Low back pain (lumbago or pain in the lumbar spine) is one of the most common conditions to confront doctors. The University of Maryland Medical Center reports 60 to 80 percent of Americans will have low back pain at some point in their lives. Treatments for low back pain range from self-help strategies to surgery and include a wide variety of different therapies, many of which can be combined. There really is no true “best” treatment. The causes of back pain often require different therapies and each person is an individual who responds differently.
Causes of Low Back Pain
The causes of low back pain generally fall into three major categories:
- Injury – Injuries could include falls, automobile accidents, repetitive motion injury, sprains and strains.
- Illness – Arthritis in the spine is one of the most common illnesses to cause low back pain. This might be rheumatoid arthritis, osteoarthritis or a similar inflammatory process. Spinal tumors can also cause pain.
- Chronic stress on the spine – Chronic spinal stress results from poor posture and body mechanics. Sitting for long periods in positions that stress the spinal muscles and lifting improperly are two common causes of spinal stress. The pain itself can result from inflammation, problems with spinal alignment, short, tense muscles or soft tissue trauma.
Acute vs. Chronic Back Pain
Acute back pain is usually the result of an injury. The pain starts suddenly, doesn’t last more than three to six months and is usually related to tissue damage such as that inflicted in a fall. Chronic back pain may result from acute back pain. It may also simply begin slowly and for no obvious reason. Chronic pain also includes pain that continues after healing has occurred, as when back surgery doesn’t relieve the pain even though the incision is completely healed. There is a third type of pain, known as neuropathic pain, which is probably due to a nerve injury. This pain combines features of both acute and chronic pain. Neuropathic pain can be severe and strike without warning, but it also persists over months or even years.
Diagnosis is Key to Treatment
As this video shows, doctors who treat lower back pain must first determine what is causing the pain and then tailor the treatment to the cause. For example, pain that results from a muscle strain is treated conservatively with gentle exercise and over-the-counter medications, while pain that results from a ruptured disc (discs are the cartilage cushions between the bones of the spine) may require surgery. In the absence of a specific cause doctors will treat the symptoms. The diagnosis of back pain begins with a review of the patient symptoms. Next comes a thorough physical examination which may be followed by imaging studies such as X-rays, an MRI or a CT scan. Other diagnostic tools include an electomyogram to assess the health of individual muscles and nerves. A pelvic and/or rectal examination can help identify possible other problems in which the pain is referred (transmitted) to the back.
Self-care can be either an initial treatment option or a management strategy for chronic pain. These strategies can all be undertaken at home and rarely require medical advice. Self-care should not include extended periods of bed rest as that weakens the muscles and can make pain worse. The application of direct heat or ice (the two treatments can also be alternated) may help relieve pain. Over-the-counter pain medications such as ibuprofen or acetaminophen can reduce inflammation and discomfort. Walking and other forms of gentle exercise help keep the muscles flexible. Posture when sleeping is important – a pillow between the legs helps promote better spinal alignment. It’s also important to maintain correct posture throughout the day and to avoid heavy lifting or twisting, which can aggravate symptoms. A chair should provide proper back support, especially if you sit in it for long periods. People whose jobs require long periods of sitting should get up and move around several times an hour.
Conservative therapy is primarily the non-surgical treatments aimed at strengthening and stretching muscles, promoting better posture and managing pain with the use of medications. It typically includes treatments such as massage and physical therapy. Massage helps loosen tight, tense muscles and relieves stress, which can contribute to pain. Physical therapy helps strengthen and stretch muscles, and can correct postural habits or body mechanics that stress the spine and contribute to pain. The importance of proper posture in back pain treatment cannot be overstressed – poor posture causes repeated stress on the muscles and other supporting structures in the musculoskeletal system. Conservative therapy may include medications such as pain relievers (including narcotic or opioid medications), muscle relaxers and anti-inflammatory medications.
Minimally Invasive Treatments
Minimally invasive treatments span the area between conservative therapy and surgery. They include techniques such as joint or facet injections and epidural injections. After carefully cleaning the skin to prevent infection, the doctor injects medications such as local anesthetics and/or steroids into the designated area. The local anesthetic provides direct pain relief and the steroid medications help relieve the inflammation that causes pain. These treatments are not always effective and are not permanent. Some patients experience immediate relief that lasts for six months to a year, while others find relief only for a month or two or not at all. They may carry a slightly higher risk of complications and side effects than conservative therapy.
