metal rods.
- Injections - a variety of injections are available that a surgeon can make into your back in order to help relieve the pain.
As with all surgical procedures, spinal surgery carries some risks. For example, following surgery, there is a 10% chance of infection. If this occurs, further surgery may be required to clean out the infection, although some cases can be treated with antibiotics.
In the case of fusion surgery, there is a 1-2% chance of the vertebrae failing to fuse into place. If this occurs, further surgery will be required.
There is a very low risk that your spinal cord will be damaged during surgery. The chances of this happening are estimated to be six in 1,000 (0.6%). In the rare situation that the spinal cord is damaged during surgery, it could result in problems ranging from some muscle weakness to total paralysis. Your bladder and bowel control may also be affected.
Before having back surgery, your surgeon will be able to fully discuss the risks and benefits of the procedure with you.
Some people with back pain choose to use complementary therapies alongside more conventional treatments, while others choose to use them as stand-alone treatments
Complementary therapies such as chiropractic, osteopathy, shiatsu and acupuncture may help to ease your back pain, and encourage you to feel relaxed.
An osteopath is a health professional who specialises in treating the skeleton and muscles, and chiropractor treats joint, muscle and bone problems, focusing on the spine.
Shiatsu is a traditional Japanese technique that is often described as ‘finger pressure’ therapy. It is a form of massage that works by applying pressure to energy lines in your body. A shiatsu therapist will use their fingers, thumbs and elbows to carry out the treatment.
Acupuncture is a form of traditional Chinese medicine which involves the insertion of very fine needles at key points in the body. This can help encourage the body to release its natural form of painkillers, known as endorphins. It can also help to stimulate nerve and muscle tissue.
For many complementary therapies, clinical studies have not produced conclusive evidence as to their safety and effectiveness. Therefore, if you are considering using a complementary therapy, you should carefully weigh up any benefits and potential risks and discuss it with your GP if you are uncertain.
Transcutaneous electrical nerve stimulation (TENS):
The transcutaneous electrical nerve stimulation (TENS) machine is an increasingly popular treatment method for people with long-term back pain. The machine delivers small electric pulses to your body through electrodes that are placed on your skin.
It is thought that these pulses work in two ways. A low electric pulse can encourage your body to produce more endorphins - the body’s own painkilling chemical. A high electric pulse can also block pain signals going from your back to your brain.
Many medical studies have been carried out on the use of TENS but the results have been conflicting. Some studies suggest that the machines are of little use, while other studies suggest that they may be able to help certain people.
You should only use a TENS machine under the direction of your GP or other healthcare professional.
The following people should avoid using a TENS machine:
- pregnant women - unless specifically advised to by their doctor,
- people with epilepsy,
- people who have a pacemaker fitted, and
- people with a history of heart disease.
Managing your pain
Pain management programmes can help you to learn how to manage your pain, increase your activities and have a better quality of life. This is done with a combination of group therapy, exercises, relaxation and education about pain and the psychology of pain.
People with persistent pain may be able to attend a specialist pain clinic for assessment and possible pain management. You need to be referred to a pain clinic by your GP or consultant. For more information on pain clinics in your area, contact the British Pain Society.
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.
Preventing back pain in children
Back pain in secondary-school-age children has been linked to heavy schoolbags and ill-fitting classroom seating. Nearly half of all teenagers in the UK have experienced occasional backache from poor posture, carrying overloaded bags, and an unhealthy lifestyle.
The best schoolbag for your child is a well designed backpack. This should be worn over both shoulders to balance out the weight. A heavy satchel or shoulder bag can put stress on your child’s spine.
Encourage your child to exercise regularly, or plan joint activities, such as a walk in the countryside or a trip to a swimming pool.
CKS Guidelines (2008). Lower back pain and /or sciatica
Waddell, G. (2004) The back pain revolution. 2nd edn. London: Churchill
Back pain expert Philip Sell on the questions to ask
We asked Philip Sell, consultant orthopaedic and spinal surgeon, what he would want to know if he was suffering from back pain.
What is the cause of my back pain?
