Back Pain – Causes, Symptoms, Diagnosis, Treatment

Back pain is a common disorder involving the muscles, nerves, and bones of the back. Pain can vary from a dull constant ache to a sudden sharp feeling. Low back pain may be classified by duration as acute (pain lasting less than 6 weeks), sub-chronic (6 to 12 weeks), or chronic (more than 12 weeks). The condition may be further classified by the underlying cause as either mechanical, non-mechanical, or referred pain. The symptoms of low back pain usually improve within a few weeks from the time they start, with 40-90% of people completely better by six weeks.

Types of Back Pain

Low back pain can be broadly classified into main  different categories

  • Musculoskeletal – mechanical (including muscle strain, muscle spasm, or osteoarthritis); herniated nucleus pulposus, herniated disk; spinal stenosis; or compression fracture. Most commonly this is due to injury to the spine, intervertebral discs, or soft tissues. Fractures such as spondylolisthesis can be both an acute and chronic process. Lumbago often is labeled as acute back pain or a strain to either the quadratus lumborum muscle or the paraspinal muscles. Disc herniation is a common type of traumatic back pain. Pregnancy is also a mechanical cause of back pain.
  • Degenerative – Osteoarthritis of the spine includes facet joint osteoarthritis, sacroiliac joint osteoarthritis, spinal stenosis, and degenerative disc disease. Furthermore, osteoporotic compressive fractures are also a degenerative process.
  • Inflammatory – HLA-B27 associated arthritis including ankylosing spondylitis, reactive arthritis, psoriatic arthritis, and inflammatory bowel disease. This is caused primarily due to inflammatory (seronegative) spondyloarthropathies such as ankylosing spondylitis. Sacroiliitis is most commonly seen. The pathophysiology of back pain depends on the etiology. Most often, it may be a part of an acute inflammatory process.
  • Oncologic – This is caused by lytic lesions to the spine, cancers of the marrow, or compressive nerve phenomena from adjacent space-occupying lesions. Often presenting as a pathological fracture.
  • Malignancy – bone metastasis from lung, breast, prostate, thyroid, among others
  • Infectious osteomyelitis; abscess. Infections of the spine, discs, epidural abscesses, or muscular/soft tissue abscesses

In addition, symptoms of lower back pain are usually described by the type of onset and duration

  • Acute pain  This type of pain typically comes on suddenly and lasts for a few days or weeks, and is considered a normal response of the body to injury or tissue damage. The pain gradually subsides as the body heals.
  • Subacute low back pain  Lasting between 6 weeks and 3 months, this type of pain is usually mechanical in nature (such as a muscle strain or joint pain) but is prolonged. At this point, a medical workup may be considered and is advisable if the pain is severe and limits one’s ability to participate in activities of daily living, sleeping, and working.
  • Chronic back pain  Usually defined as lower back pain that lasts over 3 months, this type of pain is usually severe, does not respond to initial treatments, and requires a thorough medical workup to determine the exact source of the pain.

According to the body movement or spinal mechanism

Three common classifications of back pain include:

  • Axial back pain – Also called mechanical pain, axial pain is confined to one spot or region. It may be described a number of ways, such as sharp or dull, comes and goes, constant, or throbbing. A muscle strain is a common cause of axial back pain as are facet joints and annular tears in discs.
  • Referred back pain – Often characterized as dull and achy, referred pain tends to move around and vary in intensity. As an example in the lower back, degenerative disc disease may cause referred pain to the hips and posterior thighs.
  • Radicular back pain – Commonly described as electric shock-like or searing, radicular pain follows the path of the spinal nerve as it exits the spinal canal. This type of pain is caused by compression and/or inflammation to a spinal nerve root. In the lower back (lumbar spine), radicular pain may travel into the leg. Other terms for radicular pain are sciatica or radiculopathy (when accompanied by weakness and/or numbness). It can be caused by conditions such as a herniated disc, spinal stenosis, or spondylolisthesis.
  • Thoracic Back Pain – The thoracic spine comprises the twelve vertebrae to which the ribs attach and could, therefore, be described as the “upper back” region. When compared with neck (cervical) pain, middle back pain, and lower (lumbar) back pain, pain in the thoracic region of the spine has a greater probability of being caused by a serious underlying condition. 1 Because of this, it’s important to keep an eye out for incidents and symptoms such as – Fever or chills, Unexplained/uncontrollable weight loss, Noticeable deformity, Nerve pain/numbness/tingling in the legs or lower body. Severe stiffness, particularly in the morning (which could be a sign of rheumatoid arthritis). Physical trauma (e.g., from a recent car accident). The onset of pain before the age of 20. The onset of pain after the age of 50. Constant, severe pain that is not helped by changing position
  • Middle Back Pain – Although middle back pain is sometimes considered synonymous with thoracic back pain, it can generally be described as pain that occurs above the lumbar region of the spine but below the rib cage. In cases of middle back pain, the symptoms can be vague and difficult to diagnose, which can be especially frustrating in chronic cases. There are a number of elements that can increase a person’s risk of developing middle back pain, including the following: Pregnancy, Weight gain/obesity, lack of physical activity, stress and anxiety, Smoking

As with thoracic back pain, any sudden or unusual symptoms like fever, chills, dizziness, or weight loss can be a sign of something that goes beyond back pain. If you experience such symptoms, seek medical attention right away.

Causes of Back Pain

  • Bulging or herniated disc A disc may bulge outward. A herniated disc occurs when the soft interior matter escapes through a crack or ruptures through the disc’s protective outer layer. Both disc problems can cause nerve compression, inflammation, and pain.
  • Spinal stenosis  – develops when the spinal canal or a nerve passageway abnormally narrows.
  • Spinal arthritis – also called spinal osteoarthritis or spondylosis, is a common degenerative spine problem. It affects the spine’s facet joints and may contribute to the development of bone spurs.
  • Spondylolisthesis –  occurs when a lumbar (low back) vertebral body slips forward over the vertebra below it.
  • Vertebral fractures – (burst or compression types) are often caused by some type of trauma (eg, fall).
  • Osteomyelitis – is a bacterial infection that can develop in one of the spine’s bones.
  • Spinal tumors – are an abnormal growth of cells ( a mass) and are diagnosed as benign (non-cancerous) or malignant (cancer).
  • Sprains and strains –  account for most acute back pain. Sprains are caused by overstretching or tearing ligaments, and strains are tears in tendon or muscle. Both can occur from twisting or lifting something improperly, lifting something too heavy, or overstretching. Such movements may also trigger spasms in back muscles, which can also be painful.
  • Intervertebral disc degeneration is one of the most common mechanical causes of low back pain, and it occurs when the usually rubbery discs lose integrity as a normal process of aging. In a healthy back, intervertebral discs provide height and allow bending, flexion, and torsion of the lower back. As the discs deteriorate, they lose their cushioning ability.
  • Herniated or ruptured discs – can occur when the intervertebral discs become compressed and bulge outward (herniation) or rupture, causing low back pain.
  • Radiculopathy – is a condition caused by compression, inflammation and/or injury to a spinal nerve root. Pressure on the nerve root results in pain, numbness, or a tingling sensation that travels or radiates to other areas of the body that are served by that nerve. Radiculopathy may occur when spinal stenosis or a herniated or ruptured disc compresses the nerve root.
  • Sciatica  – is a form of radiculopathy caused by compression of the sciatic nerve, the large nerve that travels through the buttocks and extends down the back of the leg. This compression causes shock-like or burning low back pain combined with pain through the buttocks and down one leg, occasionally reaching the foot. In the most extreme cases, when the nerve is pinched between the disc and the adjacent bone, the symptoms may involve not only pain but numbness and muscle weakness in the leg because of interrupted nerve signaling.
  • A traumatic injury – such as from playing sports, car accidents, or a fall can injure tendons, ligaments or muscle resulting in low back pain. Traumatic injury may also cause the spine to become overly compressed, which in turn can cause an intervertebral disc to rupture or herniate, exerting pressure on any of the nerves rooted in the spinal cord.
  • Skeletal irregularities – include scoliosis, a curvature of the spine that does not usually cause pain until middle age; lordosis, an abnormally accentuated arch in the lower back; and other congenital anomalies of the spine.
  • Abdominal aortic aneurysms – occur when the large blood vessel that supplies blood to the abdomen, pelvis, and legs becomes abnormally enlarged. Back pain can be a sign that the aneurysm is becoming larger and that the risk of rupture should be assessed.
  • Kidney stones – can cause sharp pain in the lower back, usually on one side. Low back pain is rarely related to serious underlying conditions, but when these conditions do occur, they require immediate medical attention.
  • Infections – are not a common cause of back pain. However, infections can cause pain when they involve the vertebrae, a condition called osteomyelitis; the intervertebral discs, called discitis; or the sacroiliac joints connecting the lower spine to the pelvis, called sacroiliitis
  • Cauda equina syndrome – is a serious but rare complication of a ruptured disc. It occurs when disc material is pushed into the spinal canal and compresses the bundle of lumbar and sacral nerve roots, causing loss of bladder and bowel control. Permanent neurological damage may result if this syndrome is left untreated.

