Back pain - low

Definition

Pain felt in your lower back may come from the spine, muscles, nerves, or other structures in that region. It may also radiate from other areas like your mid or upper back, a hernia in the groin, or a problem in the testicles or ovaries.

You may feel a variety of symptoms if you've hurt your back. You may have a tingling or burning sensation, a dull aching, or sharp pain. You also may experience weakness in your legs or feet.

It won't necessarily be one event that actually causes your pain. You may have been doing many things improperly -- like standing, sitting, or lifting -- for a long time. Then suddenly, one simple movement, like reaching for something in the shower or bending from your waist, leads to the feeling of pain.

Considerations

If you are like most people, you will have at least one backache in your life. While such pain or discomfort can happen anywhere in your back, the most common area affected is your low back. This is because the low back supports most of your body's weight.

Low back pain is the #2 reason that Americans see their doctor -- second only to colds and flus. Many back-related injuries happen at work. But you can change that. There are many things you can do to lower your chances of getting back pain.

Most back problems will get better on their own. The key is to know when you need to seek medical help and when self-care measures alone will allow you to get better.

Low back pain may be acute (short-term), lasting less than one month, or chronic (long-term, continuous, ongoing), lasting longer than three months. While getting acute back pain more than once is common, continuous long-term pain is not.

Common Causes

You'll usually first feel back pain just after you lift a heavy object, move suddenly, sit in one position for a long time, or have an injury or accident. But prior to that moment in time, the structures in your back may be losing strength or integrity.

The specific structure in your back responsible for your pain is hardly ever identified. Whether identified or not, there are several possible sources of low back pain:

• Small fractures to the spine from osteoporosis
• Muscle spasm (very tense muscles that remain contracted)
• Ruptured or herniated disk
• Degeneration of the disks
• Poor alignment of the vertebrae
• Spinal stenosis (narrowing of the spinal canal)
• Strain or tears to the muscles or ligaments supporting the back
• Spine curvatures (like scoliosis or kyphosis) which may be inherited and seen in children or teens
• Other medical conditions like fibromyalgia

Low back pain from any cause usually involves spasms of the large, supportive muscles alongside the spine. The muscle spasm and stiffness accompanying back pain can feel particularly uncomfortable.

You are at particular risk for low back pain if you:

• Work in construction or another job requiring heavy lifting, lots of bending and twisting, or whole body vibration (like truck driving or using a sandblaster)
• Have bad posture
• Are pregnant
• Are over age 30
• Smoke, don't exercise, or are overweight
• Have arthritis or osteoporosis
• Have a low pain threshold
• Feel stressed or depressed

• Bladder infection
• Kidney stone
• Endometriosis
• Ovarian cancer
• Ovarian cysts
• Testicular torsion (twisted testicle)

Home Care

Many people will feel better within one week after the start of back pain. After another 4-6 weeks, the back pain will likely be completely gone. To get better quickly, take the right steps when you first get pain.

A common misconception about back pain is that you need to rest and avoid activity for a long time. In fact, bed rest is NOT recommended.

If you have no indication of a serious underlying cause for your back pain (like loss of bowel or bladder control, weakness, weight loss, or fever), then you should reduce physical activity only for the first couple of days. Gradually resume your usual activities after that. Here are some tips for how to handle pain early on:

• Stop normal physical activity for the first few days. This helps calm your symptoms and reduce inflammation.
• Apply heat or ice to the painful area. Try ice for the first 48-72 hours, then use heat after that.
• Take over-the-counter pain relievers such as ibuprofen (Advil, Motrin IB) or acetaminophen (Tylenol).

While sleeping, try lying in a curled-up, fetal position with a pillow between your legs. If you usually sleep on your back, place a pillow or rolled towel under your knees to relieve pressure.

Do not perform activities that involve heavy lifting or twisting of your back for the first 6 weeks after the pain begins. After 2-3 weeks, you should gradually resume exercise.

Begin with light cardiovascular training. Walking, riding a stationary bicycle, and swimming are great examples. Such aerobic activities can help blood flow to your back and promote healing. They also strengthen muscles in your stomach and back.

Stretching and strengthening exercises are important in the long run. However, starting these exercises too soon after an injury can make your pain worse. A physical therapist can help you determine when to begin stretching and strengthening exercises and how to do so.

AVOID the following exercises during initial recovery unless your doctor or physical therapist says it is okay:

• Jogging
• Football
• Golf
• Ballet
• Weight lifting
• Leg lifts when lying on your stomach
• Sit-ups with straight legs (rather than bent knees)

Call your health care provider if

Call 911 if you have lost bowel or bladder control. Otherwise, call your doctor if you have:

• Unexplained fever with back pain.
• Back pain after a severe blow or fall.
• Redness or swelling on the back or spine.
• Pain traveling down your legs below the knee.
• Weakness or numbness in your buttocks, thigh, leg, or pelvis.
• Burning with urination or blood in your urine.
• Worse pain when you lie down or pain that awakens you at night.
• Very sharp pain.

Also call if:

• You have been losing weight unintentionally
• You use steroids or intravenous drugs.
• You have never had or been evaluated for back pain before.
• You have had back pain before but this episode is distinctly different.
• This episode of back pain has lasted longer than four weeks.

If any of these symptoms are present, your doctor will carefully check for any sign of infection (like meningitis, abscess, or urinary tract infection), ruptured disk, spinal stenosis, hernia, cancer, kidney stone, twisted testicle, or other serious problem.

