Lower Back Pain

The lumbar spine (lower back) is a remarkable structure of well-engineered interconnected nerves, ligaments, bones, joints and muscles that work together to support the weight of the upper body. The lumbar spine provides strength, flexibility and mobility for everyday motions. 

Most acute lower back pain (pain that is short term lasting a few days to a few weeks) tends to result from injury to the ligaments, joints, muscles or spinal discs. When injury is the cause of lower back pain, the body reacts by mobilising an inflammatory healing response to the area. Such inflammation can cause severe lower back pain.

Types of Low Back Pain

There are many ways to categorise lower back pain, the two most common types include:

  1. Mechanical pain (Axial pain). This is by far the most common cause of lower back pain, caused primarily by placing abnormal stress and strain on the ligaments, muscles, joints (facet joints and sacroiliac joints), or the bones in and around the vertebral column. This type of pain tends to be localised to the lower back, buttocks and sometimes the upper region of the legs. 
  2. Radicular pain. This type of pain develops when the spinal nerve root becomes impinged or inflamed. Radicular pain may follow a nerve root down into the buttock and even leg. The pain is described as sharp and intense, an electric, burning-type of pain and can be accompanied with numbness or weakness (sciatica) typically felt on only one side of the body.

 

Lower Back Anatomy

ANATOMY OF Lower Back Pain – (IMAGE HERE)

The lumbar spine consists of five vertebrae labeled L1 through to L5 and typically has a slight inward curve known as Lordosis.

The lower back region contains large muscles that support the back and allow for movement in the trunk of the body. These muscles can become strained or may spasm, which is usually the cause of lower back pain.

Connecting the five vertebrae of the lumbar spine are facet joints in the back of the spine, these allow for twisting movements as well as forward and backward extensions. The lowest two segments in the lumbar spine, L4-L5 and L5-S1 bear the majority of weight and have the most movement, making the area prone to injury.

In between the spinal vertebrae are intervertebral discs, these discs cushion the joints of the spine, act as absorbers of impact or movement and provide support. The spinal discs in the lower region of the spine, are most likely to degenerate or herniate which can cause lower back pain, or pain radiating down the legs and feet (sciatica).

The spinal cord travels from the base of the skull to where the thoracic spine (middle back) meets the lumbar spine at T12-L1. It is from this segment that the nerve roots branch out from the spinal cord, forming the Cauda Equina (where the nerves fan out into a bundle of fibres resembling a horse’s tail).

Some lower back conditions may compress these nerve roots, resulting in pain that radiates to the lower extremities, this is known as Radiculopathy.

Lower Back Pain Symptoms

Managing lower back pain appropriately at an early stage, can help limit symptoms in both time and severity. Lower back pain may begin as acute due to an injury, but can become chronic (whereby pain persists for 12 weeks or longer, even after an initial injury or underlying cause of acute lower back pain has been treated). 

Common Symptoms of Lower Back Pain

The first step in obtaining effective lower back pain relief, is to identify the symptoms and getting a diagnosis that pinpoints the underlying cause of the pain. Lower back pain is typically characterised by a combination of the following symptoms:

  1. Dull, aching pain. When pain is felt as dull and aching rather than sharp, burning or stinging. It remains within the lower back (axial pain) accompanied by aches in the hips and pelvis, with mild or severe muscle spasms and limited mobility.
  2. Pain that travels to the buttocks, legs, and feet. Sometimes lower back pain is in the form of a stinging, sharp, tingling or numb sensation that moves down the thighs and into the lower legs and feet, known as Sciatica. Sciatica is a symptom of lower back pain and occurs when the sciatic nerve is irritated and is usually only felt on one side of the body.
  3. Pain that is worse after prolonged sitting. Sitting puts pressure on the discs, causing lower back pain to worsen after being sat for long periods of time. 
  4. Pain that feels better when changing positions helps identify the source of pain.
  5. Pain that is worse after waking up and better after moving around. Many who experience lower back pain, report symptoms that are worse first thing in the morning. 

