Back Pain: Causes, Testing, Treatment and Prevention

February 27, 2019

a man with back pain

Low back pain can have many causes. However, most people (>85 percent) have "nonspecific low back pain," which means that there is not a specific disease or abnormality in the spine clearly causing the pain. Rarely, low back pain is caused by a serious spinal condition, such as an infection, tumor, or a disorder called cauda equina syndrome, which causes weakness and bowel or bladder dysfunction as well as low back pain. Other potential causes include spinal compression fractures, in which one or more vertebrae become fractured as a result of weakening and thinning of the bones due to osteoporosis.  Many people attribute their back pain to a degenerating disc or arthritis, although problems in the muscles or ligaments are more likely responsible.

Degenerative disc disease — Normal aging leads to degenerative disc disease (breakdown of the spinal discs), with small cracks and tears and loss of fluid in the discs. This can lead to other changes, including the formation of arthritic bone spurs. Calling this a "disease" is somewhat misleading because these changes occur with normal aging and frequently cause no symptoms. In fact, many people have degenerative disc disease on X-rays or MRI but have no pain or other symptoms.

Facet joint arthropathy — Facet joint arthropathy refers to arthritis in the joints connecting the vertebrae to one another (facet joints). This can lead to bone spurs around the joint and may cause low back pain. However, like degenerative disc disease, facet joint arthropathy is very common with aging and many people have arthritis but no symptoms.

Herniated disc — Wear and tear on spinal discs can lead to herniation of a disc, in which the outer covering is weakened or torn, and the soft inner tissue leaks out the hole (a "slipped disc"). Herniated discs can cause leg pain or weakness if the disc fluid presses on a nerve root. Herniated discs are commonly seen with aging and on routine testing, even in people with no low back pain. Herniated discs usually heal over time because the body breaks down and the excess disc material and it is absorbed, relieving pressure or irritation on the nerve.  A bulging disc leaks out less than a herniated disc. It is more common than a herniated disc and is seen in over half of people who have no back pain. A bulging disc usually causes no symptoms.

Occupational back pain — Factors that may contribute to low back pain at work include poor posture while sitting or standing, sitting or standing for long periods of time, driving long distances, improper lifting techniques, frequent lifting, lifting excessively heavy loads, or repetitive high-impact activities. Low back pain is as common among clerical workers who sit for prolonged periods as in people whose jobs require heavy lifting.

Psychological factorscan contribute to low back pain. These include depression, anxiety, stress, job dissatisfaction, boredom, tension, as well as how the body responds to everyday physical demands. Workplace stress can be managed with counseling. Resolving psychological factors improves a person's chances of recovering from low back pain.

TESTS — The vast majority of people with low back pain get better on their own within four to six weeks without any testing or professional  treatment.  Imaging tests, including X-rays, computed tomography (CT) scanning, or a magnetic resonance imaging (MRI), may be recommended for people with certain conditions:  — X-rays may be recommended for selected people who have risk factors or signs of infection, cancer, or vertebral compression fracture related to osteoporosis. — CT scanning and MRI is usually necessary to diagnose a broken bone, a herniated disc or spinal stenosis. These tests may be recommended if there are risk factors or signs of cancer, if surgery is being considered, or if low back pain persists for more than four to six weeks and the cause of pain cannot be determined with other methods.

However, most people with low back pain do not require a test. Disc and spine abnormalities are common even among people without low back pain. In fact, a herniated disc is seen on MRI or CT in over 25 percent of people without low back pain.

TREATMENT — Unless low back pain is caused by a serious medical condition, a rapid recovery is expected, even if there is a bulging or herniated disc. There are also many things that can help with the symptoms while the body heals itself:

Remaining active — Studies have shown that people with low back pain recover faster when they remain active. Movement helps to relieve muscle spasms and prevents loss of muscle strength.  Continue doing regular day-to-day activities and light exercises, such as walking. If back pain is severe, bedrest may be necessary for a short period of time, but generally no more than one day . When in bed, the most comfortable position may be to lie on the back with a pillow behind the knees and the head and shoulders elevated, or to lie on the side with the upper knee bent and a pillow between the knees.

Ice/Heat — Using a heating pad can help with low back pain during the first few weeks. In addition, cold may help numb the area and reduce swelling.

Work — Most experts recommend that people with low back pain continue to work as long as it is possible to avoid prolonged standing or sitting, heavy lifting, and twisting. While standing at work, elevating one foot by stepping on a stool or block of wood with one foot (and periodically alternating the foot on the block) may be helpful.

Pain medications — Nonsteroidal anti-inflammatory drugs (NSAIDs), such as aspirin, ibuprofen (sample brand names: Advil, Motrin), and naproxen (brand name: Aleve), may work better than acetaminophen (brand name: Tylenol) for low back pain. If medication is needed, it is usually more effective to take a dose on a regular basis for three to five days, rather than using the medication only when the pain becomes unbearable.  Opioids (drugs derived from morphine) are not recommended because they have not been found to be more effective than other pain medications for treating chronic back pain; additionally, they have a relatively high risk of side effects and the potential to cause harm with long-term use.

Exercise — Exercises can help to increase back flexibility and strengthen the muscles that support the back. Although starting back exercises or stretching immediately after a new episode of low back pain might temporarily increase the pain, the exercise may reduce the total duration of pain and prevent recurrent episodes.  Recommended activities include those that involve strengthening and stretching, such as yoga, tai chi, walking, swimming, use of a stationary bicycle, and low-impact aerobics. People with frequent episodes of low back pain should continue these exercises daily to prevent new episodes.

Physical therapy — If back pain has been present for more than four to six weeks or there are signs that the back pain is not improving, a healthcare practitioner may recommend working with a physical therapist to develop a formal exercise program.

PREVENTION — There are several ways to prevent low back pain from returning. Perhaps the most important are exercise and staying active. Regular exercise that improves cardiovascular fitness can be combined with specific exercises to strengthen the muscles of the hips and torso. The abdominal muscles are particularly important in supporting the lower back and preventing back pain. It is also important to avoid activities that involve repetitive bending or twisting and high-impact activities that increase stress in the spine.

Bend and lift correctly — People with low back pain should learn the right way to bend and lift. As an example, lifting should always be done with the knees bent and the abdominal muscles tightened to avoid straining the weaker muscles in the lower back.

Take a break — One of the worst things you can do for a back is sit.  Sitting causes the pressures in the lumbar spine to go up three times higher than when walking.  People who sit or stand for long periods should change positions often and use a chair with appropriate support for the back. An office chair should be readjusted several times throughout the day to avoid sitting in the same position. Taking brief but frequent breaks to walk around will also prevent pain due to prolonged sitting or standing. People who stand in place for long periods can try placing a block of wood on the floor, stepping up and down every few minutes.