Back pain

What is Back pain

If you have lower back pain, you are not alone. About 80 percent of adults experience low back pain at some point in their lifetimes. It is the most common cause of job-related disability and a leading contributor to missed work days. In a large survey, more than a quarter of adults reported experiencing low back pain during the past 3 months.

Men and women are equally affected by low back pain, which can range in intensity from a dull, constant ache to a sudden, sharp sensation that leaves the person incapacitated. Pain can begin abruptly as a result of an accident or by lifting something heavy, or it can develop over time due to age-related changes of the spine. Sedentary lifestyles also can set the stage for low back pain, especially when a weekday routine of getting too little exercise is punctuated by strenuous weekend workout.

Sudden severe back pain

Most low back pain is acute, or short term, and lasts a few days to a few weeks. It tends to resolve on its own with self-care and there is no residual loss of function. The majority of 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.

Chronic Low Back Pain

Chronic back pain is defined as pain that persists for 12 weeks or longer, even after an initial injury or underlying cause of acute low back pain has been treated. About 20 percent of people affected by acute low back pain develop chronic low back pain with persistent symptoms at one year. In some cases, treatment successfully relieves chronic low back pain, but in other cases pain persists despite medical and surgical treatment.

 What structures make up the back?

The lower back where most back pain occurs includes the five vertebrae (referred to as L1-L5) in the lumbar region, which supports much of the weight of the upper body. The spaces between the vertebrae are maintained by round, rubbery pads called intervertebral discs that act like shock absorbers throughout the spinal column to cushion the bones as the body moves. Bands of tissue known as ligaments hold the vertebrae in place, and tendons attach the muscles to the spinal column. Thirty-one pairs of nerves are rooted to the spinal cord and they control body movements and transmit signals from the body to the brain.

The cause and the reasons for back pain

The vast majority of low back pain is mechanical in nature. In many cases, low back pain is associated with spondylosis, a term that refers to 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. Some examples of mechanical causes of low back pain include:

  • Sprains and strains account for most acute back pain.
  • 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.
  • 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.
  • 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. Spondylolisthesis is a condition in which a vertebra of the lower spine slips out of place, pinching the nerves exiting the spinal column.
  • A traumatic injury, such as from playing sports, car accidents, or a fall can injure tendons, ligaments or muscle resulting in low back pain.
  • Spinal stenosis is a narrowing of the spinal column that puts pressure on the spinal cord and nerves that can cause pain or numbness with walking and over time leads to leg weakness and sensory loss.
  • 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.

Low back pain is rarely related to serious underlying conditions, but when these conditions do occur, they require immediate medical attention. Serious underlying conditions include:

  • Infections  وTumors و Cauda equine و Abdominal aortic aneurysms و  Kidney stones

 Other underlying conditions that predispose people to low back pain include:

Inflammatory diseases of the joints  و Osteoporosis و  Fibromyalgia,

What are the risk factors for developing low back pain?عوامل خطر

Beyond underlying diseases, certain other risk factors may elevate one’s risk for low back pain, including:

Age: The first attack of low back pain typically occurs between the ages of 30 and 50, and back pain becomes more common with advancing age.

Fitness level: Back pain is more common among people who are not physically fit.

Pregnancy is commonly accompanied by low back pain, which results from pelvic changes and alterations in weight loading. Back symptoms almost always resolve postpartum.

Weight gain: Being overweight, obese, or quickly gaining significant amounts of weight can put stress on the back and lead to low back pain.

Genetics: Some causes of back pain, such as ankylosing spondylitis, a form of arthritis that involves fusion of the spinal joints leading to some immobility of the spine, have a genetic component.

Occupational risk factors: Having a job that requires heavy lifting, pushing, or pulling,

Mental health factors: Pre-existing mental health issues such as anxiety and depression can influence how closely one focuses on their pain as well as their perception of its severity. Pain that becomes chronic also can contribute to the development of such psychological factors. Stress can affect the body in numerous ways, including causing muscle tension.

Backpack overload in children: Low back pain unrelated to injury or other known cause is unusual in pre-teen children.