In 85% of cases, we’re unable to be precise about why people have back pain. This can be frustrating. It may be more helpful to think about what you can do to make your back better quicker. Research has shown that occupational factors or physical factors only play a small part in back pain. Your genes are probably the most significant factor in back pain.
When should I visit my GP with back pain?
See your GP as soon as possible if the back pain is combined with difficulty in passing urine or numbness between the legs or around the bottom. For people over the age of 55 with new back pain, a previous history of cancer surgery or loss of weight should also be medically checked as soon as possible.
Should I be resting?
You may feel it’s the wrong thing to do, but keep mobile and active. Resting, bed rest in particular, can prolong the duration of an episode of back pain. Most acute episodes of back pain will settle on their own, often within days rather than weeks. Taking pain relief and keeping active will stop stiffness setting in and keep muscles in good condition.
Are there any drugs to help me cope with the pain?
Constant pain can grind you down and make it more difficult to cope. Take a combination of painkillers and anti-inflammatories, such as paracetamol (1g) every six hours and ibuprofen (400mg) every eight hours. Short courses of this type of tablet are very safe, which is why they’re available over the counter. Ask your pharmacist if it’s OK for you to take ibuprofen.
Should I be worried that my back pain will get worse as I get older?
No. Even the most serious cases of back pain usually improve with time. As people age, the discs in the back lose some of their water content and become stiffer and less likely to prolapse or have sciatica.
My friends and family have been giving me advice about how to handle my back pain. I’m confused. What should I do?
Back pain and sciatica are common conditions and everyone seems to have a story. Mixed messages about what to do or what not to do can be confusing and a bit worrying. Use reliable information sources and make sure you’re treated early.
‘I’ve picked up my life again’
Back pain was agony for Anne Parker, 68, from Berkshire, but thanks to the right diagnosis she’s now walking tall
“My bad back started 12 years ago, with pains in my right buttock. When I saw my GP, he said the problem was actually my back and gave me painkillers. I do orienteering so I tried to move and stretch more, but the pain just got worse. Then I saw an osteopath, who said I should rest.
“One morning, when I was getting up, I rubbed the bad spot on my spine. It triggered a sciatic spasm that left me immobile and screaming in pain. My GP gave me stronger painkillers and anti-inflammatories, which improved things when I was lying down or standing up, but sitting was agony. I still went walking, though. Now it’s recognised that exercise is one of the best things for certain kinds of back pain.
“A year later, I had an X-ray and an MRI scan and discovered I had a lateral stenosis, a build-up of tissue that blocks the spinal canal. The treatment was an injection of steroids into my spine. It took away the constant, gnawing pain. Three months later I was able to go orienteering again.”
‘I can continue going about my daily life’
Kiran Mohan, a 42-year old teacher, has suffered from lower back pain for the past seven years
“My back problems started in 1999 when I developed a severe pain in the heel of one of my feet, which gradually progressed to the other foot. It was incredibly painful and badly affected my walking. It was eventually diagnosed as plantar fasciitis, a condition where the heels and surrounding joints become inflamed. This condition means that I walk with a limp, which in turn kicked off my lower back pain.
“Because I’m a teacher, I’m unable to remain seated for most of the day to take the weight off my feet, which can make the problem much worse. My doctor recommended a lower back exercise class, which was a six-week course of relevant exercises. It did help and I found that the exercises gave me some relief. But over the years, I’ve also privately seen an osteopath, had acupuncture and tried Pilates. In addition, because of limping, I’ve had a couple of falls, which have caused whiplash and made my lower back pain much worse.
“In 2002, after trying just about everything, I started to see a chiropractor and since doing so I have seen a significant improvement. Unfortunately, due to my day-to-day life I’m not able to rest as much as I would like and no doubt this affects the rate of my recovery. Chiropractic treatment has certainly improved my quality of life and, with a few treatments along the way, I can continue going about my daily life.
NHS Choices links
- News: Alexander technique
- News: back to basics
- News: acupuncture
- Health A-Z: sciatica
- Health A-Z: slipped disc
- Live Well: sitting correctly
- Live Well: backache