back-pain-posture

  • Inflammatory diseases of the joints such as arthritis, including osteoarthritis and rheumatoid arthritis as well as spondylitis, an inflammation of the vertebrae, can also cause low back pain. Spondylitis is also called spondyloarthritis or spondyloarthropathy.
  • Osteoporosis – is a metabolic bone disease marked by a progressive decrease in bone density and strength, which can lead to painful fractures of the vertebrae.
  • Endometriosis – is the buildup of uterine tissue in places outside the uterus.
  • Fibromyalgia, – a chronic pain syndrome involving widespread muscle pain and fatigue.

Red flag historic or physical exam features that, when present, should raise the provider’s suspicion for a process that may require imaging for proper diagnosis. These differ slightly from adults to children based on the incidence of diseases in these age groups:

Adults

  • Lumbosacral muscle strains/sprains – Presentation: follows traumatic incident or repetitive overuse, pain worse with movement, better with rest, restricted range of motion, tenderness to palpation of muscles
  • Lumbar spondylosis – patient typically is greater than 40years old, pain may be present or radiate from hips, pain with extension or rotation, the neurologic exam is usually normal
  • Disk herniation – usually involves the L4 to S1 segments, may include paresthesia, sensory change, loss of strength or reflexes depending on severity and nerve root involved
  • Spondylolysis, Spondylolisthesis – similar to pediatrics, spondylolisthesis may present back pain with radiation to the buttock and posterior thighs, neuro deficits are usually in the L5 distribution
  • Vertebral compression fracture – localized back pain worse with flexion, point tenderness on palpation, may be acute or occur insidiously over time, age, chronic steroid use, and osteoporosis are risk factors
  • Spinal stenosis – back pain, which can be accompanied by sensory loss or weakness in legs relieved with rest (neurologic claudication), neuro exam can be within normal limits or can have progressive loss of sensation, as well as weakness. 97% of spinal tumors are metastatic disease; however, the provider should keep multiple myeloma in the differential
  • Tumor – history of metastatic cancer, unexplained weight loss, focal tenderness to palpation in the setting of risk factor
  • Infection: vertebral osteomyelitis, discitis, septic sacroiliitis, epidural abscess, paraspinal muscle abscess – The spinal procedure within the last 12 months, Intravenous drug use, Immunosuppression, prior lumbar spine surgery, fever, wound in the spinal region, localized pain, and tenderness The granulomatous disease may represent as high as one-third of cases in developing countries.
  • Fracture – Significant trauma (relative to age), Prolonged corticosteroid use, osteoporosis, and age greater than 70 years, Contusions, abrasions, tenderness to palpation over spinous processes

Pediatrics:

  • Tumor – fever, malaise, weight loss, nighttime pain, recent onset scoliosis. Osteoid osteoma is the most common tumor that presents with back pain – classically, the pain is promptly relieved with anti-inflammatory drugs such as NSAIDs
  • Infection: vertebral osteomyelitis, discitis, septic sacroiliitis, epidural abscess, paraspinal muscle abscess fever, malaise, weight loss, nighttime pain, recent onset scoliosis. Epidural abscess should be a consideration with the presence of fever, spinal pain, and neurologic deficits or radicular pain; discitis may present with a patient refusing to walk or crawl
  • A herniated disk, slipped apophysis – Acute pain, radicular pain, positive straight leg raise test, pain with spinal forward flexion, recent onset scoliosis
  • Spondylolysis, spondylolisthesis – lesion or injury to the posterior arch Acute pain, radicular pain, positive straight leg raise test, pain with spinal extension, tight hamstrings
  • Vertebral fracture – acute pain, other injuries, traumatic mechanism of injury, neurologic loss
  • Muscle strain – acute pain, muscle tenderness without radiation
  • Scheuermann’s kyphosis – chronic pain, rigid kyphosis
  • Inflammatory spondyloarthropathies – chronic pain, morning stiffness lasting greater than 30min, sacroiliac joint tenderness
  • Psychological Disorder (conversion, somatization disorder) – normal evaluation but persistent subjective pain
  • Idiopathic Scoliosis: positive Adam’s test (for more significant angle curvature), most commonly asymptomatic Of note, no definitive evidence that scoliosis causes pain, but patients with scoliosis have more frequently reported pain; therefore the provider should rule out other causes before attributing pain to scoliosis

Everyday activities or poor posture.

Back pain can also be the result of some everyday activity or poor posture. Examples include:

low-back pain

Adopting a very hunched sitting position when using computers can result in increased back and shoulder problems over time.
  • Bending awkwardly
  • Pushing something
  • Pulling something
  • Carrying something
  • Lifting something
  • Standing for long periods
  • Bending down for long periods
  • Twisting
  • Coughing
  • Sneezing
  • Muscle tension
  • Over-stretching
  • Straining the neck forward, such as when driving or using a computer
  • Long driving sessions without a break, even when not hunched

What can cause lower back pain? Or Effects Of Back Pain

Most acute low back pain is mechanical in nature, meaning that there is a disruption in the way the components of the back (the spine, muscle, intervertebral discs, and nerves) fit together and move. Some examples of mechanical causes of low back pain include:

Congenital

  • Skeletal irregularities such as scoliosis (a curvature of the spine), lordosis (an abnormally exaggerated arch in the lower back), kyphosis (excessive outward arch of the spine), and other congenital anomalies of the spine.
  • Spina bifida which involves the incomplete development of the spinal cord and/or its protective covering and can cause problems involving malformation of vertebrae and abnormal sensations and even paralysis.

Injuries

  • Sprains (overstretched or torn ligaments), strains – (tears in tendons or muscle), and spasms (sudden contraction of a muscle or group of muscles)
  • Traumatic injury such as from playing sports, car accidents, or a fall that can injure tendons, ligaments, or muscle causing the pain, as well as compress the spine and cause discs to rupture or herniate.

Degenerative problems

  • Intervertebral disc degeneration – occurs when the usually rubbery discs wear down as a normal process of aging and lose their cushioning ability.
  • Spondylosis is the general degeneration of the spine associated with normal wear and tear that occurs in the joints, discs, and bones of the spine as people get older.
  • Arthritis or another inflammatory disease – in the spine, including osteoarthritis and rheumatoid arthritis as well as spondylitis, an inflammation of the vertebrae.

