Understanding back pain

Back pain can range from minor niggles to crippling pain that seriously impacts quality of life and can lead to serious health issues.

We look at different kinds of back pain, how it might be caused and different ways to manage it.

Back pain usually affects the lower back, but it can occur anywhere along the spine. It can be short-term, lasting a few days or weeks, but for many it’s a long-term condition.

Back pain is very common, with 4 million Australians reporting living with back problems.¹

It’s estimated that up to 90% of people will experience low back pain at some point in their lifetimes.

Anyone can get back pain at any age, but it tends to be more common in people as they get older.

The back has many interconnecting structures including bones, joints, muscles, ligaments and tendons.

The back’s main support structure is the spine, which is made up of bones called vertebrae, plus the bones of the sacrum and coccyx. Between the vertebrae are discs that act as shock absorbers and allow your spine to bend. Your spinal cord threads down through the central canal of each vertebra, connecting your brain to nerves in the rest of your body.

Simply put, the back is doing a lot of work and is under pressure to perform all day, every day, whether you’re laying down, sitting, standing, walking or running.

You may experience low back pain as tension, soreness or stiffness in your lower back area. This pain is often referred to as 'non-specific' back pain and may improve on its own within a few days.

Back pain may be called either 'acute' or 'chronic' depending on how long your symptoms last. You may have:

• acute back pain (lasting less than 6 weeks)
• sub-acute back pain (lasting 6 weeks to 3 months)
• chronic back pain (lasting longer than 3 months).

Your doctor may recommend treatment options based on whether you have acute, sub-acute or chronic back pain. Alternatively, they may look at your individual risk factors.

Depending on whether you are considered at low, medium or high risk of poor outcomes, you may be matched with simpler or more intensive treatment options.

It can be difficult to know exactly what causes back pain. It’s often thought to be related to a sprain or strain in one of the interconnecting structures in the back, rather than a nerve problem. For most people with back pain, there isn't any specific underlying problem or condition that can be identified as the cause of the pain. However, there are several factors that may increase your risk of developing back pain or aggravate it once you have it. These include:

• lack of exercise, or standing, sitting or bending down for long periods
• lifting, carrying, pushing or pulling loads that are too heavy, or going about these tasks in the wrong way
• having a trip or a fall
• being stressed or anxious (which can increase muscle tension)
• being overweight
• having poor posture.

There may be other, more serious underlying causes of back pain, but these are less common. They may include:

• fracture (a crack or break) in one of the bones in the back
• osteoporosis, a condition where bones become weak, brittle and are more likely to break
• a slipped disc, when a disc bulges out and presses on a spinal nerve
• spinal stenosis, a narrowing of the spinal canal through which the spinal cord passes
• spondylolisthesis, when one of the vertebrae slips forward and out of position
• degenerative disc disease, when the discs in the spinal cord gradually become worn down
• osteoarthritis, a wear-and-tear disease affecting the joints between the vertebrae
• rheumatoid arthritis, an inflammatory condition in which the immune system causes inflammation of the lining of the joints and surrounding structures.

Back pain may also be caused by other problems including an infection or cancer, but this is rare.

Chronic pain is pain that goes on for over 3 months, or longer than the likely healing time. If you have chronic back pain, it doesn’t necessarily mean there’s ongoing disease or damage. Instead, the pain can be acting more as a complex protective measure.

Pain is produced by your brain to protect you. Unpleasant feelings such as pain change your behaviour so you can avoid injury and allow your tissues to heal. But when pain persists for a long time, even after the tissues have healed, changes can develop in nerves in the spinal cord and brain (the central nervous system). Your brain can become too protective and your pain system too good at making pain. You can get warning signs (pain) that are unnecessary or out of proportion to the stimulus. This is known as central sensitisation, or pain system sensitivity.

When your pain system becomes more sensitive, other factors in your life can contribute to increasing your back pain. These include fear of the pain, work or financial stresses, your mood and your general health. Doing things that relax you, eating well and getting a good night’s sleep may help reduce your pain.

This is why pain education and psychological support to help you gradually retrain your pain system play a role in helping to reduce or recover from chronic back pain.

