Back Pain

back pain

If you’ve got back pain, then you’re probably reading this booklet because you want to get better and because you want to understand more about this problem. You are in good company because 4 out of 5 of us get back pain at some time. However, most bouts of back pain get better in a short time and simple painkillers are all that are needed. Getting back to normal activities is the best way to cope with back pain.

This booklet is aimed at people who have more persistent (long-lasting) back pain. It explains some of the causes of back pain and what can be done to help it and prevent it happening again. The technical words in italics are explained in more detail in the glossary at the end of the page.

What is the anatomy of the back?

The back is a complicated structure built around the bones of the spinal column (see Figure 1). The spinal column consists of 24 bones (vertebrae) sitting one on top of another. It sits on a large bony bowl – the pelvis – and is topped by the skull. The bones of the spine are connected to one another by the discs at the front and by the facet joints at the back. The discs and facet joints allow the spinal column to bend and be flexible.

The nerves of the spinal cord, which connect the brain to the rest of the body, run down a hollow channel in the spine. Where the nerves pass out from the spinal column on their way to the muscles of the arms and legs they are known as nerve roots.

The bones of the back are also held together by tough bands called ligaments which, together with the spinal muscles, keep the back strong. The main muscles at the front and the back of the body are shown in Figures 3 and 4.

Why do I get a bad back?

Sprains of the back are a part of everyday life and the back is usually very good at taking these ‘knocks’. Often you can’t remember a sprain – an awkward movement may have caught your back ‘off guard’ and ‘pulled’ a muscle or sprained a ligament. Most cases of back pain are due to these sprains, which usually heal themselves within a short time.

Sometimes back pain is due to a ‘slipped’ disc, in which part of a disc may press on a sensitive structure such as a nerve. In this case the back pain may shoot into the leg causing sciatica.

More persistent back pain can occur in association with arthritis of the facet joints and degeneration of the discs (sometimes called spondylosis), but this is not always so. For example, there are people with very worn discs and facet joints who experience no pain whatsoever.

Other causes of back pain are rare – they include inflammation (see arc booklet ‘Ankylosing Spondylitis‘), and bone problems such as a fracture, infection or tumour.

Should I have an x-ray or scan?

Generally speaking, if your back pain has come on recently then a plain x-ray of your back will not help to identify the cause of the pain. There are two main reasons for this. Firstly, most back pain comes from the soft tissues of the back (such as ligaments and muscles) and these can’t be seen on an x-ray. Secondly, as we get older we all have changes in the bones of the back which are due to wear and, on a plain x-ray, these can be mistaken as the cause of the back pain.

Occasionally a CT or MRI scan may help. These are expensive tests for which there is generally a waiting list. They are normally only carried out when the doctor suspects a trapped nerve, particularly if surgery might be needed, or one of the rarer causes of back pain such as a fracture, inflammation, infection or tumour.

Why does back pain become persistent?

In some cases of persistent pain the cause of the pain (such as a facet joint or a disc) can be identified. However, it is important to realise that pain can sometimes continue even after the original cause (sprain, facet or disc) has long since settled down.

Pain may at first cause you to avoid normal activities and movement. If your initial spell of back pain lasts a long time, lack of activity can cause the back muscles to become weak, and this reduces the ability of the spine to take further knocks. You may also lose confidence in your ability to resume your normal activities. This may affect your work, your social life and your personal relationships. Naturally, you may feel depressed and anxious in this situation and this can lead to further loss of confidence, frustration and anger, particularly if family members and the medical profession appear unhelpful or unsympathetic. If you are anxious or depressed as a result of the pain you may not feel like exercising, so your muscles become weaker still, and so it goes on. Physical and psychological factors can therefore combine to create two interconnected vicious circles (see Figure 5).

This can happen to anyone, and the longer it continues the harder it will be for you to recover your movement and confidence. The sections that follow explain what can be done to prevent, or break, this cycle of pain.

What can be done to help?

Most people manage back pain by themselves and recover without any lasting problem. But people who have had one attack of back pain are likely to have others. To help protect yourself from further problems you need to keep your back flexible and strong. You also need to think about prevention, such as learning the correct way to lift heavy objects (see ‘What sort of things might make my back pain worse?’).