Nerve and spinal cord problems

  • Spinal nerve compression, inflammation, and/or injury
  • Sciatica (also called radiculopathy), caused by something pressing on the sciatic nerve that travels through the buttocks and extends down the back of the leg. People with sciatica may feel shock-like or burning low back pain combined with pain through the buttocks and down one leg.
  • Spinal stenosis, the narrowing of the spinal column that puts pressure on the spinal cord and nerves
  • Spondylolisthesis, which happens when a vertebra of the lower spine slips out of place, pinching the nerves exiting the spinal column
  • Herniated or ruptured discs can occur when the intervertebral discs become compressed and bulge outward
  • Infections involving the vertebrae, a condition called osteomyelitis; the intervertebral discs, called discitis; or the sacroiliac joints connecting the lower spine to the pelvis, called sacroiliitis
  • Cauda equina syndrome occurs when a ruptured disc pushes into the spinal canal and presses on the bundle of lumbar and sacral nerve roots. Permanent neurological damage may result if this syndrome is left untreated.
  • Osteoporosis (a progressive decrease in bone density and strength that can lead to painful fractures of the vertebrae)

Non-spine sources

  • Kidney stones can cause sharp pain in the lower back, usually on one side
  • Endometriosis (the buildup of uterine tissue in places outside the uterus)
  • Fibromyalgia (a chronic pain syndrome involving widespread muscle pain and fatigue)
  • Tumors that press on or destroy the bony spine or spinal cord and nerves or outside the spine elsewhere in the back
  • Pregnancy (back symptoms almost always completely go away after giving birth)

The Symptom of Back Pain

The main symptom of back pain is, as the name suggests, an ache or pain anywhere on

  • Pain in the back, and sometimes all the way down to the buttocks and legs. Some back issues can cause pain in other parts of the body, depending on the nerves affected.
  • In most cases, signs, and symptoms clear up on their own within a short period. If any of the following signs or symptoms accompany back pain, people should see their doctor:
  • Pain. It may be continuous, or only occur when you are in a certain position. The pain may be aggravated by coughing or sneezing, bending or twisting.
  • Patients who have been taking steroids for a few months
  • Drug abusers
  • Patients with cancer
  • Patients who have had cancer
  • Patients with depressed immune systems
  • Stiffness.

According to the British National Health Service (NHS), the following groups of people should seek medical advice if they experience back pain:

  • Weight loss
  • Elevated body temperature (fever)
  • Inflammation (swelling) on the back
  • Persistent back pain – lying down or resting does not help
  • Pain down the legs
  • Pain reaches below the knees
  • A recent injury, blow or trauma to your back
  • Urinary incontinence – you pee unintentionally (even small amounts)
  • Difficulty urinating – passing urine is hard
  • Fecal incontinence – you lose your bowel control (you poo unintentionally)
  • Numbness around the genitals
  • Numbness around the anus
  • Numbness around the buttocks
  • Dull ache,
  • Numbness,
  • Tingling,
  • Sharp pain,
  • Pulsating pain,
  • Pain with movement of the spine,
  • Pins and needles sensation,
  • Muscle spasm,
  • Tenderness,
  • Sciatica with shooting pain down one or both lower extremities
  • People aged less than 20 and more than 55 years
  • Additionally, people who experience pain symptoms after a major trauma (such as a car accident) are advised to see a doctor. If low back pain interferes with daily activities, mobility, sleep, or if there are other troubling symptoms, medical attention should be sought.

Red flag conditions indicating possible underlying spinal pathology or nerve root problem

Red flags

  • Non-mechanical pain (unrelated to time or activity)
  • Thoracic pain
  • Previous history of carcinoma, steroids, HIV
  • Feeling unwell
  • Weight loss
  • Widespread neurological symptoms
  • Structural spinal deformity

Indicators for nerve root problems

  • Unilateral leg pain > low back pain
  • Radiates to foot or toes
  • Numbness and paraesthesia in the same distribution
  • The straight leg raising test induces more leg pain
  • Localized neurology (limited to one nerve root)

Diagnosis of Back Pain

Medical and Family History

Your doctor will ask questions about your medical and family history to help determine if an injury or underlying medical condition is the source for the back pain. Some questions your doctor may ask:

  • Can you describe your pain? (e.g. sharp, aching, burning)
  • Where is the exact location of your back pain?
  • When did the pain start and how long have you had the pain?
  • What were you doing when you first noticed the pain?
  • How severe or bad is the pain?
  • What makes the pain worse or better?
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Your doctor may ask you to rate your pain on a scale from 1 to 10 to gauge the severity of the pain and talk to you about your ability to perform activities of daily living.

Physical Exam

Your doctor will likely perform a physical exam, which may include:

  • Examine your spine and posture to look for changes in the bony structure.
  • Asking you to bend or lift your legs to determine how movement affects your pain.
  • Testing your reflexes, muscle strength, and sensation.
  • The physical exam is also performed similarly between the age groups as long as the patient is old enough to communicate and participate in the review. The physical exam should include inspection, palpation, the range of motion, strength testing, provocative maneuvers, and neurologic (limb strength, sensation, and deep tendon reflex) assessments. Several provocative exercises help demonstrate or decrease suspicion of different processes.

Manual Test

  • A straight leg raise (SLR) – can be complete by raising the patient’s leg to 30 to 70 degrees. Ipsilateral leg pain at less than 60 degrees is a positive test for lumbar disk herniation. The likelihood ratio (LR) of a straight leg raise is 2, with ave likelihood ratio (NLR) of 0.5. If the pain reproduction occurs contralaterally, it is a positive test for a lumbar disk herniation with LR of 3.5 and NLR of 0.72.
  • One leg hyperextension test/stork test – Have the patient stand on one leg and (while being supported by the provider) have them hyper-extend their back. Repeat this maneuver on both sides. Pain with hyperextension is positive for a pars interarticularis defect.
  • Adam test –  Have the patient bend over with feet together and arms extended with palms together. The practitioner should observe from the front. If a thoracic lump is present on one side or the other, it is an indication of scoliosis.

Radiography

Suspected disk, nerve, tendon, and other problems – X-rays or some other imaging scan, such as a CT (computerized tomography) or MRI (magnetic resonance imaging) scan may be used to get a better view of the state of the soft tissues in the patient’s back.

  • Blood tests – CBC ,ESR,Hb, RBS,CRP, Serum Creatinine,Serum Electrolyte,
  • Myelograms
  • Discography.
  • Electrodiagnostics
  • Bone scans
  • Ultrasound imaging
  • X-rays – can show the alignment of the bones and whether the patient has arthritis or broken bones. They are not ideal for detecting problems with muscles, the spinal cord, nerves or disks.
  • MRI or CT scans – these are good for revealing herniated disks or problems with tissue, tendons, nerves, ligaments, blood vessels, muscles, and bones.
  • Bone scan – a bone scan may be used for detecting bone tumors or compression fractures caused by brittle bones (osteoporosis). The patient receives an injection of a tracer (a radioactive substance) into a vein. The tracer collects in the bones and helps the doctor detect bone problems with the aid of a special camera.
  • Electromyography or EMG – the electrical impulses produced by nerves in response to muscles is measured. This study can confirm nerve compression which may occur with a herniated disk or spinal stenosis (narrowing of the spinal canal).

Treatment of Back Pain

Not all treatments work for all conditions or for all individuals with the same condition, and many find that they need to try several treatment options to determine what works best for them. The present stage of the condition (acute or chronic) is also a determining factor in the choice of treatment. Only a minority of people with back pain (most estimates are 1% – 10%) require surgery.

Non-medical

Treatment for back pain generally depends on how long your pain lasts

Acute (short-term) back pain – usually gets better on its own. Exercises or surgery are usually not recommended for this type of pain. There are some things you may try while you wait for your pain to get better:

  • Acetaminophen, aspirin, or ibuprofen will help ease the pain.
  • Get up and move around to ease stiffness, relieve pain, and have you back doing your regular activities sooner.

Chronic (long-term) back pain – is typically treated with non-surgical options before surgery is recommended.

