Causes of Low Back Pain
1) Understanding low back pain
Low back pain is one of the most common and challenging conditions experienced by people worldwide. It is the leading cause of disability and the most prevalent musculoskeletal issue globally. In fact, studies suggest that up to 84% of people may experience low back pain at some point in their lives.
No age group is immune, and even children can suffer from it. Low back pain can be classified as acute (lasting less than 6 weeks), subacute (6-12 weeks), or chronic (more than 12 weeks) based on the duration of symptoms.
The condition itself is a symptom rather than a diagnosis, characterised by pain and discomfort below the lower ribs and above the lower glutes, potentially with leg pain, also known as radicular pain. Low back pain is a common reason for visits to a general practitioner and the second leading cause of sick leave.
Most cases are not due to a serious spinal condition, and a thorough health and clinical examination is usually sufficient without the need for MRI unless there are suspected serious conditions (red flags). Psychosocial factors, often referred to as "yellow flags," can increase the risk of developing chronic low back pain and long-term disability.
Summary
Almost everyone experiences low back pain at some point in their lives.
Low back pain is usually harmless. It may appear suddenly and last for a few days or weeks.
During an episode of low back pain, the best thing you can do is carry on with your daily life and stay as physically active as possible.
Resting too much or spending a lot of time in bed can make the back pain last longer.
2) The complexities of chronic low back pain
While many recover from low back pain within a few weeks, about 10%-40% of sufferers experience recurrent episodes that can lead to chronic low back pain, defined as pain persisting for 12 weeks or more. Often, there is no identifiable cause for the pain, which can make management challenging.
Psychosocial factors such as fear avoidance, abnormal illness behaviour, catastrophizing, low self-efficacy, and depression are significantly associated with poor outcomes. These factors can lead to a cycle of diminished physical and social activities, fear, avoidance behaviours, and worsening physical and psychological conditions.
Summary
Chronic low back pain can be debilitating and is often challenging to manage.
Those with chronic low back pain often experience other factors such as depression, anxiety, fear, and worry.
3) Risk factors for low back pain
Lack of movement (sedentary lifestyle).
Weak core.
Poor stability.
Working in prolonged, twisted positions.
Sitting in one position for a long time (long hours at the office).
Repetitive or strenuous physical activities.
Smoking increases the frequency of coughing, which intensifies the compression of the intervertebral disc on the nerve root. Smoking can also reduce vertebral blood flow, thereby accelerating the degenerative process.
Obesity (exerts significantly greater disc compression force; chronic low-grade inflammation).
High physical stress at work.
Psychological stress (stress at the workplace, financial or family-related worries, anxiety, self-doubt, depression).
Changes in the central nervous system that affect how you perceive pain (fibromyalgia, chronic pain syndrome).
Motor vehicle collision.
Genetics.
Summary
The fewer risk factors that apply to you, the lower your chances of developing low back pain.
4) Red flags for low back pain
The ability to recognise red flag findings of serious causes of low back pain ensures prompt diagnosis and appropriate action. Specific causes of low back pain that suggest immediate attention (red flags) include infection, cancer, fractures, inflammatory disease, traumatic accidents, and severe spinal cord or nerve root compression. Below are some potential red flag signs of low back pain that may require further investigation:
The presence of acute back pain in patients under the age 18 or over the age 50 may be a cause for concern.
Spinal cord and nerve root compression can result from epidural hematomas (bleeding between the inside of the skull and the outer covering of the brain) and present with sudden acute low back pain.
A history of fever, chills, or recent illness in a person with severe low back pain can be an indicator of a spinal infection.
Urinary retention, sexual dysfunction, loss of sensation at the area of the buttocks and/or inner thighs, and bowel incontinence are frequently associated with cauda equina syndrome.
Impaired immune system, such as those people who have cancer and are on chemotherapy.
Those with chronic low back pain may seek invasive treatments such as surgery and may have a history of lumbar puncture that increases the risk of infection.
