Back pain

What is back pain?

The usual sequence of events

Incidence of back pain

Causes of back pain

Prevention / remedies / treatment for back pain

Warnings

References

What is back pain?

Back pain can come on suddenly (acute) or persist as chronic pain for years, depending on its cause. It can be a dull ache, or sharp and piercing; be quite specific in location or widespread; it may radiate into the limbs; and it may include weakness or numbness.

Back pain can be described anatomically: neck (cervical), upper back (thoracic), lower back (lumbar) or tailbone (sacral).

The spine is a complex network of nerves, discs, joints, muscles, tendons and ligaments, all of which are capable of producing pain. Being the largest nerve channel in the body means that it has the capacity to generate and carry a high level of pain. Pain can radiate to the arms and legs through the large nerves that originate in the spine.

Back pain affects almost everyone at some time. It is a common part of a modern lifestyle because we spend a large part of our lives sitting (eating, using a computer, reading, driving, watching TV etc) without exercising the major muscles in the back and buttocks. A hundred or more years ago when people walked everywhere and did a lot of physical work, back ache was rare.

The spine provides strength and protection to the sensitive spinal cord and nerve roots, while allowing flexibility and movement in all directions. A healthy spine is protected and encased in strong, flexible muscles that are regularly exercised by walking and stretching.

Back pain does not usually need urgent medical attention. Most episodes of back pain heal themselves within 6 weeks. Inflammation is often present, especially if there is an acute phase which typically lasts from two to twelve weeks.

The usual sequence of events

Abnormalities such as a slipped disc, misaligned spine or disc degeneration are common and found in many people. They do not necessarily cause pain or any other problems. It is possible to live a normal, pain-free life without even knowing that you have one of these "abnormalities". Disc degeneration is found in a third of people with no pain at all, and one in five people have no pain but do have a disc protrusion, a form of "slipped" disc. Bent or misaligned spines are even more common, including among healthy and athletic people. Usually a scan showing that you have such a problem does more harm than good.

Real, definitive physical causes of back pain such as a tumour, bone fracture, pressure on a nerve, infection or arthritis are only found in 5 - 15% of cases. All other cases are labelled as "non-specific".

Unfortunately MRIs and x-rays often find a slipped disc or misalignment in people who are suffering from back pain. The desperate patient usually demands swift intervention to fix the "cause" they believe the scan has revealed. Both patients and doctors think that if they can see something then they should do something. Patients who now believe that they have a damaged, fragile back start avoiding normal physical activity, especially walking.

Remember that most forms of medical treatment such as surgery and spinal injections are lucrative. Most back specialist doctors won't spend an hour explaining to a patient that the things seen on his MRI may not be the reason for his back pain, and that it is more likely to be his worrying financial, work or marital problems, problematic children or that he is not sleeping well.

Surgery with unproven benefits or which debilitates the patient or makes the pain worse, is common. In 2019 Cigna, an American health insurer, found that 87% of customers who had spinal-fusion surgery for wear and tear of spinal discs were in so much pain two years later that they needed further intrusive treatment. Spinal injections, another invasive treatment, often do little if any good.

The best treatment is usually non-medical, avoiding pharmaceutical drugs and hospitals. Better to do stretching exercises and keep moving. Don't lie around or in bed for days on end - that will likely make things worse. Above all, be patient. The problem is usually not your physical back, it is more likely that the brain's pain-signalling system is confused - and unfortunately medical experts do not know why. The pain may be partly or completely psychosomatic. In most cases the right exercises, relaxation and the passage of time will ease the pain. Unlike surgery and other invasive treatments, they cost little and are unlikely to make things worse.

Incidence of back pain

Back pain is the top cause of disability, measured by the aggregate number of years lived in poor health. It is the most common reason people need to take time off work. (3)

90% of people will experience back pain at some time in their lives, and half of all people will have an episode every year.

Lower back pain (lumbago) is a muscular-skeletal disorder that affects about 80% of people at some time in their lives.

In the USA 26% of adults report back pain lasting at least one day every three months. Also in the USA, 41% of adults aged between 26 and 44 years reported having back pain in the previous 6 months. (1)