Nonsurgical Treatments

  • Pain relievers – that are taken by mouth or applied to the skin. Examples include acetaminophen and aspirin. Your doctor may suggest steroid or numbing shots lessen your pain. Involves using pulleys and weights to stretch the back, which may allow a bulging disk to slip back into place. Your pain may be relieved while in traction, although pain returns once you aren’t in traction.
  • Practice healthy habits – such as exercise, relaxation, regular sleep, proper diet, and quitting smoking.
  • Manipulation – Professionals use their hands to adjust or massage the spine or nearby tissues.
  • Compression packs – 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.
  • Acupressure A therapist applies pressure to certain places in the body to relieve pain. Acupressure has not been well studied for back pain. Move your body properly while you do daily activities, especially those involving heavy lifting, pushing, or pulling. Back pain is generally treated with non-pharmacological therapy first, as it typically resolves without the use of medication. Superficial heat and massage, acupuncture, and spinal manipulation therapy may be recommended.
  • Heat therapy –  is useful for back spasms or other conditions. A review concluded that heat therapy can reduce symptoms of acute and sub-acute low-back pain.
  • Regular activity and gentle stretching exercises – are encouraged in uncomplicated back pain, and are associated with better long-term outcomes. Physical therapy to strengthen the muscles in the abdomen and around the spine may also be recommended.
  • These exercises  – are associated with better patient satisfaction, although it has not been shown to provide functional improvement. However, one study found that exercise is effective for chronic back pain, but not for acute pain. If used, they should be performed under the supervision of a licensed health professional.
  • Massage therapy – may give short-term pain relief, but not functional improvement, for those with acute lower back pain. It may also give short-term pain relief and functional improvement for those with long-term (chronic) and sub-acute lower pack pain, but this benefit does not appear to be sustained after 6 months of treatment. There does not appear to be any serious adverse effects associated with massage.
  • Acupuncture – may provide some relief for back pain. However, further research with stronger evidence needs to be done.
  • Spinal manipulation is a widely-used method of treating back pain, although there is no evidence of long-term benefits.
  • Back school – is an intervention that consists of both education and physical exercises. A 2016 Cochrane review found the evidence concerning back school to be very low quality and was not able to make generalizations as to whether back school is effective or not.

The Medication 

If non-pharmacological measures are not effective, medications may be tried.

  • NSAIDs Prescription-strength drugs that reduce both pain and inflammation. Pain medicines and anti-inflammatory drugs help to relieve pain and stiffness, allowing for increased mobility and exercise. There are many common over-the-counter medicines called non-steroidal anti-inflammatory drugs (NSAIDs). They include mainly or first choice etodolac, then aceclofenacetoricoxib, ibuprofen, and naproxen.
  • Muscle Relaxants –  These medications provide relief from spinal muscle spasms.  Muscle relaxants, such as baclofen, tolperisone, eperisone, methocarbamol, carisoprodol, and cyclobenzaprine, may be prescribed to control muscle spasms.
  • Neuropathic Agents – Drugs(pregabalin & gabapentin) that address neuropathic—or nerve-related—pain. This includes paresthesia, radiating pain with numbness, diabetic neuropathy pain, myalgia, burning, numbness, and tingling sensation
  • Calcium & vitamin D3 To improve bone health and healing fracture. As a general rule, men and women age 50 and older should consume 1,200 milligrams of calcium a day, and 600 international units of vitamin D a day.
  • Vitamin B1, B6, and B12 – It is essential for neuropathic pain management, pernicious anemia, with vitamin b complex deficiency pain, paresthesia, numbness, itching with diabetic neuropathy pain, myalgia, etc.
  • Skeletal muscle relaxers – may also be used. Their short-term use has been shown to be effective in the relief of acute back pain. However, the evidence of this effect has been disputed, and these medications do have negative side effects.
  • In people with nerve root pain and acute radiculopathy – there is evidence that a single dose of steroids, such as dexamethasone, may provide pain relief.
  • Epidural corticosteroid injection – (ESI) is a procedure in which steroid medications are injected into the epidural space. The steroid medications reduce inflammation and thus decrease pain and improve function. ESI has long been used to both diagnose and treat back pain, although recent studies have shown a lack of efficacy in treating low back pain.
  • Carisoprodol – This muscle relaxant was investigated in two high-quality studies on acute low back pain. The first study compared carisoprodol with diazepam [. Carisoprodol was superior in performance on all the outcome parameters measured. A comparison of carisoprodol with cyclobenzaprine‐hydrochloride in the second study revealed no statistically significant differences between the two treatments [.
  • Chlorzoxazone – This muscle relaxant was compared with tizanidine in one high-quality study in a very small sample of patients with degenerative lumbar disc disease [. No differences were found between the treatments.
  • Cyclobenzaprine‐hydrochloride – Cyclobenzaprine was compared with diazepam in a low-quality trial on chronic low back pain, but no significant differences between the treatments were identified [. There was also no significant difference between cyclobenzaprine and carisoprodol in one high-quality study on acute low back pain [.
  • Diazepam – In comparison with carisoprodol, diazepam was found to be inferior in performance on muscle spasms, global efficacy, and functional status in a high-quality trial on acute low back pain [. In a very small high-quality trial (30 people) comparing diazepam with tizanidine, there were no differences in pain, functional status, and muscle spasm after seven days [.
  • Tizanidine – This muscle relaxant was compared with chlorzoxazone and diazepam in two very small high quality [. Both trials did not find any differences in pain, functional status, and muscle spasms after 7 days.
  • Pridinol mesylate – One low-quality trial showed no differences between this muscle relaxant and thiocolchicoside on pain relief and global efficacy.

Surgery of Back Pain

Surgery for back pain is typically used as a last resort when a serious neurological deficit is evident. A 2009 systematic review of back surgery studies found that, for certain diagnoses, surgery is moderately better than other common treatments, but the benefits of surgery often decline in the long term. 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.

NIH’s National Institute of Neurological Disorders and Stroke (NINDS) lists the following as some of the surgical options for low back pain. But NINDS also cautions that “there is little evidence to show which procedures work best for their particular indications.”

  • Vertebroplasty and kyphoplasty – These procedures are used to repair compression fractures of the vertebrae caused by osteoporosis. Both procedures include the injection of glue-like bone cement that hardens and strengthens the bone.
  • Spinal laminectomy/spinal decompression – This is performed when spinal stenosis causes a narrowing of the spinal canal that results in pain, numbness, or weakness. The surgeon removes the bony walls of the vertebrae and any bone spurs, aiming to open up the spinal column to remove pressure on the nerves.
  • Discectomy – This procedure is used to remove a disk when it has herniated and presses on a nerve root or the spinal cord. Laminectomy and discectomy are frequently performed together.
  • Foraminotomy – In this procedure, the surgeon enlarges the bony hole where a nerve root exits the spinal canal to prevent bulging discs or joints thickened with age from pressing on the nerve. Foraminotomy is a surgery that cleans out and widens the area where the nerve roots leave the spinal canal. By opening up this area, the pressure on the nerves from spinal stenosis can be relieved.
  • Nucleoplasty also called plasma disk decompression – This laser surgery uses radiofrequency energy to treat people with low back pain associated with a mildly herniated disk. The surgeon inserts a needle into the disk. A plasma laser device is then inserted into the needle and the tip is heated, creating a field that vaporizes the tissue in the disk, reducing its size and relieving pressure on the nerves.
  • Spinal fusion – The surgeon removes the spinal disk between two or more vertebrae, then fuses the adjacent vertebrae using bone grafts or metal devices secured by screws. Spinal fusion may result in some loss of flexibility in the spine and requires a long recovery period to allow the bone grafts to grow and fuse the vertebrae together.
  • Artificial disk replacement – This is considered an alternative to spinal fusion for the treatment of people with severely damaged disks. The procedure involves the removal of the disk and its replacement by a synthetic disk that helps restore height and movement between the vertebrae. Disc replacement surgery replaces a damaged disc with a synthetic one. This procedure is limited to patients who do not have complicating factors.
  • Laser surgery – uses a needle that produces bursts of laser energy to reduce the size of a damaged disc. This relieves pressure on the nerves.
  • Radiofrequency lesioning – of the affected nerves blocks inputs of the pain signals from entering the spinal cord.[rx]

Some surgical treatments are not recommended by NINDS, which cautions, for example, that intradiscal electrothermal therapy is “of questionable benefit.” NINDS notes that radiofrequency denervation provides only temporary pain relief and that “evidence supporting this technique is limited.”