If your pain has just come on and is severe it may help to take some painkillers (such as paracetamol or aspirin) and it will feel more comfortable to rest. But do not rest for more than a few days – at this point you should try and get back to normal activities and do some gentle exercises (see ‘What back exercises should I do?’).

If the pain is severe or not getting better after a few days, you should see a doctor, physiotherapist, chiropractor or osteopath who will examine you to make sure your back problem is straightforward. They may advise specific treatments. These may involve manipulation (see ‘Would manipulation help?’) or exercises and education about back pain. They may also recommend some form of pain relief such as the use of hot packs, acupuncture or TENS. You may need an injection in the back area, particularly if you have sciatica.

Will an operation be needed?

Surgery is only used in a few cases (probably less than 1% of all cases of back pain). For example, a large piece of displaced disc can press on the nerves of the spinal cord and cause bladder problems (such as difficulty in passing or controlling urine). In this rare situation you need urgent surgery to remove the disc fragment. For severe cases of sciatica, surgery may sometimes be needed to relieve the pressure on the nerve. For less severe disc disease, it is usually better to let nature ‘take its course’ and, in most cases, the condition will improve without surgery.

How active should I be?

Generally, the more active the better. Unless your pain is very severe or causing bad sciatica you should try to stay mobile. Do some specific back exercises every day and some general fitness exercise as well (see ‘What back exercises should I do?’). Remember, specific exercises keep your back supple and strong, and general exercises help you feel good about yourself and help release natural painkillers (endorphins).

What can be done for persistent back pain?

If your back pain lasts for many months you will need help to cope. The answer may be a pain management programme which aims to teach you how to control, and live with, your pain. Understandably, people avoid situations which make their back pain worse, such as certain positions and activities. However, in persistent back pain the pain may not be an indication of damage or inflammation (see ‘Why does back pain become persistent?’). Education, therefore, plays an important part in the pain management approach, and will include a full explanation of the physical and psychological factors contributing to a person’s pain. It is usually possible for people to exercise and get fitter. This may be a slow process, but it helps people regain their physical confidence so that they can do more despite their pain. Specific exercises also help to strengthen the back muscles that have become weak with lack of use.

Pain management programmes vary from outpatient group sessions, usually led by physiotherapists, to residential in-patient programmes lasting 2–3 weeks. There are only a few residential centres in the UK but there are many non-residential centres. These programmes include education, exercise, coping strategies and the use of medication, and are delivered by a team including doctors, nurses and physiotherapists. Psychologists are also usually part of the team as they can explain why you might suffer psychological distress (often felt as anxiety and depression) and how you can cope with this.

What back exercises should I do?

Exercise is the most important way that you can help yourself. Any form of continuing pain will mean that you stop moving so well. This leads to your muscles wasting and this will make your back weaker and easily tired. So you need to restore strength and flexibility in your back. The body needs strong back muscles to work as a shock absorber for jolts and knocks which are part of daily life. If you look at Figure 3 you will see that the back is covered largely by muscles.

Your job is to:

  • regain flexibility
  • build up muscle strength and stamina
  • improve your general fitness.

You may be advised about specific exercises by a physiotherapist. Even when your back is sore you can make a start without putting too much stress on your back. Also, remember that your back may feel sore after the first few days of exercise – this is normal so don’t let it put you off (it may help to take some painkillers before exercising on these days).

The exercises fall into three main groups:

  • Stretching exercises These include exercises for the back and leg muscles (see Figure 6).
  • Strength, stamina and stabilizing exercises These include
    exercises for the back, stomach and leg muscles (see Figure 7).
  • Exercise for general fitness This includes any exercise which makes you out of breath, but choose something you enjoy such as swimming, cycling or keep-fit classes.

Any exercise is easier if you increase it gradually and if you do it along with someone else. You may have to reorganise your daily routine in order to fit the exercises in, but plan to do at least 30–45 minutes a day. Regular exercise not only keeps your back fit but also helps to strengthen bones, and will release natural chemicals (endorphins) which are the body’s own painkillers. If you are overweight, exercise will also help you to lose weight, which will reduce the strain on your back.