Causes of back pain

• Psychological and emotional factors. Tension - those who are stressed, depressed or unhappy in their work or relationships are more likely to have chronic back pain. The stress of a horrible boss, bad marriage or a sick child may bring on backache. People who suffer mental trauma as children are more likely to experience back pain in middle age. Several studies suggest that these psychological factors may correlate more closely with back pain than structural abnormalities revealed in MRI and x-ray medical imaging scans.
• A sprain or a small tear in a muscle or ligament, often from lifting awkwardly or a sudden twisting.
• Misalignment. Difference in the length of the legs, a twist or bend in the alignment of the spinal column or surrounding muscles, misalignment of the pelvis. The problem may have existed since birth, or caused by trauma, disease, tension etc.
• Wrong pillow. If you sleep on your back or your front, you probably do not need a pillow. If you sleep on your side, your pillow should be high enough and firm enough to keep your head aligned with your spine all night.
• Muscle spasm from stress or poor posture.
• Pregnancy. 50-70% of pregnant women experience back pain because of the additional weight and change in centre of gravity. (2)
• Being inactive or unfit.
• Being overweight.
• Sitting or working for more than 15 - 30 minutes at a desk at an uncomfortable height, or in an uncomfortable posture. If you are sitting, try resting your feet on the floor or on a low stool. When driving for long periods try putting a pillow behind the small of your back. Take frequent breaks to stretch and walk around for a few minutes.
• Arthritis.
• Osteoporosis.
• Referred pain from elsewhere in the body.
• Inflammation from an infection or various inflammatory diseases such as ankylosing spondylitis.
• Nutritional deficiencies, which can also cause osteoarthritis and osteoporosis. The most common and important deficiency is vitamin D. The next most important deficiency is magnesium. Other micronutrient deficiencies which can cause back pain include boron, vitamin E, and vitamin K2.
• Wearing high heeled shoes.
• Rapid temperature changes, cold wind.
• A slipped disk is a tear in the outer ring of the spinal cartilage that lets the soft centre bulge out.
• Stenosis is the narrowing of the spinal canal.
• Other medical conditions. Many other conditions can cause back pain, such as multiple myeloma or a tumour, or calcification.

Prevention / remedies / treatment for back pain

• Be patient. Back pain seldom requires urgent medical treatment. Only 1 - 5% of people with back pain have a cause that requires urgent treatment, such as an infection or a tumour. Most pain episodes come with some form of inflammation, which can last from 2 to 12 weeks.
• Stay active. Exercise within the limits of pain usually aids recovery, depending on the cause. It may be more appropriate when there is chronic, rather than acute back pain. Stretching, strengthening and aerobic exercise is helpful to restore motion and strength, relieve pain and prevent future pain episodes. Walk as much as you can. Yoga, tai-chi and psychological therapies aimed at reducing stress are all recommended.
• Get a pillow of the right height. If you always sleep on your side, which is the best position in which to sleep provided other factors don't prevent you, then you need a pillow high enough and firm enough that your head is horizontal. In other words, your head should not be at an angle - up or down.
• Sit on the side of your bed or on a comfortable chair. Gently lean forward until your chest is resting on your thighs, or as far forward as you can comfortably go. Relax and deep breathe in that position for a minute. Gently stand up.
• Walk backwards. The principle is using the "opposite" muscles and ligaments to those being used when the injury occurred. Start slowly, smoothly, push through the toe. Initially go for 100 metres, build up to 200 metres as you strengthen your back and your knees in the right places. After you adapt and feel comfortable, increase the resistance by dragging something while you walk backwards. This is especially good for knee pain.
• Correct possible nutritional deficiencies. The most common and important micronutrient deficiency is vitamin D. Also ensure you have a good level of magnesium. Other possible micronutrient deficiencies which can cause back pain include boron, vitamin E, and vitamin K2. A good source of vitamin E is wheat germ oil, and a good food source is soaked sunflower seeds. Vitamin K2 is made by bacteria in your gut, and if you have a healthy gut biome you may be sufficient. However, if you have taken antibiotics or you do not have a microorganism-friendly diet, you may need to supplement, often using vitamin D3 plus K2 drops.
• Heat. Some people find a hot bath helps. Another option is a heat wrap that stays warm for 4-6 hours. Others have reported good results from infrared heat and red light therapy.
• Cold. Ice or cold pack. Cold compression therapy.
• Massage, preferably by an experienced therapist. Acupressure or pressure point massage may be more effective.
• Acupuncture.
• Spinal manipulation (chiropractic care).
• Squat on the toilet.
• Inclined Bed Therapy (IBT).
• When lifting anything, bend your knees and keep your back straight. Use your legs to do the lifting, not your back. Avoid lifting and twisting at the same time.
• Try sleeping on your back with a pillow under your knees, or on your side with your knees bent and a pillow between your knees.
• Extensive bed rest (more than two days) may slow recovery.
• See details of remedies recommended by Grow Youthful visitors, and their experience with them.

Warnings

See a doctor if you have:

• Severe backache that is bad enough to interrupt sleep.
• Back pain from an injury, especially if you suffer from osteopenia / osteoporosis.
• Losing weight or have a fever with the back ache.
• Difficulty in controlling your bowels or bladder.
• Tingling, numbness or muscle weakness in the anal or genital area.
• Progressive weakness in the legs.
• You have a history of cancer, or cancer is likely.

References

1. Deyo RA, Mirza SK, Martin BI. Back pain prevalence and visit rates: estimates from U.S. national surveys, 2002. Spine (Phila Pa 1976). 2006 Nov 1;31(23):2724-7.

2. Ostgaard HC, Andersson GB, Karlsson K. Prevalence of back pain in pregnancy. May 1991, Spine 16 (5): 549-52. PMID 1828912.

3. The Economist Magazine dated 18 January 2020.