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.

What the Science Says About Complementary Health Approaches for Low-Back Pain

Mind and Body Approaches:

Acupuncture

  • Acupuncture is a technique in which practitioners stimulate specific points on the body—most often by inserting thin needles through the skin.
  • A 2017 evaluation of 49 studies of acupuncture for low-back pain with more than 7,900 participants found evidence that acupuncture has a modest benefit on acute low-back pain and a moderate benefit on chronic low-back pain.
  • A 2018 review by the Agency for Healthcare Research and Quality (AHRQ) looked at the impact of therapies for chronic low-back pain at least 1 month after the end of treatment. It found that acupuncture was associated with slightly greater effects on pain and function at 1-6 months when compared to controls, such as sham (simulated) acupuncture or usual care. One study also found a greater reduction in pain after more than 12 months.
  • The American College of Physicians clinical practice guideline on low-back pain treatment includes acupuncture as an option for initial treatment of chronic low-back pain (based on moderate-quality evidence) and as a treatment option for acute/subacute low-back pain (based on low-quality evidence).
  • Serious complications of acupuncture are rare.
  • For more information, see the NCCIH webpage on acupuncture.

Biofeedback

  • Biofeedback is a technique that measures body functions and gives you information that may help you learn to control them. A type of biofeedback called electromyography (EMG) biofeedback, which involves measurements of muscle tension, has been evaluated for low-back pain.
  • A 2010 review of three studies (64 participants) found low-quality evidence that EMG biofeedback is helpful for short-term relief of chronic low-back pain.
  • The American College of Physicians clinical practice guideline for low-back pain treatment includes EMG biofeedback as an option for initial treatment of chronic low-back pain (based on low-quality evidence).
  • No harmful effects of EMG biofeedback for low-back pain have been reported.

Cupping

  • Cupping is a practice that involves creating suction on the skin using a glass, ceramic, bamboo, or plastic cup.
  • A 2017 review of 6 studies (458 participants) of cupping for low-back pain showed better results for cupping than for usual care or medication, but it’s uncertain whether these differences are real because different types of cupping were used in different studies, making them hard to compare, and because some of the studies were of poor quality.
  • Cupping can cause side effects such as persistent skin discoloration, scars, burns, and infections. Because cupping equipment can become contaminated with blood, it can spread blood-borne diseases if it is not sterilized or disinfected between patients.
  • For more information, see the NCCIH webpage on cupping.

Dry Needling

  • Dry needling is a procedure in which thin needles are inserted directly into specific hard, tender spots (called myofascial trigger points) in muscles. The needles are the same type used in acupuncture, but the points where the needles are inserted are chosen in a different way.
  • An evaluation of 16 studies of dry needling for low-back pain (1,233 participants) found evidence that it may be helpful. However, the research was not of high enough quality for definite conclusions to be reached.
  • Serious complications of dry needling are rare.

Low-Level Laser Therapy

  • Low-level laser therapy is a light source treatment; laser acupuncture is one type of low-level laser therapy. The mechanisms by which low-level laser therapy may relieve pain are not well understood.
  • A review of 15 studies (1,039 participants) of low-level laser therapy for low-back pain found evidence that it may be beneficial, but only with higher laser doses and relatively short duration of pain (less than 30 months), and only in studies that did not involve acupuncture.
  • A 2018 AHRQ review that looked at the impact of therapies for chronic low-back pain at least 1 month after the end of treatment found only one relevant study of low-level laser therapy. That study showed moderately greater effects of laser therapy on pain and slightly greater effects on function, compared to sham (simulated) laser therapy, after 1-6 months.
  • The American College of Physicians clinical practice guideline for low-back pain treatment includes low-level laser therapy as an option for initial treatment of chronic low-back pain (based on low-quality evidence).
  • The U.S. Food and Drug Administration has cleared the marketing of devices for low-level laser therapy. Studies of low-level laser therapy for low-back pain did not find evidence of any harmful effects.
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Massage Therapy

  • Massage therapy involves manipulating the soft tissues of the body with the goal of helping to manage a health condition or enhance wellness.
  • A 2015 review of 25 studies of massage for low-back pain, with about 3,000 participants, found that it may produce short-term improvements in pain. The quality of the evidence was low to very low.
  • A 2018 AHRQ review that looked at the impact of therapies for chronic low-back pain at least 1 month after the end of treatment found that massage therapy was associated with slightly greater effects on pain and function after 1-6 months, compared to sham (simulated) massage or usual care. There was no evidence of an effect at 6-12 months.
  • The American College of Physicians clinical practice guideline for low-back pain treatment includes massage as a treatment option for acute/subacute low-back pain (based on low-quality evidence). It does not recommend massage therapy as an option for chronic low-back pain.
  • The risk of harmful effects from massage therapy appears be below.
  • For more information, see the NCCIH webpage on massage therapy

Mindfulness-Based Stress Reduction

  • The term “mindfulness” can refer to a variety of practices, but most definitions involve keeping attention or awareness on the experience of the present moment and being open or accepting toward that experience. Mindfulness-based stress reduction (MBSR) is a structured program that teaches meditation and mindfulness, including the incorporation of mindfulness into everyday life.
  • A 2017 review of 7 studies (864 participants) that evaluated MBSR for low-back pain found evidence of short-term improvements in pain intensity and physical functioning, but it was uncertain whether the improvement was large enough to be meaningful to patients.
  • A 2018 AHRQ review that looked at the impact of therapies at least 1 month after the end of treatment found that MBSR was associated with slightly greater effects on pain after 1-6 and 6-12 months when compared to usual care. There was no evidence of an impact on function.
  • The American College of Physicians clinical practice guideline for low-back pain treatment includes MBSR as an option for initial treatment of chronic low-back pain (based on moderate-quality evidence).
  • Mindfulness-based interventions are usually considered safe for most people. However, because only a few studies have systematically looked in detail for harmful effects, it isn’t possible to make definite statements about their safety.

Progressive Relaxation

  • Progressive relaxation is a method of systematically tensing and relaxing muscle groups in different parts of the body. The goal is to eliminate both physical and mental tension.
  • A 2010 review of 3 studies (74 participants) of progressive relaxation for low-back pain found low-quality evidence for lower pain intensity in people who used this technique.
  • The American College of Physicians clinical practice guideline for low-back pain treatment includes progressive relaxation as an option for initial treatment of chronic low-back pain (based on low-quality evidence).
  • Relaxation techniques such as progressive relaxation rarely cause side effects. People with heart disease should consult their health care providers before using progressive relaxation.
  • For more information, see the NCCIH webpage on relaxation techniques.

Prolotherapy

  • Prolotherapy is a technique that involves repeated injections of irritant solutions into ligaments in the back in an effort to strengthen them and reduce low-back pain.
  • A 2010 review of 5 high-quality studies (366 participants) of prolotherapy for low-back pain found conflicting evidence on whether this technique was helpful.
  • In studies of prolotherapy for low-back pain, increases in pain and stiffness after treatment were common, but these effects only lasted for short periods of time.

Spinal Manipulation

  • Spinal manipulation is a technique in which practitioners use their hands or a device to apply a controlled thrust to a joint of the spine. The amount of force can vary, but the thrust moves the joint more than it would on its own. Spinal manipulation is different from spinal mobilization, which doesn’t involve a thrust.
  • A 2017 review of 15 studies (1,699 participants) of spinal manipulation for acute low-back pain found moderate-quality evidence that this treatment is associated with modest improvements in pain at up to 6 weeks. In the same review, 12 studies (1,381 participants) indicated that spinal manipulation can improve function (moderate-quality evidence).
  • A 2018 combined analysis of 9 studies (1,176 participants) found moderate-quality evidence that manipulation and mobilization are likely to reduce pain and improve function in people with chronic low-back pain. Manipulation appeared to produce a larger effect than mobilization.
  • A 2018 AHRQ review that looked at the impact of therapies for chronic low-back pain at least 1 month after the end of treatment found that spinal manipulation had slightly greater benefits on function after 1-6 months and 6-12 months and on pain after 6-12 months, when compared to sham (simulated) manipulation or other controls.
  • The American College of Physicians clinical practice guideline for low-back pain treatment includes spinal manipulation as an option for treating acute/subacute low-back pain (low-quality evidence) and for initial treatment of chronic low-back pain (low-quality evidence).
  • Mild, temporary side effects after spinal manipulation, such as local discomfort at the manipulation site or increased pain, are common. Cases of serious side effects have occurred in patients who received manipulation of the lower back, but it’s unclear whether the treatment actually caused the problems.
  • For more information, see the NCCIH webpage on spinal manipulation.