When lower back pain is felt in the morning, it is usually due to stiffness caused by long periods of rest, decreased blood flow during sleep and possibly due to the quality of mattress and pillows used. These symptoms usually go away after getting up and moving around. 

Lower back pain varies on an individual basis with many factors influencing the pain experienced, ranging from: financial stress, exercise, and general activity levels to mental and emotional health.

Common Causes Of Lower Back Pain

This list below includes the more common causes of lower back pain, but there are many more. Finding the optimal treatment for lower back pain usually depends on obtaining a correct clinical diagnosis (internal link here to LBP Diagnosis) that identifies the underlying cause of the patient’s symptoms.

  1. Lumbar herniated disc. When the jelly-like centre of a lumbar disc protrudes through the tough outer layer that encases it, irritation to nearby nerve roots can occur. The herniated portion of the disc is full of proteins that cause inflammation when it reaches the nerve root. It is this inflammation, as well as nerve compression, that causes pain. 
  2. Degenerative disc disease. At birth the spinal discs are full of water and at their healthiest. As we age the spinal discs lose hydration and wear down over time. As the disc loses hydration, they in turn lose their cushioning effect and cannot resist force so well. The disc wall takes the brunt of force, developing tears, causing pain or weakening that can lead to a disc herniation. 
  3. Facet joint dysfunction. Behind each spinal disc there are two facet joints at each motion segment in the lumbar spine. These joints have cartilage between the bones and are surrounded by a capsular ligament which contain a dense network of nerves. These joints can be painful by themselves, or in conjunction with spinal disc pain. (IMAGE HERE)
  4. Sacroiliac joint dysfunction. Connecting the sacrum at the bottom of the spine to each side of the pelvis, is the Sacroiliac joint (a strong, low-motion joint that primarily absorbs shock and tension between the upper body and the lower body). If this joint becomes inflamed or if there is too much or too little motion, pain can ensue.
  5. Spinal stenosis. This condition causes pain when there is a narrowing of the spinal canal where the nerve roots are located. The narrowing can be central, forminal, or both, at a single level or multiple levels in the lower back.
  6. Spondylolisthesis. This condition occurs when one vertebra slips over the adjacent one. The pain can be caused by compression of the nerves (leg) or instability (back).
  7. Osteoarthritis. This condition occurs when there is wear and tear of the disc and facet joints. It causes pain, inflammation, instability, and is slowly progressive, often associated with ageing. It is also referred to as spondylosis or degenerative joint disease.
  8. Deformity. Scoliosis or kyphosis is the deformity in curvature of the spine. This deformity is associated with lower back pain if it leads to the breakdown of the facet joints, discs, sacroiliac joints or stenosis.
  9. Trauma. Dislocations of the spine or acute fractures can lead to lower back pain that develops after a trauma, such as a fall or a motor vehicle accident.
  10. Compression fracture. A fracture occurring in the cylindrical vertebra where the bone essentially caves in on itself, can cause sudden pain. This kind of fracture is most commonly a result of weak bones, such as from osteoporosis, seen frequently amongst older people.

It is important to note that the presence of one or more of these conditions does not necessarily mean that they are the cause of pain. Osteoarthritis or degenerative disc disease for example, could appear on an imaging study but the person may not report pain.

Diagnosing Lower Back Pain

Getting an accurate diagnosis identifying the underlying cause of the pain is important in guiding treatment. From the patient’s symptoms and medical history, a doctor will usually have a general idea of the source of the patient’s pain. 

