‘I have back pain, what is causing it and what should I do?’

As a physiotherapist this is probably the most common question I get asked at social occasions (along with the ‘what’s causing my clicking joints‘ and the ‘don’t you get tired‘ questions that I covered in previous blogs..)

Tempting as it is to answer ‘I have no idea unless I do a full assessment and examination of you’ I do try to come up with something a tad more useful! Here is my answer broken down into two parts.

​Part one: what is causing my back pain?

Back pain can be caused by a multitude of structures including spinal discs and joints, muscles, ligaments and tendons. Please click on the following link if you would like to learn more about the structures that can cause back pain and common back conditions.

However, it is not as ‘simple’ as learning the anatomy of the region because structures can refer to different locations. For example, pain in your hip can be caused by a damaged structure in your spine. If that doesn’t confuse you enough then consider that the longer you have pain the more your central nervous system – namely your brain – becomes involved, so that after several months of pain there are established pain pathways that are independent of the original damage. No, it is not ‘all in your head.’ No one ‘makes up pain’ for the fun of it, but it is no longer just a straight forward matter of damaged structure=pain, it is far more complicated than that.

Part two: what can I do about it?

Luckily this answer is more simple than the first part because there are some generic treatments that work on pain, irrespective of the cause. That is not to say that all treatments will work with everything and everyone, that is why a thorough assessment by a Physiotherapist or Osteopath is essential so that treatment can be directed per the diagnosis. The treatments can be divided roughly into those that can give short term relief and those that can give long term relief.

A lot of the headlines stating ‘x treatment doesn’t work for low back pain’ that get splashed all over the mainstream media are based on findings that some treatments provide only short term relief and their long-term efficacy has not been proven. The treatments are also more expensive because they require the time and expertise of a qualified health professional as opposed to just self-treatment, group treatment or verbal or written advice. Therefore, these treatments do not offer the cost effectiveness that our health systems are interested in and therefore get a bad reputation. However, from my experience, patients are interested in short AND long term pain relief so here they are, categorised accordingly

Short term relief:

1) Movement.
Bed rest has unequivocally been shown to make back pain worse. If you can walk, walk. If you can only to some teeny jiggling movements or rocking of your knees while lying on the floor, then do it. Slowly but surely your movements should increase (over hours and days if not seconds and minutes.) Gradually build up your movements in small increments so that eventually you can do gentle exercise. The sooner you can do a form of exercise that involves you increasing your heart and breathing rate slightly, the better (see long term relief below.)

2) Reassurance
Getting seen by a Physiotherapist or Osteopath who can explain your diagnosis and treatment plan can go a long way to reducing your pain. This is not a sales pitch, I am told this time and time again by patients and there is some good research evidence to back this up too.

3) Avoid sitting on low seats like the sofa and avoiding lying slumped in bed. Sit on higher chairs with your low back and pelvic well supported and get up as regularly as you can. Click on this link for more on sitting posture. 

4) Avoid lifting and carrying. This will be instinctive. Check out my previous blog for more on long term lifting and carrying techniques to avoid back pain flare ups.

5) Massage. Make sure you see a qualified health professional like a Physiotherapist or Osteopath who will also give you advice on exercises and other self-management techniques. (Please don’t trust anyone apart from your GP who tells you to have an X-ray. See my previous blog here for more on that subject.)

6) Joint mobilisations or manipulation in the form of hands on techniques, followed up with exercises to maintain this mobility. It is normally not advisable to mobilise the joints of the lower back itself because this could make you worse but it can be useful to get the joints above and below moving – your upper back and your hips.

7) ‘Acupuncture’ or ‘dry needling.’ 
There is research to show that it can help reduce pain. Again, have it done by a qualified health professional like a Physiotherapist who will do it as part of the treatment plan not as the sole treatment.

8) Taping.
This will not provide structural support but can help to alleviate the pain and get you moving short term. Should be used by your physio as part of the treatment not as the sole treatment.