People who have arthritis in other joints can also do appropriate back exercises, but they may need different exercises – in this case it is best to take advice from a physiotherapist.

What sort of things might make my back pain worse?

Everyone is different but generally there are a number of situations which will make your back pain worse:

  • Sitting too long in one position, especially in a poor position, e.g. slumped in a chair (see Figure 8).
  • Driving is often a situation you can’t avoid but make sure the seat is adjusted correctly for your height (use a cushion to sit on if necessary). You should also maintain your lumbar curve, which is the curve that forms the hollow in the lower part of your back, and take regular breaks when on a long journey (see Figure 9). Some people find the Alexander technique helpful for improving posture and reducing muscle tension.
  • Lifting heavy weights incorrectly. Avoid lifting heavy objects if you can. If you must do it, always keep the weight close to your body and bend your knees.
  • Spending long periods bending over, such as when gardening. Use special gardening tools: see ‘What aids and appliances are available?’ Also see arc booklets ‘Your Home and Arthritis’ and ‘Gardening and Arthritis’.
  • Worrying. Try to avoid stress and too much worry – this can often make your back pain worse. You may want to try relaxation classes. Talk to others and make a plan about things which worry you.
  • Not taking regular exercise and doing your back routine!

Do corsets help?

Corsets are still commonly prescribed by doctors but they don’t usually do the job they are meant to do (which is to restrict your movement and carry some of the weight of the upper body). People can become dependent on corsets. It is better to strengthen your back by doing exercises and not rely on corsets.

Would manipulation help?

Manipulation may help to get rid of a spell of back pain – it is most often done by chiropractors and osteopaths but also by physiotherapists and some doctors. There are different types of manipulation which vary from imparting small movements to the spine directly with the hands to more vigorous movements using the limb as a ‘lever’. Ask your GP or consultant, or see ‘Useful addresses’.

Should I get a new bed?

Many people with back pain prefer a firm surface to lie and sleep on as they feel the back is better supported in this way. Many so-called orthopaedic beds provide this level of firmness. However, you may be able to get the same effect just by putting a board under your mattress. Look around carefully and try things out before buying a new bed.

What aids and appliances are available?

If you have long-standing back pain you may need to change how you do things to avoid making the pain worse. For example, as mentioned earlier, gardening can make you bend over for long periods of time. You should make changes such as using long-handled gardening tools. You can also buy back supports (not corsets!) for use when sitting at home, at work or in the car. Most towns have a centre or shop where these aids can be tried and purchased, for example Disabled Living Centres (see ‘Useful addresses’). You could also ask for advice from an occupational therapist who will help you change activities and advise on equipment or supports. See also arc booklets ‘Your Home and Arthritis’ and ‘Gardening and Arthritis’.

Do any special diets help?

If you are overweight you should consider a weight-reducing diet because of the extra strain that your weight puts on your leg joints and back. Exercise will help you to lose weight. As you will also be advised to stop smoking (as this may be an independent cause of back pain), you should take extra care to prevent the weight gain that often follows (see arc booklet ‘Diet and Arthritis’).

Should I give up work?

The answer to this question depends on your back pain, your age and your job. During a spell of back pain, we recommend that you try to stay at work or get back to work as soon as possible. If your job involves heavy physical work you may need some help when you return – talk to your foreman or boss. Statistics show that the longer you are off work the less likely it is that you will return.

People who work – particularly in physical jobs – may struggle if they develop persistent back pain. This is recognised by the Department for Work & Pensions. Your local Disability Employment Adviser (contacted via the local Jobcentre or Jobcentre Plus office) can arrange work assessment and retraining. If you are disabled due to back pain and wish to carry on working then either the Disability Employment Adviser or the Employment Medical Advisory Service may be able to help. The help they can provide will vary from person to person but they can, for example, provide necessary equipment to make it easier for you to do your job. A period of rehabilitation may help you get back to work (see ‘What can be done for persistent back pain?’).

What will the future hold for me?