Patient History

Before a physical exam, the patient will discuss symptoms and medical history. This typically includes:

  1. Information about current symptoms. How far does the pain spread? What does the pain feel like— sharp, tight, dull, achy, stinging? Is the pain better or worse at certain times of day? 
  2. Activity level. Does the person lead a generally more active or sedentary lifestyle? How often does the person exercise?
  3. Sleep habits. How many hours of sleep does the patient get? What sleep position is preferred? (Link to MATTRESS & PILLOW Products here)
  4. Posture. What kind of posture feels comfortable or uncomfortable? 
  5. Injuries. Has the person had any recent injuries or past injuries that might be relevant now?
Answers to these questions provide a doctor with a fuller picture of the patient’s daily life, indicating more specific possibilities for their lower back pain. 

Physical Exam

A typical physical examination for lower back pain includes a combination of the following steps, with the goal to further narrow down possible causes of pain:

  • Palpation. A doctor will feel, by hand (also called palpation), along the lower back to locate any muscle spasms, tightness, areas of tenderness, or joint abnormalities.
  • Neurologic exam. This likely includes a motor exam, which involves manual movement of knee, hip and back extension as well as flexion (movement forward and backward). 
  • Range of motion test. Bending or twisting in certain positions, to look for positions that worsen or recreate pain.
  • Reflex test. The patient’s reflexes in the legs will be checked to evaluate weakened responses and decreased muscle strength. A nerve root might not be responding as it should if reflexes are diminished.
  • Leg raise test. Laying on the back and raising one leg as high and as straight as possible. If this leg raise test recreates lower back pain, a herniated disc might be suspected.
Lower back pain is usually diagnosed by a doctor given the information gleaned from a patient’s medical history and physical examination.

Diagnostic Imaging Tests

To gain more information on the cause of a patient’s pain, an imaging scan is sometimes needed when a patient’s pain is severe (not improving with nonsurgical treatments and not relieved within two or three months).

Common imaging tests include:

  1. X-rays are used to look at the bones of the spine. They show abnormalities, such as arthritis, fractures, bone spurs, or tumours.
  2. CT scan/Myelogram. This detailed image allows doctors to look closely at the spine from different angles and provides a cross-sectioned image of the spine.
  3. An MRI, provides a detailed image of spinal structures without using the radiation required with x-rays. An MRI can detect abnormalities with soft tissues, such as: muscles, ligaments and intervertebral discs. An MRI might also be used to locate misalignments or joint overgrowth in the spine.

 

Treatments For Lower Back Pain

Many treatment options for lower back pain can be tailored to an individual patient’s needs. Treatments include: medicinal remedies, alternative care, care administered at spinal health centres (link to shc list) or even care at home. Depending on the patient’s diagnosis, some treatments may be more effective than others. Many people find a combination of treatments to be best.

1. Self-Care for Lower Back Pain

Self-care can be effective for treating mild or acute pain such as from a muscle strain, or to reduce the effects of chronic, severe pain. Some self-care methods include:

  • Short rest period. Briefly avoiding strenuous activity can improve many episodes of lower back pain. It is not advised to rest for more than a few days, as too much inactivity can make healing more difficult.
  • Activity modification. One variant of resting is to stay active but avoid activities and positions that aggravate the pain. Avoiding, or minimising, activities and positions that worsen the pain, will help prevent or reduce back spasms and foster a better healing environment.
  • Heat/ice therapy. A warm bath, hot water bottle, electric heating pad, or chemical/adhesive heat wraps can improve blood flow and relax tense muscles. This brings the nutrients and oxygen that muscles need, to heal and stay healthy. Ice or cold packs can be used to reduce swelling if the lower back is painful due to inflammation. When returning to regular activity, alternating heat and ice can be especially helpful. Applying heat before activities helps relax muscles, allowing for better flexibility and mobility. On the other hand, applying ice after activity, reduces the chances of an area becoming irritated and swollen from exercise. It’s important that you protect the skin while applying heat and ice to prevent tissue damage. (Link to Heat Therapy and Ice Pack here)
  • Over-the-counter pain medications. The most common over-the-counter (OTC) medications are aspirin, ibuprofen, and naproxen. These OTCs are anti-inflammatory medicines, which alleviate lower back pain caused by a swollen nerves or muscles.