Tai Chi

  • Tai chi is a centuries-old mind and body practice that combines certain postures and gentle movements with mental focus, breathing, and relaxation.
  • A 2016 review of 3 studies of tai chi for low-back pain (385 participants), all of which involved at least 10 weeks of tai chi, found it was helpful. In two additional studies, not included in the review, tai chi was at least as helpful as some other treatments for low-back pain and better than no treatment.
  • The American College of Physicians clinical practice guideline for low-back pain treatment includes tai chi as an option for initial treatment of chronic low-back pain (based on low-quality evidence).
  • Tai chi is generally considered safe. It may lead to minor aches and pains but is unlikely to cause serious injury.
  • For more information, see the NCCIH webpage on tai chi.

Transcutaneous Electrical Nerve Stimulation (TENS)

  • In transcutaneous electrical nerve stimulation (TENS), a person wears a battery-powered device with electrodes placed on the skin over the painful area. The device generates electrical impulses that may modify the perception of pain.
  • A 2018 review of 9 studies (404 participants) of TENS or a related technique called interferential current for low-back pain or neck pain was unable to reach any conclusions about whether the techniques were helpful.
  • Side effects of TENS include skin irritation and rashes at the sites where the electrodes are applied. See your health care provider before using TENS to make sure it is safe for you. TENS devices should not be used by pregnant women, people with certain health conditions such as epilepsy, or those with implanted medical devices such as pacemakers.

Yoga

  • Yoga, as practiced in the United States, typically emphasizes physical postures, breathing techniques, and meditation.
  • A 2017 review of 12 studies (1,080 participants) of yoga for low-back pain concluded that yoga, when compared to interventions that did not involve exercise, produced small to moderate improvements in back-related function after 3 and 6 months and may also have been slightly more effective for pain. It was uncertain whether there was any difference between yoga and exercise for either back pain or function.
  • A 2018 AHRQ review that looked at the impact of therapies for chronic low-back pain at least 1 month after the end of treatment found that yoga was associated with moderately greater effects on pain and slightly greater effects on function at 1-6 and 6-12 months, when compared to controls (such as being on a waiting list for a yoga program).
  • The American College of Physicians clinical practice guideline for low-back pain treatment includes yoga as an option for initial treatment of chronic low-back pain (based on low-quality evidence).
  • Yoga is generally considered safe for healthy people when performed properly, under the guidance of a qualified instructor. However, as with other types of physical activity, injuries can occur. People with health conditions, older adults, and pregnant women may need to avoid or modify some yoga poses and practices.
  • For more information, see the NCCIH webpage on yoga.

Herbal Products

  • A variety of herbal products, administered either orally (by mouth) or topically (by rubbing on the skin) have been tested for low-back pain. There’s evidence that cayenne, used topically, reduces pain. Other herbal products that might be beneficial include devil’s claw or white willow bark, used orally, and comfrey, Brazilian arnica, and lavender essential oil used topically.
  • It’s important to be aware that herbal products may have side effects or interact with medications. Talk with your health care provider about the safety of any herbal products you’re considering or using for low-back pain.

Vitamin D

  • Studies that compared blood vitamin D levels in people with and without low-back pain have shown that, on average, people with low-back pain were more likely to be deficient in the vitamin. This association was particularly noticeable in people under age 60, especially women. However, a 2018 review of 8 studies of vitamin D supplementation (747 participants) did not find vitamin D to be helpful in improving low-back pain.
  • Taking excessive amounts of vitamin D can be harmful. The recommended upper limit for vitamin D intake for adults is 4,000 IU/day.

Rehabilitation of Back Pain

Step 1 Early treatments

Medications may include:

  • Analgesics and NSAIDS
  • Opioid drugs prescribed by a physician (opioids should be used only for a short period of time and under a physician’s supervision, as opioids can be addictive, aggravate depression, and have other side effects)
  • Anticonvulsants—prescribed drugs primarily used to treat seizures—may be useful in treating people with sciatica
  • Antidepressants such as tricyclics and serotonin, and norepinephrine reuptake inhibitors have been commonly prescribed for chronic low back pain (prescribed by a physician)

Self-management:

  • Hot or cold packs
  • Resuming normal activities as soon as possible may ease pain; bed rest is not recommended
  • Exercises that strengthen core or abdominal muscles may help to speed recovery from chronic low back pain. Always check first with a physician before starting an exercise program and to get a list of helpful exercises.

Step 2 Complementary and alternative techniques include:

  • Acupuncture is moderately effective for chronic low back pain. It involves inserting thin needles into precise points throughout the body and stimulating them (by twisting or passing a low-voltage electrical current through them), which may cause the body to release naturally occurring painkilling chemicals such as endorphins, serotonin, and acetylcholine.
    • Behavioral approaches include:
    • Biofeedback involves attaching electrodes to the skin and using an electromyography machine that allows people to become aware of and control their breathing, muscle tension, heart rate, and skin temperature; people regulate their response to pain by using relaxation techniques
    • Cognitive therapy involves using relaxation and coping techniques to ease back pain
  • Transcutaneous electrical nerve stimulation (TENS) involves wearing a battery-powered device which places electrodes on the skin over the painful area that generate electrical impulses designed to block or modify the perception of pain
  • Physical therapy programs to strengthen core muscle groups that support the low back, improve mobility and flexibility, and promote proper positioning and posture are often used in combination with other interventions
  • Spinal manipulation and spinal mobilization are approaches in which doctors of chiropractic care use their hands to mobilize, adjust, massage, or stimulate the spine and the surrounding tissues. Manipulation involves a rapid movement over which the individual has no control; mobilization involves slower adjustment movements. The techniques may provide small to moderate short-term benefits in people with chronic low back pain but neither technique is appropriate when a person has an underlying medical cause for the back pain such as osteoporosis, spinal cord compression, or arthritis.

Spinal injections include:
Trigger point injections can relax knotted muscles (trigger points) that may contribute to back pain. An injection or series of injections of a local anesthetic and often a corticosteroid drug into the trigger point(s) can lessen or relieve pain.

Epidural steroid injections into the lumbar area of the back are given to treat low back pain and sciatica associated with inflammation. Pain relief associated with the injections tends to be temporary and the injections are not advised for long-term use.

Radiofrequency ablation involves inserting a fine needle into the area causing the pain through which an electrode is passed and heated to destroy nerve fibers that carry pain signals to the brain. Also called a rhizotomy, the procedure can relieve pain for several months.

  • Traction involves the use of weights and pulleys to apply constant or intermittent force to gradually “pull” the skeletal structure into better alignment. Some people experience pain relief while in traction but the back pain tends to return once the traction is released.