Everyone is different, so it is impossible to describe a typical person with back pain. Don’t forget that this is a common problem, so many of the people around you are back pain sufferers. As mentioned earlier, people who have had one spell of back pain tend to get more – these spells may become more frequent and last longer. It may be possible for you to prevent this happening. Even if the back pain becomes persistent it may be possible to avoid the disability associated with it – see ‘Summary: What can I do to help myself?’ below.

Are any self-help groups available?

BackCare is the parent organisation for a number of local self-help groups which meet on a regular basis. Activities vary from meetings with a speaker to social activities and education and pain management, sometimes with exercise classes. The Pain Relief Foundation provides audiotapes dealing with back pain. (See ‘Useful addresses’.)

Summary: What can I do to help myself?

  • Remember, don’t panic! Most spells of back pain will get better.
  • Don’t rest for too long after the start of the pain – 2–3 days at most. Too much rest is bad for you – your muscles become flabby, your bones become thin (lose density), and it becomes even harder to get going again.
  • Gradually increase your normal activities, avoiding painful movements at first.
  • Do your back exercises regularly (see ‘What back exercises should I do?’) and without fail twice a day. This is your chance to fight back. You won’t notice a dramatic change but over time your back will become stronger and you’ll feel more confident about it. You will be able to lift again within the safety limits recommended.
  • Take up some additional form of exercise (what, more?! Yes, more! – we suggest you change your way of life). Keep-fit classes, exercise bikes and swimming are all good exercises.
  • Stop smoking. It makes exercising difficult and it may make back pain worse.

Glossary

Acupuncture – a method of obtaining pain relief which originated in China. Very fine needles are inserted, virtually painlessly, at a number of sites (called meridians) but not necessarily at the painful area. Pain relief is obtained by interfering with pain signals to the brain and by causing the release of natural painkillers (called endorphins).

Alexander technique – a method of teaching bodily awareness and reducing unwanted muscle tension. Lessons are given by qualified teachers who will assess and advise on such things as your standing and seating posture and your patterns of movement.

CT/MRI scans – computer tomographic (CT) scans use x-rays, and magnetic resonance imaging (MRI) uses magnets. Both involve the scanner taking a 3D picture of your body. You will have to lie very still for a few minutes as the pictures are taken. Sometimes an injection is given to improve the quality of the films. Both scanners can make you feel a bit claustrophobic so you should tell the radiographer if this worries you. MRI scanners are noisy, but you will be provided with ear mufflers!

Disc – the piece of gristle in between the vertebrae (the bones of the spine) which allows your spine to be flexible. A ‘slipped’ disc occurs when a piece of disc becomes detached or bulges out. It can then press on a nerve and cause pain. The disc as a whole doesn’t actually slip out.

Facet joints – the small joints between the vertebrae which allow the spinal column to rotate. The facet joints are at the back of the spine. Sometimes these can be the cause of back pain.

Injections – injections are sometimes given to help the pain. These may be given into tender points, the space around the spine (an epidural injection) or the facet joints. The injections sometimes have to be done in the x-ray department to allow better placement of the needle.

Ligament – tough fibrous bands which are attached to the vertebrae and give stability to the spine. They also restrict spinal movements.

Pelvis – the bones of the pelvis form a bowl shape which is connected to the spinal column at the sacroiliac joint and to the leg bones at the ball-and-socket joints of the hips. The pelvis contains vital organs such as the bladder and rectum and, in women, the womb.

Sciatica – pain felt in the leg due to irritation of the sciatic nerve, a major nerve running from the spine to the leg.

Spinal column – the name given to the backbone. It consists of the vertebrae, stacked one upon the other and connected by ligaments and muscles.

Spinal cord – a cord which runs down the centre of the spine and contains the nerves which connect the brain to all the other parts of the body. The nerve fibres are surrounded by several protective layers and pass through the vertebrae (the bones of the back). The spinal cord and the brain together form the central nervous system.

Spondylosis – normal ageing changes in the spine, which are frequently seen on plain x-rays.

TENS – transcutaneous electrical nerve stimulation. A TENS machine is a small battery-driven device. Small pads are applied over the painful area and the low voltage stimulation produces a pleasant tingling sensation. This can relieve pain by interfering with pain signals to the brain.

Vertebra (plural ‘vertebrae’) – one of the bones which make up the spinal column.

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