Low back pain, back pain, pain in the buttock area, aching, pain, disorder, degeneration, sciatic pain, sciatica, herniated disc, nonspecific back pain, aging, stiffness, rigidity, overuse injury, overtraining, under-recovery
Low back pain refers to the pain or discomfort felt between the lower rib cage and the upper part of the buttocks. It can range in intensity from mild soreness to completely debilitating pain, which may be felt locally or radiate to the abdomen or lower limbs. The pain can be acute, subacute or chronic, affecting movement, quality of life and mental well-being.
Low back pain is a global public health issue that significantly impacts productivity, causing considerable strain on both individuals and the society. It is the fifth most common reason for seeking medical attention and almost everyone experiences low back pain at least once in their lifetime. Often, low back pain is a recurring issue, making its understanding and appropriate treatment essential.
The pain may stem from some structural changes or damage in the back, but more often, it is classified as nonspecific low back pain, where there are insufficient structural changes to explain the origin of the pain. Regardless of the type of low back pain, conservative treatment is typically the primary option for rehabilitation.
This text focuses on nonspecific low back pain and its underlying causes. Additionally, we will in short, explore several structural reasons for low back pain. The classification of low back pain used in this text is based on the model developed by Professor Peter O'Sullivan. O'Sullivan has had a long career as both a researcher and clinician in the field of musculoskeletal disorders, particularly in pain management.
Epidemiology and Etiology
Low back pain is the most common musculoskeletal disorder worldwide and a leading cause of reduced work capacity and diminished quality of life. It can occur at any age, even in children and adolescents, but low back pain is most commonly observed in individuals aged 30 to 60. Women experience low back pain slightly more often than men; however, most people will experience at least one episode of low back pain in their lifetime, regardless of gender.
Physically demanding work, repetitive movements that strain the back or prolonged sitting seem to increase the prevalence of low back pain. Furthermore, factors such as lack of physical activity, smoking and obesity can further worsen the prognosis.
Recurrent episodes of low back pain become more common with aging, and approximately 5-10% of low back pain cases develop into chronic conditions. Chronic low back pain, lasting more than three months, significantly increases the risk of disability and negatively impacts quality of life. Timely and appropriately calibrated responses can help reduce the individual and societal burdens caused by low back pain. Chronic low back pain is often associated with psychosocial factors, which can further decrease the likelihood of recovery.
The majority of low back pain cases (90-95%) are classified as nonspecific low back pain, meaning there is no identifiable structural reason or pathology to explain the pains origin. However, this does not imply that there are no explanations for low back pain or that it is somehow mysterious. Such beliefs can sometimes contribute to an increased perception of pain associated with low back issues. Below is a framework based on Peter O'Sullivan's research regarding the classification and prevalence of low back pain.
Alaselkäkivun luokittelu Peter O'Sullivanin mukaan.
Symptoms
Low back pain can manifest as a dull, aching sensation or as sharp, stabbing or radiating pain. It is often accompanied by feelings of stiffness or fatigue in the lower back or pelvic region. The pain may radiate to the buttocks, lower abdomen or legs and it can be associated with numbness, tingling or weakness in the muscles.
The intensity of the pain can vary widely, ranging from mild discomfort to completely debilitating pain. However, the level of pain does not necessarily correlate with the severity of any underlying tissue damage. Occasionally, the most severe pain may result from very minor disturbances, while advanced pathological changes or injuries may include very little pain even be painless.
The symptoms of low back pain can vary greatly:
Discomfort or pain that increases with certain movements or positions.
A sense of tightness or fatigue in the lower back, which may hinder the performance of daily activities.
Numbness or tingling that radiates to the legs, which may indicate a potential nerve injury.
Difficulties in standing, walking or sitting for extended periods are also relatively common.
Nonspecific Low Back Pain
Nonspecific low back pain refers to pain for which there is no identifiable structural cause. In these cases, there may not necessarily be any significant strain or injury; rather, the pain may appear to arise spontaneously. This may feel strange, leading some to believe that it means the back has become painful on its own. Such thoughts can easily give rise to the idea that the back is difficult or impossible to treat. However, nonspecific low back pain does not imply that the back is sore without reason; rather, it suggests that underlying factors other than structural causes are present.
Nonspecific low back pain can be broadly divided into two categories: mechanical back pain and non-mechanical back pain, with mechanical back pain being significantly more common than non-mechanical forms.
Mechanical back pain can further be categorized into pain caused by movement disorders or disturbances in movement control. In both cases, there is increased stress on the back, leading to pain. For instance, there may be impaired control in the core region, causing the back to move uncontrollably and impacting its structures or there may be weakness in force production in the pelvis or restrictions in hip movement, resulting in excessive load being placed on the structures of the lower back. If this continues for an extended period, recovery of the back may be disrupted, leading to overstrain.
