Everything you ever wanted to know about back pain (but were afraid to ask)

In any given month, nearly a third of the adult population in the developed world has back pain. After coughs and colds, low back pain (LBP) is the most common reason for visits to the GP. It hurts like mad, but most of us recover within a week – further flare-ups are common but full recovery is the norm after each bout, though up to 40% of people with LBP will have pain lasting more than three months. Despite a host of treatment options including acupuncture, manual therapies, drugs, injections and surgery, nothing is more likely to work than staying active. Just when you least feel like it, and it hurts the most, is when experts say you have to get moving.

Why does my back hurt?

It is hard to know. Experts describe the pain, stiffness and soreness that so many of us experience as “non-specific” or “musculoskeletal” LBP. The diagnosis implies that underlying serious disease (pressure on the spinal cord, vertebral fracture or collapse, infection, cancer, inflammatory arthritis and pain from other organs) has been ruled out. The problem may lie in the discs, joints, ligaments or muscles of the lower back. Chiropractor Shanthini Fonseka explains: “The root cause of most back pain is early degeneration caused by overuse or excessive force, bad posture, lack of resting time or lack of essential nutrition leading to mechanical problems of the spine.” You are most at risk of LBP if you are overweight, smoke, are pregnant, depressed or on steroids.

When is back pain not from the back?

Lots of abdominal problems can cause back pain, including kidney stones and infection, pancreatitis, duodenal ulcers and aortic aneurysms (widening of the aorta) – but in these cases, you are likely to have additional symptoms that suggest the underlying cause.

How do I know whether my back pain is dangerous?

In rare cases, back pain can be due to dangerous pressure on the spinal cord (cauda equina), cancer in the spine or infection. Warning symptoms or “red flags” for this include significant trauma, long-term steroid use and a history of cancer. If your back hurts and you can’t stand up, pass urine or feel your anus and genitals, you need to call an ambulance. But Australian academic Dr Christopher Williams warns against over-reliance on the red-flag symptoms and says you need to trust your own judgment, too. “Red flags are unfortunately not very accurate in screening for serious pathology presenting as back pain. If people are concerned about the nature of their back pain, I would always recommend that they consult an appropriately trained health professional for assessment.”

Should I get an x-ray or scan just to be sure?

No. Experts agree that imaging (x-rays and scans) are not needed for LBP that has lasted for fewer than four weeks, when there are is no concern about serious underlying disease. As Williams says: “There is no correlation between back pain and the structural diagnoses that patients often receive (for example, a disc bulge) as a result of a scan, so these are not usually helpful.”

Well it hurts. What can I do?

Lesley Colvin, a pain medicine specialist in Edinburgh, says the best evidence is for exercise. “If I had back pain, I’d do exercise that strengthens the core, such as yoga, pilates and stretching.”

Williams advises: “Avoid bed rest. There is some evidence that simple pain medications are helpful to relieve pain. But their effectiveness is minimal and has large variation between individuals. There is some evidence that heat packs are beneficial. For most people, the pain will subside quickly and they can be reassured that there is no serious injury or lasting damage.”

Colvin is alarmed by the “exponential rise” in the use of strong opiates that include codeine products. “There’s limited evidence that they work and significant evidence of harm. In 2012, 18% of the population of Scotland were prescribed opioids – some were addicts or in palliative care but a significant percentage were prescribed for pain.”

Physio, osteopathy, chiropractic – which is best?

Manual therapies seem much of a muchness, though practitioners may disagree. Physio, osteopathy and chiropractic are all approved by the National Institute for Health and Care Excellence and use a mix of spinal manipulation, spinal mobilisation and massage. Consultant physiotherapist Chris Mercer does not think there is much to choose between them. They use similar techniques and feel similar to patients, but their philosophy differs. “Just having passive manual therapy done to you isn’t likely to be very helpful. It’s a means to an end, which is to get moving and to encourage self-reliance.”

It’s been going on for more than a month. What now?

Colvin says: “Physiotherapy is helpful for pain that lasts more than four to six weeks. There’s some evidence of short-term benefit from acupuncture and osteopathy, and mixed evidence about Tens machines. Chiropractic may work; the evidence isn’t there, but that doesn’t mean it doesn’t.”

Never mind a month, I’ve had backache for years

Being in pain for that long takes its toll. The advice is to have an assessment that takes into account the physical, psychological and social impact of the pain. Your path back to living life to the full may include talking therapies, acupuncture, injections, stronger painkillers and surgery. Recent research suggest a course of antibiotics (which also act as anti-inflammatory drugs) may help, but further work is needed.

When to seek advice

Seek emergency care if you experience:
Difficulty passing or controlling urine.
Numbness around your back passage or genitals.

See your GP if you experience:
Severe pain worsening over several weeks.
Fever, weight loss, feel unwell.
Other problems, such as rheumatoid arthritis or cancer.
Numbness, pins and needles, or weakness in one or both legs.
Unsteady walking.