Step 3 More advanced care options

Surgery
When other therapies fail, surgery may be considered to relieve pain caused by worsening nerve damage, serious musculoskeletal injuries, or nerve compression. Specific surgeries are selected for specific conditions/indications. However, surgery is not always successful. It may be months following surgery before the person is fully healed and there may be a permanent loss of flexibility. Surgical options include:

  • Vertebroplasty and kyphoplasty for fractured vertebra are minimally invasive treatments to repair compression fractures of the vertebrae caused by osteoporosis. Vertebroplasty uses three-dimensional imaging to assist in guiding a fine needle through the skin into the vertebral body, the largest part of the vertebrae. Glue-like bone cement is then injected into the vertebral body space, which quickly hardens to stabilize and strengthen the bone and provide pain relief. In kyphoplasty, prior to injecting the bone cement, a special balloon is inserted and gently inflated to restore height to the vertebral structure and reduce spinal deformity.
  • Spinal laminectomy (also known as spinal decompression) is done when a narrowing of the spinal canal causes pain, numbness, or weakness. During the procedure, the lamina or bony walls of the vertebrae are removed, along with any bone spurs, to relieve pressure on the nerves.
  • Discectomy and microdiscectomy involve removing a herniated disc through an incision in the back (microdiscectomy uses a much smaller incision in the back and allows for a more rapid recovery). Laminectomy and discectomy are frequently performed together and the combination is one of the more common ways to remove pressure on a nerve root from a herniated disc or bone spur.
  • Foraminotomy is an operation that “cleans out” or enlarges the bony hole (foramen) where a nerve root exits the spinal canal. Bulging discs or joints thickened with age can narrow the space where the spinal nerve exits and press on the nerve. Small pieces of bone over the nerve are removed through a small slit, allowing the surgeon to cut away the blockage and relieve pressure on the nerve.
  • Nucleoplasty also called plasma disc decompression (PDD), is a type of laser surgery that uses radiofrequency energy to treat people with low back pain associated with mildly herniated discs. Under x-ray guidance, a needle is inserted into the disc. A plasma laser device is then inserted into the needle and the tip is heated to 40-70 degrees Celsius, creating a field that vaporizes the tissue in the disc, reducing its size and relieving pressure on the nerves.
  • Radiofrequency denervation uses electrical impulses to interrupt nerve conduction (including pain signaling). Using x-ray guidance, a needle is inserted into a target area of nerves and the region is heated, which destroys part of the target nerves and offers temporary pain relief.
  • Spinal fusion is used to strengthen the spine and prevent painful movements in people with degenerative disc disease or spondylolisthesis (following laminectomy). The spinal disc between two or more vertebrae is removed and the adjacent vertebrae are “fused” by bone grafts and/or metal devices secured by screws. Spinal fusion may result in some loss of flexibility in the spine and requires a long recovery period to allow the bone grafts to grow and fuse the vertebrae together. Spinal fusion has been associated with an acceleration of disc degeneration at adjacent levels of the spine.
  • Artificial disc replacement is an alternative to spinal fusion for treating severely damaged discs. The procedure involves removing the disc and replacing it with a synthetic disc that helps restore height and movement between the vertebrae.
  • Interspinous spacers are small devices that are inserted into the spine to keep the spinal canal open and avoid pinching the nerves. It is used to treat people with spinal stenosis.

Implanted nerve stimulators

  • Spinal cord stimulation uses low-voltage electrical impulses from a small implanted device that is connected to a wire that runs along the spinal cord. The impulses are designed to block pain signals that are normally sent to the brain.
  • Dorsal root ganglion stimulation also involves electrical signals sent along a wire connected to a small device that is implanted into the lower back. It specifically targets the nerve fibers that transmit pain signals. The impulses are designed to replace pain signals with a less painful numbing or tingling sensation.
  • Peripheral nerve stimulation also uses a small implanted device and an electrode to generate and send electrical pulses that create a tingling sensation to provide pain relief.

Rehabilitation teams use a mix of healthcare professionals from different specialties and disciplines to develop programs of care that help people live with chronic pain. The programs are designed to help the individual reduce pain and reliance on opioid pain medicines. Programs last usually two to three weeks and can be done on an in-patient or out-patient basis.

Lower back pain exercises

http://rxharun.com/low-back-pain-exercise

A series of exercise routines you can do to help reduce any lower back pain (occasionally referred to as low back pain), including tension, stiffness, and soreness. These exercises from physiotherapists and BackCare expert Nick Sinfield help to stretch, strengthen and mobilize the lower back. When starting out, go gently to get used to the movements and work out how far you can go into each position without feeling pain.

Aim to do this routine at least once a day if the pain allows. You can complement this routine with walking, cycling and water-based activities. You are advised to seek medical advice before starting these back pain exercises and to stop immediately if you feel any pain.

Bottom to heels stretch

Stretches and mobilizes the spine

exercise-low-back-pain

Start position: Kneel on all fours, with your knees under hips and hands under shoulders. Don’t over-arch your lower back. Keep your neck long, your shoulders back and don’t lock your elbows.

Action: Slowly take your bottom backward, maintaining the natural curve in the spine. Hold the stretch for one deep breath and return to the starting position.

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Repeat 8 to 10 times.

Tips:

  • Avoid sitting back on your heels if you have a knee problem.
  • Ensure correct positioning with the help of a mirror.
  • Only stretch as far as feels comfortable.

Knee rolls

Stretches and mobilizes the spine

backpain-knee-roll

Start position: Lie on your back. Place a small flat cushion or book under your head. Keep your knees bent and together. Keep your upper body relaxed and your chin gently tucked in.

Action: Roll your knees to one side, followed by your pelvis, keeping both shoulders on the floor. Hold the stretch for one deep breath and return to the starting position.

Repeat 8 to 10 times, alternating sides.

Tips:

  • Only move as far as feels comfortable.
  • Place a pillow between your knees for comfort.

Back extensions

Stretches and mobilizes the spine backward

backpain-exercise/Back extensions

Start position: Lie on your stomach, and prop yourself on your elbows, lengthening your spine. Keep your shoulders back and neck long.

Action: Keeping your neck long, arch your back up by pushing down on your hands. You should feel a gentle stretch in the stomach muscles as you arch backward. Breathe and hold for 5 to 10 seconds. Return to the starting position.

Repeat 8 to 10 times.

Tips:

  • Don’t bend your neck backward.
  • Keep your hips grounded.

Deep abdominal strengthening

Strengthens the deep supporting muscles around the spine

http://rxharun.com/Deep abdominal strengthening

Start position: Lie on your back. Place a small, flat cushion or book under your head. Bend your knees and keep your feet straight and hip-width apart. Keep your upper body relaxed and your chin gently tucked in.

Action: As you breathe out, draw up the muscles of your pelvis and lower abdominals, as though you were doing up an imaginary zip along your stomach. Hold this gentle contraction while breathing from your abdomen for 5 to 10 breaths, and relax.

Repeat 5 times.

Tips:

  • This is a slow, gentle tightening of the lower abdominal region. Don’t pull these muscles in using more than 25% of your maximum strength.
  • Make sure you don’t tense up through the neck, shoulders or legs.

Pelvic tilts

Stretches and strengthens the lower back

backpain-exercise-Pelvic tilts

Start position: Lie on your back. Place a small, flat cushion or book under your head. Bend your knees and keep your feet straight and hip-width apart. Keep your upper body relaxed and your chin gently tucked in.

Action: Gently flatten your low back into the floor and contract your stomach muscles. Now tilt your pelvis towards your heels until you feel a gentle arch in your lower back, feeling your back muscles contracting and return to the starting position.

Repeat 10 to 15 times, tilting your pelvis back and forth in a slow rocking motion.

Tips:

  • Keep your deep abdominals working throughout.
  • Don’t press down through the neck, shoulders or feet.

Modification

  • Place one hand on your stomach and the other under your lower back to feel the correct muscles working

Use Pillows For Back Pain Effectively

Pillows are one way to help you sleep in a proper sleeping position. By propping your problem areas with a pillow, you can improve your chances of getting a restful night’s sleep. The correct pillow and mattress can also support your spine and prevent you from developing any stiffness or pain at night. The important thing is you reduce the strain around the joints.

Pillow Use for Side Sleepers

For side sleepers, putting a pillow between your knees can lift your one leg and keep your hips and knees in a neutral alignment. This position also helps relax the hip and stomach muscles. Side sleepers can also use a small pillow to fill up the space between the mattress and your waist or neck curve.