See your GP as soon as possible if you experience back pain and any of the following:

• Loss of bladder or bowel control (incontinence) or difficulty urinating
• Numbness or tingling around your genitals or buttocks (particularly in a shape like a saddle)
• Numbness, pins and needles or weakness in one or both legs (including below the knees), your back or anywhere else
• Chest pain
• A fever (high temperature)
• Unexplained weight loss
• Redness or swelling on your back
• Pain that doesn’t improve after resting or gets worse, particularly at night
• Pain that starts after a fall or injury.

These symptoms are known as red flags, and they could be a sign of something more serious.

If you see a GP, they may ask you questions about your symptoms, medical history and lifestyle. They will also likely do a physical examination to check your general range of movement (such as how you walk, sit, stand and bend). It may help to think about answers to the following questions about your back pain before the appointment:

• When did the pain start?
• Where is the pain?
• Can you describe what the pain feels like?
• Have you had back problems in the past?
• Does anything make the pain better or worse?

If you have back pain, further testing is not normally useful or recommended unless your symptoms don’t improve after a few weeks or if you have any of the red flags listed above. If your GP does send you for tests, they may include:

• an X-ray
• a CT scan (a test that uses X-ray equipment and computer software to create images of the inside of the body)
• an MRI scan (a test that uses magnets and radio waves to produce images of the inside of the body)
• blood tests.

These tests are used to find out if there could be a more specific, underlying cause for your back pain.

Self-help measures are often very helpful for back pain and are encouraged.

If your back pain is severe or chronic, your GP may initially refer you for manual (physical) and psychological therapies, along with exercise. Learning about how pain works can help improve chronic back pain, and programs that combine pain education with graded brain and body exercises can help reduce pain system sensitivity.²

If these are not successful, your GP may prescribe appropriate medication.

If an underlying cause of back pain is suspected, your GP may refer you to a back or pain specialist or clinic for diagnosis and specialised treatments.

There are many things you can do at home to help with low back pain, including the following:

• Stay active and continue your daily activities as normally as you can. This includes staying at work or returning as soon as you’re able. Prolonged bed rest may make back pain worse, so after the first day or 2, it’s recommended to limit time in bed.
• Include some regular walking. An Australian study found regular walking combined with pain education to be effective at reducing back pain and lowering the chances of it recurring.3
• Try some simple back exercises or stretches recommended by your GP or physiotherapist.
• Learn how to safely lift and carry items, and avoid heavy lifting and twisting.
• Apply heat or cold to the affected area. Some people find that this may help in the short term. You can buy specially designed heat or cold packs from most pharmacies.
• Reduce your stress levels through relaxation techniques such as meditation and deep breathing, and connecting regularly with family and friends.

For temporary pain relief, an over-the-counter anti-inflammatory medicine (such as ibuprofen) is often enough to help ease acute low back pain. Paracetamol on its own is not recommended for low back pain.

You could also try creams, lotions and gels that contain anti-inflammatory ingredients. But make sure you don’t apply an anti-inflammatory cream as well as taking an anti-inflammatory tablet or capsule, as they can interact. Talk to your GP or pharmacist for more advice about using anti-inflammatory medicines.

If your pain is severe or chronic, your GP may prescribe stronger medication.

Always read the accompanying consumer medicine information leaflet, and ask your GP or pharmacist for advice if you have any questions.

Manual (physical) therapies may be recommended as part of a treatment program for back pain. This may involve things like exercises, posture advice or massage, often with a physiotherapist.

Back pain can usually be managed with some of the simple treatments listed above, but a small percentage of people may have ongoing problems. Back surgery is usually a last resort in people who have an underlying cause for their pain.

Good back care can help reduce your risk of getting low back pain. To help look after your back, make sure you:

• take regular exercise. Low-impact activities such as walking and swimming are often recommended
• try relaxation techniques to help keep your stress levels to a minimum
• learn how to lift and carry objects (or children) safely. Squat down, hold the object close to your body and lift with your legs, always keeping your back straight. Always get help or use equipment if a load is too heavy
• maintain good posture, keep your shoulders back and don't slouch.

Musculoskeletal Health Australia provides information and support for people living with arthritis and musculoskeletal conditions. Visit their website or call them on 1800 263 265.

Pain Australia works towards improving the quality of life for those living with pain. Visit their website for resources and support, including their National Pain Services Directory.