Hi, I’m Dr Mike Evans and today we’re talking about low back pain, a problem that people often take care of themselves, but even then, it’s one of the top two reasons people visit doctors and responsible for up to 40% of all missed work days.
OK, let me begin by giving you a bit of a mixed message. For most of us, back pain is actually not a quote “disease”. It’s more part of the normal experience since we’ve walked on two legs. Spinal structures such as bones, ligaments, joints, discs, and nerves interact in marvellous ways to support us to do the million things we do with our backs, but occasionally this backfires and gives us what we call mechanical back pain. The severity of the pain, which can be extreme, does not always reflect the seriousness of the underlying problem, and the vast majority gets better by itself without medical intervention.
On the other hand, while we know it does get better, 30% of you have a recurrence within six months and 40% within a year. If this sounds familiar it may be helpful to stop seeing recurrent back pain as discrete events and more as a chronic vulnerability, that you need to create what I call “a back resilience plan”. Maybe learn some lessons from people that mange their chronic diseases well. They build a support team and reach out early when there’s a problem. They make small changes and focus on basics like managing stress, getting quality sleep.
So let’s start with the pain itself. Let’s keep it simple and talk about tow patterns. First is what we call back dominant pain. Most commonly this pain radiates down the back to our butt and / or around the hips. Some patients just have pain in the back, and others can sometimes feel pain all the way down the leg. But it’s the back pain that is dominant. Most of these patients get relief, or aggravation, of pain with particular movements or positions. For example when they arch backwards or bend forwards. Typically this kind of back pain comes and goes, or comes in spasms as you move. In fact, back dominant pain is a good pain because there’s no damage to the nerves or spinal cord, and no surgery is needed.
The second pattern is leg dominant pain, and there are two common presentations. The first typically comes form a disc problem that puts pressure on the nerve in your back that travels down the legs. This is often referred to as sciatica. When this nerve is compressed or irritated we get pain down the leg, anywhere from below the buttock to the foot. There may be pain in the back as well but this time the leg pain is dominant. It’s a constant pain but tends to feel better when we lie down.
Sciatica often gets better by itself, but we may need to give you special advice or medications and sometimes imaging, especially if there are thoughts of surgery. So it’s a good idea to talk to your care team if you have sciatica.
The second presentation is a leg pain that predictably comes only when you stand or walk or run and is relieved when you bend forward and especially when you sit. The pain can be anywhere in the leg and patients describe a gradual worsening or heaviness in the legs as they walk which causes them to stop. The medical term for this leg pain is neurogenic claudication and it typically happens to people over 60 and is caused by significant narrowing, or what we call stenosis, of the spinal tunnel containing the nerves. When this gets severe it makes it hard for your nerves to keep up with your activity.
Now, pain predominantly in the back, especially if it is intermittent or short lasting is almost always benign. But it’s good to quickly review what we call “red flags” – signs that you may need more investigation. The first red flag is a sudden change in your normal bowel or bladder control, or numbness around the groin and rectal area, which makes us think something might be pressing on the spinal nerves there. The second red flag wonders whether infection is the source of your back pain. So for example if you have a sustained fever, if you’re an IV drug user, if you have a weakened immune system, or at high risk for urinary or other infections. The third red flag is about your risk for fracture in your back. So if your pain started with a big fall, or car accident, or perhaps your bones are brittle because of osteoporosis. The fourth red flag is wondering whether cancer might be involved. So if you have a history of cancer, particularly in the prostate, breast, or lung, and your pain is constant, lasting weeks, even when lying down, or at night, or you have other insidious symptoms such as unexplained weight loss, you need to follow this up. Finally there’s back pain that comes from diseases that cause lots of inflammation such as ankylosing spondylitis. This is rare, but when we look at people with chronic back pain it can be seen in as many as one in twenty. It tends to start when people are younger, say ages 15 to 35. They have night pain, and lots of morning stiffness lasting over an hour, but this gets better with movement.