Back surgery is generally considered a last resort treatment for back pain – especially in the absence of a condition like a ruptured disc that is pressing on a nerve – as back pain often improves on its own or with conservative treatment. Surgery also has more risks than other forms of treatment, so patient and doctor must assess the potential risks and benefits. Modern back surgery includes many less invasive methods that can be performed in an outpatient surgery center. An endoscope, which is a tiny camera mounted on a long flexible tube, allows the use of a small incision and a shorter anesthesia period. Endoscopic surgeries are less traumatic to the body tissues and often have a shorter healing time. Surgeons can use endoscopes to remove a ruptured disc or bone, relieve nerve pressure or perform a bone graft. Larger and more invasive procedures usually require a hospital stay. Surgery is much more likely to be performed after an acute injury that doesn’t respond to conservative treatment or when there is an obvious and serious problem like a ruptured disc or fracture in one or more bones of the spine.
Alternative medicine is a catch-all term that simply means non-traditional or non-conventional medicine. It encompasses the use of herbs, homeopathy and traditional treatment from disciplines such as Chinese and Ayurvedic medicine. For example, the University of Maryland Medical Center notes that turmeric and willow bark can help relieve pain and inflammation, while Devil’s Claw can relieve pain and improve mobility. Capsaicin (the substance that gives chili peppers their heat) can act as a pain reliever when applied directly to the skin. Other forms of alternative medicine include acupuncture, aromatherapy and homeopathy. Research on alternative medicine is often limited, but many of these treatments have minimal risks and some people find them helpful. This is one of those “try it and see” treatments. Alternative therapies may take longer to elicit a patient response than conventional treatment, so patience is necessary.
In addition to conventional or alternative therapy, there are treatments for back pain that lie somewhere in the middle and are often used in combination with the first two methods of treatment. For example, physical therapy is important for several reasons.
- First, a good physical therapist can identify musculoskeletal characteristics that may be causing back pain or making it worse, such as muscle imbalances.
- Second, a physical therapist can assess gait, posture and body mechanics and teach patients how to improve all three.
- Third, physical therapy includes additional modalities such as diathermy (direct heat application) and electrical muscle stimulation.
Chiropractic is another form of treatment for back pain. Once considered well out of the mainstream, chiropractic treatment is now moving into the conventional treatment arena, as evidenced by the willingness of insurers to pay for these treatments. Chiropractic focuses on spinal alignment and the doctor manipulates the spine and other joints to promote better alignment, relieve pain and reduce muscle spasm. A chiropractor may use his or her hands to manipulate the spine or a tool called an Activator that works directly on the affected joint.
Although exercise may be part of different therapy strategies, it is important enough to deserve mention in its own right. Strong muscles decrease the risk of injury, as does flexibility. Muscles work in pairs – one muscle bends the joint and the other straightens the joint. If either muscle is overly weak or strong, it affects posture and gait, and can increase back pain. The core muscles of the trunk are particularly important in treating low back pain. Abdominal muscles provide support to the spine. The quadratus lumborum, for example, lies in the abdomen on the back of the abdominal wall. Although it is the deepest abdominal muscle, it is commonly referred to as a back muscle because it lies right against the spine and helps support it. Regular exercise that targets the abdominal and back muscles can help decrease pain and prevent further injury. Exercises like swimming, yoga and tae chi are easy on joints and can promote muscle strength, balance and flexibility. Anyone who suffers from back pain should get regular exercise.
Diet is important in treating back pain for two reasons. First, being overweight or obese increases the risk of back pain. This is partly because it often results from low levels of physical activity (which by itself contributes to back pain) and partly because people who are overweight or obese often have poor muscle tone and may have balance problems. The second reason diet matters is that certain dietary habits contribute to inflammation. For example, sugar is known to have inflammatory effects, while foods high in antioxidants – such as leafy green vegetables and berries – help reduce inflammation. Caffeine and alcohol can disrupt sleep, which makes it more difficult to manage back pain and increases stress (which causes muscle tension). Healthy fats that contain Omega-3 fatty acids, found in fatty fish and flax seeds, may help reduce inflammation.
The treatment of back pain is a complex issue and there is no one treatment or “magic bullet” that works best in all situations. For the patient who suffers from low back pain, the take-home message is to keep an open mind and try various strategies to see what is most helpful in your situation. In all cases, self-care strategies, exercise, correct posture and body mechanics, diet and proper rest will be helpful and will promote overall health as well as helping in the treatment of lower back pain. These same techniques can also help prevent back injuries and chronic pain in the first place.