Lower Back Pain
Low back pain (sometimes referred to generally as lumbago) is a common symptom of musculoskeletal disorders or of disorders involving the lumbar vertebrae. It can be either acute, subacute or chronic in its clinical presentation. Typically, the symptoms of low back pain show significant improvement within two to three months from its onset. In a significant number of individuals, low back pain tends to be recurrent in nature with a waxing and waning quality to it. In a small proportion of sufferers this condition can become chronic. Population studies show that back pain affects most adults at some stage in their life and accounts for more sick leave and disability than any other single medical condition.
An acute lower back injury may be caused by a traumatic event, like a car accident or a fall. It occurs suddenly and its victims will usually be able to pinpoint exactly when it happened. In acute cases, the structures damaged will more than likely be soft tissue like intervertebral discs, muscles, ligaments and tendons. With a serious accident, osteoporosis or other causes of weakened vertebral bones, vertebral fractures in the lumbar spine may also occur. At the lowest end of the spine, some patients may have tailbone pain (also called coccyx pain or coccydynia). Others may have pain from their sacroiliac joint at the bottom of the lumbar spine, called sacroiliac joint dysfunction (see sacroiliac joint for more information). Chronic lower back pain usually has a more insidious onset, occurring over a long period of time. Physical causes may include osteoarthritis, rheumatoid arthritis, degeneration of the discs between the vertebrae, or a spinal disc herniation, a vertebral fracture (such as from osteoporosis), or rarely, a tumor (including cancer) or infection.
One method of classifying lower back pain is by the duration of symptoms: acute (less than 4 weeks), subacute (4-12 weeks), chronic (greater than 12 weeks).
Most cases of lower back pain are due to skeletal degeneration or musculoligamentous injury and are referred to as non specific low back pain. The full differential diagnosis however includes may other less common conditions.
- Apophyseal osteoarthritis
- Diffuse Idiopathic Skeletal Hyperostosis
- Degenerative discs
- Scheuermann's kyphosis
- Spinal disc herniation (slipped disc)
- Spinal stenosis
- Spondylolisthesis and other congenital abnormalities
- Non-specific muscular or ligamentous strains or sprains
- Leg length difference
- Restricted hip motion
- Misaligned pelvis - pelvic obliquity, anteversion or retroversion
- Seronegative spondylarthritides (e.g. ankylosing spondylitis)
- Rheumatoid arthritis
- Infection - epidural abscess or osteomyelitis
- Bone tumors (primary or metastatic)
- Intradural Spinal tumors
- Osteoporotic fractures
- Tension myositis syndrome
- Paget's disease
- Pelvic/abdominal disease
- Prostate Cancer
- oxygen deprivation
Diagnosing the underlying cause of low back pain is usually done by a medical doctor, osteopathic physician, physiotherapist (physical therapist) or by a chiropractor. Often, getting a diagnosis of the underlying cause of low back pain and/or related symptoms is quite complex. A complete diagnosis is usually made through a combination of a patient's medical history, physical examination, and, when necessary, diagnostic testing, such as an MRI scan or x-ray.
X-rays are not required in lower back pain except in the cases where "red flags" are present.If the pain is of a long duration X-rays may increase patient satisfaction.
- Recent significant trauma or milder trauma if age is > 50 years
- Unexplained weight loss
- Unexplained fever
- Previous or current cancer
- Intravenous drug use
- Osteoporosis or chronic corticosteroid use
- Age > 70
- Focal neurological deficit
- Duration greater than 6 weeks
For the vast majority of patients, low back pain can be treated conservatively. A systematic review of randomized controlled trials made a number of recommendations
Acute back pain
- Analgesics (pain medications), such as NSAIDs or acetaminophen.
- Muscle relaxants for acute or chronic pain. There are, however, concerns with side effects, and their general use is discouraged.
- Stay physically active.
- Exercise is no more effective than no treatment or other conservative treatments for acute low back pain.
- There is continuing conflict of opinion on the efficacy of spinal manipulation (SM) therapy for nonspecific (i.e., unknown cause) low back pain; methods for formulating treatment guidelines differ significantly between countries, casting some doubt on the guidelines' reliability. A 2007 U.S. guideline weakly recommended SM as one alternative therapy for spinal low back pain in nonpregnant adults when ordinary treatments fail,whereas the Swedish guideline for low back pain was updated in 2002 to no longer suggest considering SM therapy for acute low back pain for patients needing additional help, possibly because the guideline's recommendations were based on a high evidence level. A 2008 review found strong evidence that SM is similar in effect to medical care with exercise, and moderate evidence that SM is similar to physical therapy and other forms of conventional care. A 2007 literature synthesis found good evidence supporting SM and mobilization for low back pain and exercise for chronic low back pain. Of four systematic reviews published between 2000 and May 2005, only one recommended SM, and a 2004 Cochrane review stated that SM or mobilization is no more or less effective than other standard interventions for back pain. A 2008 systematic review found insufficient evidence to make any recommendations concerning medicine-assisted manipulation for chronic low back pain.
Chronic back pain
The follow measures have been found to be effective for chronic non-specific back pain
- Exercise appears to be slightly effective for chronic low back pain.
- Acupuncture may help chronic pain; however, a more recent randomized controlled trial suggested insignificant difference between real and sham acupuncture.
- Intensive multidisciplinary treatment programs may help subacute or chronic low back pain.
- Behavioral therapy
- Arch support
- The Alexander Technique was shown in a UK clinical trial to have long term benefits for patients with chronic back pain.
- Back schools have shown some effect in managing chronic back pain.
Other therapies that might have some benefit
Additional treatments have been more recently reviewed by the Cochrane Collaboration:
- Massage therapy may benefit some patients.
- Ice and/or heat application (or moist heat) has uncertain benefit.
Individual randomized controlled trials, thus interpretation may be subject to publication bias, also confounded by absence of double blinding have shown benefit for:
- Viniyoga, Iyengar, and Hatha yoga (small trial).
- Correcting leg length difference may help. To correct leg length difference, insert a hard rubber or cork heel pad into the shoe of the short leg if the difference between the two legs is 3/8ths inch or less. If more, have a shoe repairman build up the sole and heel. Taper the toe to avoid tripping. If more than 3/4 inch, start with 1/2 of what you need so that your body can adjust.
- Muscle Energy Technique (MET) may help (small study).
Other treatments that were not reviewed are
- Education and attitude adjustment (TMS)
- Increasing internal hip rotation
- Increase internal hip rotation with stretching or connective tissue massage
- Medical cannabis
Because of variations in clinical study methodology, a review of clinical studies in any one area is not necessarily conclusive.
For any one condition, it may be necessary to try a variety of treatments in order to find the best one (or combination) to best manage the pain. In almost all cases, physical therapy and/or a regular exercise program that includes stretching, strengthening and low impact cardio conditioning will be part of the treatment and rehabilitation program.