In non-mechanical back pain, psychosocial factors such as stress, exhaustion, depression, insomnia or harmful beliefs about pain can contribute to or exacerbate the pain. Lifestyle choices also appear to play a significant role in the development of non-mechanical low back pain. Lack of exercise, increased alcohol consumption, smoking or poor dietary habits can initiate, exacerbate or prolong back pain.
Irrelevant attitudes, harmful beliefs related to pain, abnormal pain behavior, financial factors, work-related stressors, emotional aspects or family-related issues are all examples of potential psychosocial factors that can influence an individual's experience of pain.
It is crucial to identify the underlying mechanism and utilize this understanding when developing a treatment plan. Not all low back pain can be treated with the same approaches, so a comprehensive assessment that includes both mechanical and non-mechanical factors is essential for planning and implementing effective treatment strategies.
Specific Low Back Pain
Specific low back pain occurs when the structure causing the pain is known. This may be due to age-related structural changes or the aftermath of trauma. Only 5-10% of all low back pain cases are classified as specific. Below are a few examples of specific low back pain.
Spinal Stenosis
Spinal canal stenosis, also known as spinal stenosis, is a result of age-related degenerative changes in the spine, which reduce the space available for nerve and vascular structures and lead to narrowing. Symptoms vary from pain and numbness in the lower back, buttocks, thighs or legs, to intermittent walking difficulties or weakness in the back and lower limbs. Spinal canal stenosis is often associated with age-related changes in the spine, such as osteoarthritis and degenerative discs. If you would like to read more about spinal canal stenosis, you can do so here.
Herniated Disc
A herniated disc, also referred to as a disc prolapse, occurs when the gel-like inner mass of the disc presses against its outer wall, causing it to bulge outward. This increases pressure and irritates the nerve roots emerging from the spinal canal, leading to pain. The pain caused by a herniated disc is typically felt more intensely in the lower limbs than in the back, although back pain can also occur. To read more about herniated discs, click here.
Spondylolysis
Spondylolysis is a condition characterized by skeletal changes in the posterior arch of a vertebra, indicating increased strain. The changes can range from swelling to fractures. Typical symptoms of spondylolysis include pain and stiffness in the back, which worsens with stress on the back. Spondylolysis can occur in both adults and children, but the underlying causes may differ slightly between age groups. It is essential to take childhood and adolescent back pain seriously and investigate potential underlying causes. If you want to read more about back pain in children and adolescents, you can do so here.
Spondylolisthesis
Spondylolisthesis, or vertebral slippage, is a stage following the loosening of the vertebral arch, where a fracture in the arch allows a vertebra to shift relative to the lower vertebra. The slippage of the vertebra may also be externally visible as a bulge in the spine. The symptoms and clinical findings are similar to those observed in spondylolysis.
Modic Changes
Modic changes in the vertebrae, particularly Modic-1 changes, can cause localized back pain. Modic-1 changes are inflammatory alterations in the vertebrae resulting from disc degeneration. These changes are visible on MRI scans as increased fluid levels within the vertebrae. The more vertebrae involved or the larger the changes visible in the scans, the more likely it is that they cause pain. Treatment for Modic-1 changes is primarily focused on effectively managing inflammation, so anti-inflammatory medications and reducing/palpitating painful activity form the basis for treatment.
Tumors and Infections
Tumors and infections can also cause localized or radiating back pain. A typical symptom of an intradural spinal tumor is radiating back pain in the lower limbs, which makes it hard to stand or walk. Spinal tumors can be either benign or malignant, making early detection and evaluation critical.
In addition to back pain, symptoms of spinal infections may include difficulty walking or limping. Fever is also a characteristic symptom of the condition; however, the absence of fever does not rule out the possibility of infection.
Assessment and Diagnosis
Accurate assessment and diagnosis are essential components in the management of specific low back pain. A comprehensive medical history and clinical examination complement imaging studies that help identify the underlying causes.
When to Seek Medical Attention?
Moderate and recurring low back pain can be viewed as an inconvenience and it doesn’t always require significant intervention for recovery. It’s helpful to adopt a similar attitude towards low back pain as one would with a cold—taking some time to rest and allowing it to heal. However, if the pain persists, it’s essential to investigate the underlying factors. Specifically, if low back pain lasts longer than two weeks without improvement or if it is accompanied by concerning symptoms, it is advisable to discuss the situation with a healthcare professional.
If the back pain is accompanied by significant weakness, changes in bowel or bladder function, numbness in the area around the anus and genitals or severely debilitating radiating pain in the lower limbs, a prompt medical evaluation is necessary.