Symptoms

Back pain varies widely. Some symptoms  may suggest that the back pain  has a more serious cause. These include fever, recent trauma, weight loss, a history of cancer and neurological symptoms, such as numbness, weakness or incontinence (involuntary loss of urine). Back pain usually is accompanied by other symptoms that may help point to its cause. For example:

  • Back sprain or strain– Back pain typically begins on the day after heavy exertion. Muscles in the back, buttocks and thighs are often sore and stiff. The back may have areas that are sore when touched or pressed.
  • Fibromyalgia – In addition to back pain, there are usually other areas of pain and stiffness in the trunk, neck, shoulders, knees and elbows. Pain may be either a general soreness or a gnawing ache, and stiffness is often worst in the morning. People usually complain of feeling abnormally tired, especially of waking up tired, and they have specific areas that are painful to touch, called tender points.
  • Degenerative arthritis of the spine– Together with back pain, there is stiffness and trouble bending over, which usually develops over many years.
  • Inflammatory arthritis, including ankylosing spondylitis and related conditions– In these disorders, there is pain in the lower back, together with morning stiffness in the back, hips or both. There also can be pain and stiffness in the neck or chest or an extremely tired feeling. Other features may include psoriasis, eye pain and redness, or diarrhea, depending on the specific disorder causing back pain. This group of diseases is a relatively rare cause of back pain.
  • Osteoporosis– This common condition is characterized by thinned, weakened bones that fracture easily. It is most common in postmenopausal women. When vertebrae become compressed because of fracture, posture may become stooped over or hunched along with back pain. Osteoporosis is not painful unless a bone fractures.
  • Cancer in the spinal bones or nearby structures– Back pain is consistent and may become worse when you are lying down. Numbness, weakness or tingling of the legs that continues to get worse. If cancer spreads to spinal nerves that control the bladder and bowel, there may be bowel or bladder incontinence (loss of control).
  • Protruding disk– People with significant disk disease sometimes have severe pain in the lower back. If a disk compresses a nerve, the pain may spread down one leg. The pain gets worse during bending or twisting.
  • Spinal stenosis– Pain, numbness and weakness affect the back and legs. Symptoms get worse when you are standing or walking, but are relieved by sitting or leaning forward.
  • Pyelonephritis– People with a kidney infection typically develop sudden, intense pain just beneath the ribs in the back that may travel around the side toward the lower abdomen or sometimes down to the groin. There also can be a high fever, shaking chills and nausea and vomiting. The urine may be cloudy, tinged with blood or unusually strong or foul-smelling. There may be additional bladder related symptoms, such as the need to urinate more often than normal or pain or discomfort during urination.

Diagnosis

Your doctor  will ask about your symptoms and your medical history. He or she will examine your back muscles and spine and will move you certain ways to check for pain, muscle tenderness or weakness, stiffness, numbness or abnormal reflexes. For example, if you have a disk problem, you may have pain in your lower back when the doctor raises your straightened leg.

Your symptoms and the physical examination may give your doctor enough information to diagnose the problem. However, with back pain, your doctor may only be able to tell you that the problem is not serious. If your doctor determines that your back pain is caused by muscle strain, obesity, pregnancy or another cause that is not urgent, you may not need any additional tests. However, if he or she suspects a more serious problem involving your vertebrae or spinal nerves, especially if your back pain has lasted longer than 12 weeks, you may need one or more of the following tests:

  • X-rays of your back
  • Blood test
  • Urine tests
  • Spinal magnetic resonance imaging (MRI)
  • Computed tomography (CT) scan
  • Nerve conduction studies and electromyography to determine whether nerves, muscles or both may be injured
  • Bone scan, especially if you have a previous history of cance

Treatment of back pain

Treatment for low back pain generally depends on whether the pain is acute or chronic. In general, surgery is recommended only if there is evidence of worsening nerve damage and when diagnostic tests indicate structural changes for which corrective surgical procedures have been developed.

Conventionally used treatments and their level of supportive evidence include:

Hot or cold packs have never been proven to quickly resolve low back injury; however, they may help ease pain and reduce inflammation for people with acute, subacute, or chronic pain, allowing for greater mobility among some individuals.

Activity: Bed rest should be limited. Individuals should begin stretching exercises and resume normal daily activities as soon as possible, while avoiding movements that aggravate pain. Strong evidence shows that persons who continue their activities without bed rest following onset of low back pain appeared to have better back flexibility than those who rested in bed for a week. Other studies suggest that bed rest alone may make back pain worse and can lead to secondary complications such as depression, decreased muscle tone, and blood clots in the legs.