Pillow Use for Back Sleepers

Sleeping on the back or supine is the most recommended sleep position to get rid of upper middle back pain after sleeping. It does not only promote good neck and spinal posture at rest but helps relieve pain related to a muscle strain or injury. These conditions include a stiff neck, rotator cuff tear injuries, adhesive capsulitis, and ankylosing spondylitis. Unfortunately, no matter how healthy this sleeping position is, only 8% of the world’s population sleeps in this pose. Like all the sleeping positions, sleeping on the back can also use a little bit of padded support. In this case, it’s the knees that will benefit a lot from a pillow. When you sleep with knees, spinal cord, and neck muscles extended straight; you also risk creating lower back strain. That is because when you sleep, you are pulling your pelvis out of its neutral alignment and into an arched lower back.

Remedies Upper Back & Neck Pain After Sleeping

By propping a memory foam or regular small pillow under your knees, your legs will bend in a more natural sleeping posture. This sleeping position can also help get rid of severe shoulder pain and upper-middle back pain after sleeping, as it places your body in a more neutral position. If you feel like this position is too uncomfortable, you can prop your head and neck with a memory foam pillow against the mattress. That can ensure that your body is straight while its natural curve is supported.

Pillow Use for Stomach Sleepers

Stomach sleeping, also known as prone sleeping, is a very problematic sleep posture. Stomach sleepers put too much pressure and unnecessary tension on their rotator cuff tendons, facet joints, stomach, neck, spinal cord, and back muscles. Medical professionals advise patients to avoid it altogether. The sleeping posture also requires the neck to be rotated to one side for breathing purposes, further increasing your risks of getting a stiff neck.

Pillows do not do a good job of support with this position. However, you can try putting a flat pillow under your stomach to increase the length of your lower back curve. This further relaxes the muscles and rotator cuff tendons. You can try propping your head with a pillow to retain your body’s natural alignment during your sleep.

Correct positioning is essential to ease back pain. Although pillows may be effective, they often fall out of place during sleep. The best way to eliminate, or at least curb, upper back pain is to ensure a good night’s sleep. That is best achieved by using an adjustable bed frame that can put the spine in a neutral position that does not strain the vertebrae, muscles, or joints. A good mattress is also essential. It should cushion the body’s joints. The best way to avoid upper back pain after sleeping is by ensuring you get a good restorative sleep every night.

Homeopathy Treatment for Back Pain

  • Aesculus – Pain in the very low back (the sacral or sacroiliac areas) that feels worse when standing up from a sitting position, and worse from stooping, may be eased with this remedy. Aesculus is especially indicated for people with low back pain who also have a tendency toward venous congestion and hemorrhoids.
  • Arnica montana – This remedy relieves lower back aches and stiffness from overexertion or minor trauma.
  • Bryonia – This remedy is indicated when back pain is worse from even the slightest motion. Changing position, coughing, turning, or walking may bring on sharp, excruciating pain. This remedy can be helpful for back pain after injury and backaches during illness.
  • Calcarea carbonica – This is often useful for low back pain and muscle weakness, especially in a person who is chilly, flabby or overweight, and easily tired by exertion. Chronic low back pain and muscle weakness may lead to inflammation and soreness that are aggravated by dampness and cold.
  • Calcarea phosphorica – Stiffness and soreness of the spinal muscles and joints, especially in the neck and upper back, may be relieved by this remedy. The person feels worse from drafts and cold, as well as from exertion. Aching in the bones and feelings of weariness and dissatisfaction are often seen in people who need this remedy.
  • Natrum muriaticumBack pain that improves from lying on something hard or pressing a hard object (such as a block or book) against the painful area suggests a need for this remedy. The person often seems reserved or formal but has strong emotions that are kept from others. Back pain from suppressed emotions, especially hurt or anger may respond to Natrum muriaticum.
  • Nux vomicaThis remedy is indicated for muscle cramps or constricting pains in the back. Discomfort is made worse by cold and relieved by warmth. The pain usually is worse at night, and the person may have to sit up in bed to turn over. Backache is also worse during constipation, and the pain is aggravated when the person feels the urge to move the bowels.
  • Rhus Toxicodendron – This remedy can be useful for pain in the neck and shoulders as well as the lower back when the pain is worse on initial movement and improves with continued motion. Even though in pain, the person finds it hard to lie down or stay still for very long, and often restlessly paces about. Aching and stiffness are aggravated in cold damp weather and relieved by warm applications, baths or showers, and massage.
  • Sulfur – This remedy is often indicated when a person with back pain has a slouching posture. The back is weak and the person feels much worse from standing up for any length of time. Pain is also worse from stooping. Warmth may aggravate the pain and inflammation.

Other Remedies

  • Cimicifuga (also called Actaea racemosa) – Severe aching and stiffness in the upper back and neck, as well as the lower back—with pains that extend down the thighs or across the hips — may be eased with this remedy. It is often helpful for back pain during menstrual periods, with cramping, heaviness, and soreness. A person who needs this remedy typically is talkative and energetic, becoming agitated or depressed when ill.
  • Dulcamara – If back pain sets in during cold damp weather, along with catching a cold, or after getting wet and chilled, this remedy may be indicated. Stiffness and chills can be felt in the back, and pain is usually worse from stooping.
  • Ignatia – Back pains related to emotional upsets—especially grief—will often respond to this remedy. The muscles of the lower back may spasm, and twitches, drawing pains, and cramps often occur in other areas.
  • Kali carbonicum – Kali Carbonicum is a homeopathic medicine for lower back pain with the feeling that the knees are going to “give in.”
  • Hypericum perforatum – This homeopathic remedy relieves lower back pain with sharp throbbing pain.
  • Ruta graveolens – This is used to relieve lower back pain caused or worsened by staying immobile.

5 Essential oils that relieve back pain and inflammation

Along with physical therapy sessions and at-home exercises, consider using the following 5 essential oils throughout your recovery process:

1. Peppermint Oil

Peppermint oil is known for its menthol undertones, which are widely used for body pains. One of nature’s most potent analgesics, this type of oil helps sore muscles and reduces inflammation. It’s also known for calming those uncomfortable spasms that lead to muscle cramps. After a workout or physical therapy session, rub some peppermint oil on your back, and witness its healing properties. A similar oil is Wintergreen Oil, which has similar analgesic properties and is closely related to aspirin because of the methyl salicylate within it.

2. Lemongrass Oil

Next up is lemongrass oil, which is great for several health problems, among them chronic inflammation. We are talking about arthritis, cancer, or cardiovascular disease. When it comes down to back pain, lemongrass oil is among our top contenders! Because of its healing properties, it has become a popular essential oil in treating bodily aches. To use, apply a small amount to the sore area. Massage the area and let it do it work its magic. Lemongrass oil treats back pain by reducing inflammation, consequently, reducing the pain.

3. Ginger Oil

You may have heard of ginger commonly used in cooking. However, did you know it has other beneficial properties that go beyond being a delicious spice? The most notable benefits you’ll receive from ginger oil are anti-inflammatory properties. The best way to use ginger oil for back pain is to soak in a ginger oil-infused bath. A hot bath with 4-5 drops of oil is recommended. Simply lay there until the water cools. Along with alleviating inflammation, ginger oil soothes the digestive system and improves its function.

4. Lavender Oil

Lavender is among the most popular essential oils currently on the market. This is because it offers several ailments. Not only can it help alleviate headaches and promotes relaxation, but its benefits also transfer to back pain. You can apply this oil topically or add it to a warm bath. We even recommend using lavender oil in a diffuser. This will create a soothing effect and improve your mood. Inhaling this smell will relax your body.

5. Eucalyptus Oil

Last but not least, eucalyptus oil works wonders on back pain. It is known for its anti-inflammatory properties as well as its antibacterial ones. This oil is great for soothing sore muscles and joints. It contains strong analgesic and anti-inflammatory properties. If you suffer from mild back pain or body stiffness, applying some to the sore area works wonders! It’s no surprise it is a top-rated oil for backaches.

Prevention

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
  • Practice 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.

Posture

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

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 program.

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 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 a 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.

References

Back Pain

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