Self-Care for Acute Low Back Pain
Sudden onset low back pain can be a frightening experience, especially for those who have never encountered it before. The immediate reaction for many is to seek medical examinations and treatments, though this is rarely necessary. Most low back pain cases resolve on their own within a few weeks. Here are some tips to support your recovery:
Continue Your Daily Activities: Do not let mild or moderate pain prevent you from carrying out your everyday tasks. It is entirely safe to function with some discomfort, as long as the pain does not escalate. If we consider pain intensity on a scale of 0-10, any activity that does not cause the pain to exceed 5/10 is unlikely to worsen or prolong the low back pain.
Avoid Prolonged Bed Rest: Long-term bed rest is generally not beneficial for recovery. If your back feels tired or painful while engaging in activities, it is perfectly acceptable to rest, such as lying down for a short period. However, remaining in one position for too long may prolong the duration of the pain, so this is not recommended.
Engage in Light Exercise: Walking or other light activities help maintain mobility, improve fluid and blood circulation, reduce tension and support recovery. Although walking or gentle exercises may feel challenging at first, they often expedite healing and alleviate pain.
Try Heat or Cold Therapy: Applying a heat pack locally can help relax the muscles and promote blood flow to the area. Conversely, cold therapy can effectively reduce pain. You may try both methods to see which works better for you.
Take Pain-Relieving Medication as Needed: For mild to moderate back pain, over-the-counter paracetamol is usually sufficient. For moderate to severe pain, nonsteroidal anti-inflammatory drugs (NSAIDs) can provide relief. In cases of severe pain, prescription pain medication may be required.
However, it is essential to note that medications can irritate the digestive tract and internal organs and may increase the risk of developing gastric or duodenal ulcers. Older adults, in particular, have a higher risk of stomach ulcers, so medication should be used cautiously.
Rehabilitate Yourself: Once acute pain has subsided, you can begin rehabilitation and focus on preventing the pain from recurring. Start your rehabilitation process and concentrate on preventing future recurrences of pain. Therapeutic exercise can effectively help reduce the chances of low back pain returning after an episode. A physiotherapist can guide you in designing a program tailored to your specific needs.
Physical Therapy
The content of physical therapy varies based on symptoms, pain areas and any clinically observable findings. Physical therapy always begins with a thorough assessment aimed at identifying the factors that have contributed to the onset of back pain. This information allows for the development of a plan that not only addresses the current back pain but also aims to reduce the risk of recurrence.
Physical therapy is always tailored to the individual, but it often includes some combination of the following methods:
Progressive Exercise and Load Modification:
Manage the overall load on the back
Reduce compression and stretching forces on irritated tissues
Improve body control
Enhance fluid and blood circulation
Alleviate pain
Improve the sliding properties of possibly irritated nerves
Enhance and balance mobility
Strengthen muscles
Manual Therapy:
Alleviate pain and activate descending pain pathways
Reduce friction or pinching loads on irritated tissues
Decrease muscle tension
Improve the performance of muscles and joints
Reduce cortisol release in tissues
Improve blood flow in treated tissues
Enhance mobility
Decrease the disruptive nature of pain
Read more about the effectiveness of manual therapy and the methods used here.
Psychophysical Therapy:
Modify harmful thoughts and beliefs that patients may have about pain and the associated discomfort. Mindfulness and relaxation techniques can also activate descending pain pathways by promoting a mental state that may reduce the transmission of pain signals to the brain. Understanding pain and its mechanisms empowers individuals to be actively involved in their pain management and modulation. Awareness of emotional and psychological factors affecting pain helps individuals adapt to changes in pain and reduces the anxiety associated with it.
Guidance and Counseling:
Provide sufficient information about the nature of the condition, underlying factors and prognosis so that pain does not induce excessive fear. Knowledge of the healing process and treatment prognosis enhances motivation for self-directed rehabilitation and improves self-efficacy. Additionally, factors that positively or negatively impact the treatment prognosis and timeline are discussed, allowing for necessary adjustments. This reduces patient uncertainty and potential distress, making it easier to live with pain.
Summary
Low back pain is a common issue that affects nearly everyone at least once in their life. The majority of low back pain cases are classified as nonspecific, involving both mechanical and non-mechanical factors. While the pain can be disruptive and limit daily activities, the prognosis is generally good. Most individuals recover within a few weeks without the need for extensive examinations or treatments.
You should seek medical attention if the pain persists, becomes extremely severe or is accompanied by signs of progressive nerve damage. Sudden onset low back pain can often be effectively managed with home remedies for a few weeks, as long as the pain remains mild or moderate. In such cases, the best treatment approach is to practice "active rest." Common pain relief medications include a combination of paracetamol and nonsteroidal anti-inflammatory drugs (NSAIDs).
The risk of recurrence or persistent pain can be effectively managed through physical therapy. In these cases, identifying underlying factors and developing an individualized treatment plan yields the best possible results.
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