Strengthening exercises, beyond general daily activities, are not advised for acute low back pain, but may be an effective way to speed recovery from chronic or subacute low back pain. Maintaining and building muscle strength is particularly important for persons with skeletal irregularities. Health care providers can provide a list of beneficial exercises that will help improve coordination and develop proper posture and muscle balance. Evidence supports short- and long-term benefits of yoga to ease chronic low back 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 combinations with other interventions.

Medications: A wide range of medications are used to treat acute and chronic low back pain. Some are available over the counter (OTC); others require a physician’s prescription. Certain drugs, even those available OTC, may be unsafe during pregnancy, may interact with other medications, cause side effects, or lead to serious adverse effects such as liver damage or gastrointestinal ulcers and bleeding. Consultation with a health care provider is advised before use.

Manual therapy and massage

Spinal manipulation and spinal mobilization are approaches in which professionally licensed specialists (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 have been shown to provide small to moderate short-term benefits in people with chronic low back pain. Evidence supporting their use for acute or subacute low back pain is generally of low quality. Neither technique is appropriate when a person has an underlying medical cause for the back pain such as osteoporosis, spinal cord compression, or arthritis.

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 that relief is usually temporary. Once traction is released the back pain tends to return. There is no evidence that traction provides any longterm benefits for people with low back pain.

Acupuncture is moderately effective for chronic low back pain. It involves the insertion of thin needles into precise points throughout the body. Some practitioners believe this process helps clear away blockages in the body’s life force known as Qi (pronounced chee).

Biofeedback is used to treat many acute pain problems, most notably back pain and headache. The therapy involves the attachment of electrodes to the skin and the use of an electromyography machine that allows people to become aware of and selfregulate their breathing, muscle tension, heart rate, and skin temperature. People regulate their response to pain by using relaxation techniques. Biofeedback is often used in combination with other treatment methods, generally without side effects.

Nerve block therapies aim to relieve chronic pain by blocking nerve conduction from specific areas of the body. Nerve block approaches range from injections of local anesthetics, botulinum toxin, or steroids into affected soft tissues or joints to more complex nerve root blocks and spinal cord stimulation. When extreme pain is involved, low doses of drugs may be administered by catheter directly into the spinal cord. The success of a nerve block approach depends on the ability of a practitioner to locate and inject precisely the correct nerve. Chronic use of steroid injections may lead to increased functional impairment.

Epidural steroid injections are a commonly used short-term option for treating low back pain and sciatica associated with inflammation. Pain relief associated with the injections, however, tends to be temporary and the injections are not advised for long-term use. An NIH-funded randomized controlled trial assessing the benefit of epidural steroid injections for the treatment of chronic low back pain associated with spinal stenosis showed that long-term outcomes were worse among those people who received the injections compared with those who did not.

Surgery

When other therapies fail, surgery may be considered an option to relieve pain caused by serious musculoskeletal injuries or nerve compression. It may be months following surgery before the patient is fully healed, and he or she may suffer permanent loss of flexibility.

Surgical procedures are not always successful, and there is little evidence to show which procedures work best for their particular indications. Patients considering surgical approaches should be fully informed of all related risks.

Prevention

You can help prevent some forms of back pain by strengthening your back with exercises and by avoiding activities that lead to back injury. Measures that may help prevent back pain include:

  • Maintaining good posture.
  • Sleeping on your side or on your back with a pillow under your knees if you can.
  • Exercising regularly, but stretch before and after.
  • Practicing abdominal crunches to strengthen abdominal muscles, which support your lower back. Also, walk or swim regularly to strengthen your lower back.
  • Always lifting objects from a squatting position, using your hips and your legs to do the heavy work. Avoid lifting, twisting and bending at the same time.
  • To help prevent osteoporosis, make sure you get enough calcium and vitamin D daily to meet the dietary requirements for your age group. Follow a routine program of weight-bearing exercise. Avoid smoking and limit the amount of alcohol you drink. If you are a woman who has entered menopause, speak with your doctor about testing for osteoporosis and medications that can help to prevent or reverse it.Avoiding sitting or standing for extended periods of time.
  • Wearing soft soled shoes with heels that are less than 1 and one-half inches high.