9) Use warmth.
Some people like to use warmth and cold intermittently for low back pain. The research is not conclusive on which is better. Basically, try both and see which works best for you. Just make sure you don’t get a heat or cold burn. Wrap up any hot or cold packs in towels to modify the temperature, only leave them on for a maximum of 5-10 minutes, check regularly that your skin is not going red, don’t lie directly on the hot/cold pack and don’t put a hot or cold pack on and fall asleep.

10) Painkillers and anti-inflammatories.
Until you can get an appointment with your GP go to your local Pharmacist and ask them for advice. They will give you the most effective non-prescription medications that are safe for you as an individual. As you may have read in the papers recently these should be used for short term relief only and you will need to do something else to sort the problem out long term.

Long term relief

1) General exercise and pacing

Time and time again the research comes back with this being the single most important way of treating and preventing low back pain. It is important that you build it up in small increments and are consistent in the frequency and intensity of exercise. It is much better to do a small amount daily than doing it in intensive bursts.

Teach yourself to pace yourself in all activities that aggravate your pain. I am not referring just to exercise, you need to include sitting, walking, standing, work, stairs and/or any other daily activity that is affected by your pain. Write an activity diary so you can reflect on how steady you are being with all your activities. It is frustrating at first and it help to have an experienced physio on your side to guide you through it.

2) Cardiovascular exercise

As soon as you can move enough to get your heart and lungs pumping your brain and body will thank you for a million reasons ranging from the endorphins that help interrupt established pain pathways to the increase in general circulation that aids healing.

3) Strength exercises

For most people this will involve things like mini squats, lunges, step ups, step downs, modified press ups and dips and balance exercises with body-weight only, but for others it might involve weights either at home or in the gym. The key is to strengthen your body for the things you want it to do. Obviously if your goal is to play football then you will need to take longer to build up your strength than if you just want to be able to take the dog for a walk.

4) Exercises to improve the way you sit, stand and move

Your body’s muscles and bones are designed to share the forces that we impose on them daily whether sitting at a desk or hitting a tennis ball If these structures are in the wrong place the stresses and strains will be placed excessively on some bits and not enough on others. Both being over strained or under strained is bad for muscles and bones.

Therefore, a fundamental part of what physios do is to show you how to move your body to make sure it is doing its job optimally. Once we have shown you how do to this it is up to you to practice the movements (AKA exercises) to make sure that the muscles that need to become stronger or more active do so, that the structures that are designed to take load do so and that your brain learns that this is your new normal way to move.

So, your physio may well show you how to correct the way you: sit. stand, drive, walk, run, squat, go up and down stairs, lift or carry, bend down to pick something up, swing your tennis racket, bend to dribble in hockey… you get my drift.

5) Specific strengthening of the muscles in your low back and pelvis

These muscles include the pelvic floor muscles, transverse abdominus muscle, obliques, multifidus and your diaphragm (in the form of diaphragmatic breathing.) This lot get a lot of stick because if they are trained in isolation to the rest of your body then they are a bit pointless. However, if they are trained in combination with the other things I have mentioned already they can make significant improvements in your back pain. Often it is easier to train these deep core muscles lying down but ultimately you need to train them in standing and doing all your day to day activities.

More important advice:

Time frames

You may have got the gist that back pain can go away in a few hours to a few months so your recovery will be equally as variable. Most goes away quickly if you follow the advice above.

If you have had pain for a few months it will take a few months of treatment to go away. If you have had it for a few years, it will take a good year or two to get better.

If you are in the latter category please do not think that you need to have weekly or even monthly treatment during this time. Your Physiotherapist is likely to want to see you regularly in the first few weeks but should quickly reduce the treatment sessions down to once every few weeks because most of the ‘treatment’ will be being done by you.

When to seek immediate help

If you have the following symptoms in addition to low back pain you should see a Doctor immediately. Sudden worsening of pins and needles, tingling, numbness, weakness or reduced control in your arms and/or legs, bowel incontinence (difficulty controlling your bowels,) bladder retention (difficulty releasing the fluid in your bladder,) reduced sensation in your legs and particularly in your genital or ‘saddle’ region.

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I look forward to your comments or questions.