What to expect at your health care provider's office

When you first see your doctor, you will be asked questions about your back pain, including how often it occurs and how severe it is. Your doctor will try to determine the cause of your back pain and whether it is likely to quickly get better with simple measures such as ice, mild painkillers, physical therapy, and proper exercises. Most of the time, back pain will get better using these approaches.

Questions will include:

• Is your pain on one side only or both sides?
• What does the pain feel like? Is it dull, sharp, throbbing, or burning?
• Is this the first time you have had back pain?
• When did the pain begin? Did it start suddenly?
• Did you have a particular injury or accident?
• What were you doing just before the pain began? Were you lifting or bending? Sitting at your computer? Driving a long distance?
• If you have had back pain before, is this pain similar or different? In what way is it different?
• Do you know the cause of previous episodes of back pain?
• How long does each episode of back pain usually last?
• Do you feel the pain anywhere other than your back, like your hip, thigh, leg or feet?
• Do you have any numbness or tingling? Any weakness or loss of function in your leg or elsewhere?
• What makes the pain worse? Lifting, twisting, standing, or sitting for long periods of time?
• What makes you feel better?
• Are there any other symptoms present? Weight loss? Fever? Change in urination? Change in bowel habits?

During the physical exam, your doctor will try to pinpoint the location of the pain and figure out how it affects your movement. You will be asked to:

• Sit, stand, and walk. While walking, your doctor may ask you to try walking on your toes and then your heels.
• Bend forward, backward, and sideways.
• Lift your legs straight up while lying down. If the pain is worse when you do this, you may have sciatica, especially if you also feel numbness or tingling in one of your legs.

Your doctor will also move your legs in different positions, including bending and straightening your knees. All the while, the doctor is assessing your strength as well as your ability to move.

To test nerve function, the doctor will use a rubber hammer to check your reflexes. Touching your legs in many locations with a pin, cotton swab, or feather tests your sensory nervous system (how well you feel). Your doctor will instruct you to speak up if there are areas where the sensation from the pin, cotton, or feather is duller.

Most people with back pain recover within four to six weeks. Therefore, your doctor will probably not order any tests during the first visit. However, if you have any of the symptoms or circumstances below, your doctor may order imaging tests even at this initial exam:

• Pain that has lasted longer than one month
• Numbness
• Muscle weakness
• Accident or injury
• Fever
• If you are over 65
• You have had cancer or have a strong family history of cancer
• Weight loss

In these cases, the doctor is looking for a tumor, infection, fracture, or serious nerve disorder. The symptoms above are clues that one of these conditions may be present. The presence of a tumor, infection, fracture, or serious nerve disorder change how your back pain is treated.

Tests that might be ordered include an X-ray, a myelogram (an X-ray or CT scan of the spine after dye has been injected into the spinal column), a CT of the lower spine or MRI of the lower spine.

Hospitalization, traction, or spinal surgery should only be considered if nerve damage is present or the condition fails to heal after a prolonged period.

Many people benefit from physical therapy. Your doctor will determine if you need to see a physical therapist and can refer you to one in your area. The physical therapist will begin by using methods to reduce your pain. Then, the therapist will teach you ways to prevent getting back pain again.

If your pain lasts longer than one month, your primary care doctor may send you to see either an orthopedist (bone specialist) or neurologist (nerve specialist).

Prevention

Exercise is important for preventing future back pain. Through exercise you can:

• Improve your posture
• Strengthen your back and improve flexibility
• Lose weight
• Avoid falls

A complete exercise program should include aerobic activity (like walking, swimming, or riding a stationary bicycle) as well as stretching and strength training.

To prevent back pain, it is also very important to learn to lift and bend properly. Follow these tips:

• If an object is too heavy or awkward, get help.
• Spread your feet apart to give a wide base of support.
• Stand as close to the object you are lifting as possible.
• Bend at your knees, not at your waist.
• Tighten your stomach muscles as you lift the object up or lower it down.
• Hold the object as close to your body as you can.
• Lift using your leg muscles.
• As you stand up with the object, DO NOT bend forward.
• DO NOT twist while you are bending for the object, lifting it up, or carrying it.

Other measures to take to prevent back pain include:

• Avoid standing for long periods of time. If you must for your work, try using a stool. Alternate resting each foot on it.
• DO NOT wear high heels. Use cushioned soles when walking.
• When sitting for work, especially if using a computer, make sure that your chair has a straight back with adjustable seat and back, armrests, and a swivel seat.
• Use a stool under your feet while sitting so that your knees are higher than your hips.
• Place a small pillow or rolled towel behind your lower back while sitting or driving for long periods of time.
• If you drive long distance, stop and walk around every hour. Bring your seat as far forward as possible to avoid bending. Don't lift heavy objects just after a ride.
• Quit smoking.
• Lose weight.
• Learn to relax. Try methods like yoga, tai chi, or massage.

References

Rakel D. Low Back Pain. In:Integrative Medicine. Elsevier; 2003:423-431.

Sierpina VS, Curtis P, Doering J. An Integrative Approach To Low Back Pain. Clin Fam Pract. 2002; 4(4); 817.

US Preventative Services Task Force. Primary Care Interventions to Prevent Low Back Pain: Brief Evidence Update. Rockville, MD: Agency for Healthcare Research and Quality; February 2004.

Illustrations

Lumbar vertebrae

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