2. Exercises for Lower Back Pain

4 Easy Stretches for Lower Back Pain Video

Physical therapy is usually part of a lower back pain management regimen.  These are a few types of exercises used to rehabilitate the spine:

  • Stretching. Almost everyone can benefit from stretching muscles in the lower back, buttocks, hips, and legs (especially the hamstring muscles). These muscles support the weight of the upper body. The more mobile these muscles are, the more the back can move without injury. It is usually advised to start with small stretches for 20 to 30 seconds and stop a stretch if it causes pain.
  • Strengthening exercises. Strengthening the abdominal, hip, and gluteal muscles that support the spine, also called the core muscles, can help relieve lower back pain. The McKenzie method and Dynamic Lumbar Stabilization are two common programs.
  • Low-impact aerobics. These exercises increase blood flow and support healing from injuries without jarring the spine. Low-impact aerobics can include: walking, using stationary bikes, step machines and water therapy
People with lower back pain who regularly do aerobic exercises, report fewer recurring pain episodes and are more likely to stay active and functional when pain flares.

Exercise that elevates heart rate for a sustained period of time, benefits the body. Regular physical activity is important for maintaining the range of motion and flexibility of a healthy spine. When spinal structures go unused for too long, stiffness and discomfort can worsen.

3. Alternative Treatments

Non-medical treatments may be referred to as alternative or complementary care. The term “alternative” should not imply inferior, but instead non traditional, according to western medical standards.

There are many patient reports of lower back pain relief from alternative treatments. Common options include:

  • Nutrition. Improving one’s nutritional intake of Vitamin D, Calcium, Magnesium for bones, Glucosamin and Chondroitin (for soft tissues, supporting and maintaining the health of the lower back).
  • Manual manipulation. A healthcare practitioner such as a Chiropractor, Osteopath or Physiotherapist make physical adjustments to the spine with the goal of reducing stiffness and improving mobility, discomfort or pain. 
  • Acupuncture. Acupuncture can be used to stimulate points on the body thought to correct the body’s “qi,” or life force. It is believed that proper qi decreases discomfort in the body and pain. (Find an Acupuncturist link here
  • Massage therapy. Applied to the lower back, massage therapy can relieve the muscle spasms that usually contribute to lower back pain. Massages also increase the blood flow to the lower back, helping to speed up healing by bringing nutrients and oxygen to damaged muscles.
  • Mindful meditation. Meditation may be helpful in reducing the perception of pain, depression, anxiety and sleep problems that commonly occur with chronic pain. Meditative techniques include everything from deep breathing exercises, to an altered focus approach.

4. Back Pain Surgery

Surgery is usually not recommended for mild to moderate back pain, or for pain that has lasted for less than 6 to 12 weeks. Additionally, back surgery is not an option if the cause of the pain is undetectable through imaging tests.

Tips to Prevent Lower Back Pain

  1. Exercise your core. It is important to have strong core muscles to avoid injury and provide support to the lower back. Low-impact cardiovascular exercises—like walking—increases blood flow to the spine, suppling healing nutrients and hydration to the structures in your lower back.
  2. Correct your posture. Having a poor posture places pressure and stress on your back, can cause disc degeneration or can worsen an existing condition. Support the natural curve in your lower spine by using an ergonomic chair (product link here), reminding yourself to check your posture as you work throughout the day. If you sit most of the day, get up and walk around at least once an hour. If you can, use a standup desk for at least part of the day. (Stand up desk here link)
    Read: Ten Tips for Improving Posture and Ergonomics
  3. Lift heavy objects correctly. Even if you’re young and strong, if you lift a heavy object incorrectly you can still injure your lower back. If you don’t know the proper technique, (create a page and make it an internal link here)
  4. Be a savvy athlete. Regardless of how fit and athletic you are, a wrong move could injure. Make sure you understand the potential lower-back pitfalls of your favourite sport. See below for more information:

Preventing Lower Back Pain (Articles)