After red flags the next question we often get in clinic is “should I have an x-ray or CT scan or MRI?”. So if you have a red flag or are considering surgery for constant leg pain, imaging may be an excellent idea. But less than 5 in 100 patients will actually have a red flag. So does having an x-ray help for the other 95? The answer is “no”. Professor Richard Deyo and his group calculated that only 1 in 2500 back x-rays show an important finding. OK you say, so not too helpful, but what’s the harm? Well there’s the radiation, there’s wasted time and money, but it’s more that that. One famous study MRI’d 98 people with health backs and no back pain, and found disc problems in two thirds of them. The problem with this is that it turns out your outlook or your attitude is actually very important to outcomes in low back pain. What we don’t want Is people saying to themselves “oh, I have back disease so I better stop exercising”. Or every time they feel a twinge they feel they have a quote “illness”.
This brings us to the next type of flags, what we call yellow flags. These four flags predict an increase risk that somebody’s acute low back pain will become chronic. Number one is the belief that back pain is harmful or potentially severely disabling. Secondly is fear and avoidance of activity or movement because of back pain. When I think of these two risk factors I actually think of a trial done with baggage handlers and maintenance workers at an airport who were in bad shape from back pain and had been off work for months. Dr Bart Staal and his colleagues in Maastricht, a beautiful town in the Netherlands, divided these workers with severe low back pain into tow groups. The first group received usual care. The second group received the same but were also slowly exposed to more and more activity and exercise, and were conditioned to understand that they could function normally despite the presence of some back pain with their activity. In other words, the investigators helped them overcome yellow flag #1, the belief that all back pain is harmful. And that opened the door to overcome yellow flag #2, reducing avoidance of activity. It was mind over matter. If the worker didn’t mind some pain the back pain actually didn’t matter. Third yellow flag was a tendency towards low mood and isolation, which is so true of all chronic diseases. And the fourth yellow flag is a strong expectation that passive rather than active treatments will help. Believing you just need to sit there and have therapists work on you rather than owning the fact that it’s not just the therapists that need to do the work – you do to.
So now you know what to watch for, lets end with what works for back pain. Let’s start with movement. Until the 1990s advice to rest was a common treatment approach for low back pain. The exact nature of the rest varied but often that meant staying in bed full time. What we know now is this actually makes people worse. Sometimes people with back pain do have to rest, so for example with more severe sciatica. But people who don’t move at all do worse.
Motion is lotion and over-the-counter medications can really help. And I think one of the key ways they work is to reduce pain so that you can keep moving.
Other things that have demonstrated effectiveness for pain relief include spinal manipulation, typically by a chiropractor or an osteopath, massage, and even acupuncture. These therapies combined with exercise can be considered active therapies and are often done by your local physiotherapist.
Some exercise strategies may be effective once your pain is reduced like Pilates of yoga to improve your core and trunk strength. But the benefits are hard to prove in research trials.
Treatments like spinal manipulation or acupuncture should not be done indefinitely. Most of the trials maxed out as eight to ten sessions and often less. If they don’t work for you initially, more treatments will unlikely benefit.
Two other approaches that have been proven to work, especially in for more chronic back pain are cognitive behavioural therapy – changing the way you think and therefore behave around low back pain, and being taken care of by what we call a multi-disciplinary team – a team with different skill sets. We see this often in medicine, complex problems seem to rarely find their solution in one place.
OK, let’s step back and summarise. First you need to know that the prognosis for low back pain is excellent. Only about one third of patients with low back pain seek medical care, so most improve on their own. Over time, up to 90% of patients we do see with acute low back pain recover. The first episode may be brief or last several weeks but it does go away. Unless there are red flags these people do fine by acknowledging the pain but not focusing on it, by keeping moving and perhaps some active therapy. But there’s no need for x-rays or other imaging. Generally less is more with this type of back pain.
Although there is less high quality data to support this, many patients often respond to small changes such as modifying their workstations, taking breaks from sitting, or improving their posture.
For those with chronic or recurrent pain the outlook is still good. Primary care samples suggest that one third of patients are substantially improved after just a few weeks and two thirds after a few months but with recurrent or chronic back pain we both need to work a little harder to get you better. As I mentioned earlier, seeing this vulnerability and developing a resilience plan for your back that might include: yoga, or Pilates, or specific exercises that fit with your back pain pattern, walking, reconsidering your attitudes and having some people you can turn to early for active therapy can all help.
So in the end back pain is actually not that much different from a lot of things in life. Your mindset and daily habits are critical and so is self-knowledge. Trying a few of the treatments we’ve discussed, knowing what works for you, knowing red flags and when you need to seek care, and finally, understanding that movement is medicine. Thanks, and take care.