An accident in older adults after a fall that causes low back pain is concerning for vertebral fractures due to acute spinal cord compression.
Unexplained weight loss is commonly correlated with malignancy, along with the presence of night pain or pain when resting regardless of changing body position, which may be associated with bone cancer.
Summary
Suspicion of red flag conditions accounts for only 5–10% of low back pain complaints.
A thorough health history and examination can help distinguish between musculoskeletal low back pain and serious low back pain that needs further investigation.
5) Imaging for low back pain
The past two decades have seen a paradigm shift in the way we use imaging when managing low back pain. Imaging was once a routine part of the diagnosis for most cases of low back pain. However, evidence now shows us that imaging is useful only in a small group of individuals where there is suspicion of red flag conditions, which account for only 5–10% of low back pain complaints. For the remaining 90–95% of low back pain cases, imaging will not guide management and can cause more harm than benefit. While structural findings such as age-related changes and disc herniations are commonly found in those with low back pain, they are also present in a large proportion of asymptomatic individuals (pain free) and the incidence of these findings increases with age. Incidental findings may also be discovered, that lead to further investigations, even though they may pose no risk to health, causing unnecessary worry or concern.
One study by Jensen et al (1994) examined the prevalence of findings on MRI scans of the lumbar spine in 98 asymptomatic people without back pain. Only 36% of the 98 asymptomatic subjects had normal discs at all levels; 52% of the subjects had a bulge at at least one level; 27% had a protrusion; and 1% had an extrusion. 38% had findings from more than one location. The findings were similar for men and women. The study concluded that many people without back pain have disc bulges or protrusions but not extrusions. This study shows that many people without back pain have disc bulges or protrusions. Therefore, the discovery by MRI of bulges or protrusions in people with low back pain may frequently be coincidental.
Summary
Low back pain can be managed with conservative care such as advice, exercise, physical therapy, chiropractic care, or pain management.
A thorough health history and examination can help distinguish between musculoskeletal low back pain and serious low back pain that needs further investigation.
Unnecessary imaging or routine imaging often creates fear, delays recovery, and does not usually help to find the cause of the back pain or guide further action.
The care plan for most cases of low back pain is the same whether imaging is used or not.
You may know other people who have had a scan of their spine that revealed “degenerative changes." But most of the changes seen on imaging are more common the older you get, just like grey hair and wrinkles.
6) Posture and low back pain
Spinal posture alterations are classified as structural and non-structural. Structural can include some specific conditions, such as idiopathic scoliosis, congenital scoliosis, and Scheuermann kyphosis. Non-structural is mainly caused by poor posture, uneven muscle distribution, nerve root irritation, and some types of inflammation. Below are some of the influencing factors for altered postures:
Structural or anatomical (scoliosis)
Ageing (childhood postures are markedly different from postures of other ages)
Physiological (tiredness, holding a position for a long time, physical changes during pregnancy can sometimes lead to permanent compensatory changes)
Pathological (Illness can change our posture, especially when it comes to bone and joint diseases)
Occupational (high physical activity levels and sedentary jobs)
Entertainment (gaming, Netflix)
Environmental (people who feel cold will present a different posture)
Social and cultural (different living habits have different effects on posture)
Emotional (emotional pain may prompt the individual to take a defensive posture)
Some postural changes can cause lumbar discomfort and pain. Any prolonged posture without movement is a risk factor for low back pain and can lead to a lack of muscle strength, poor stability of deep core muscles, and poor muscle flexibility. One study found that those who use computers on a daily basis report more shoulder, neck, and low back pain than those who do not use computers.
(A) Lordosis is characterised by the excessive anterior forward tilt of the pelvis and increased lordosis of the lumbar spine. Several studies have discussed the relationship between lumbar lordotic curvature and low back pain.
(B) Sway-back presents with forward movement of the head, elongated cervical vertebrae, flattening of the lower lumbar region, and a slight backward tilt of the pelvis.
(C) Roundback/kyphosis is one of the most common postural conditions and is characterised by an excessively rounded back (kyphosis). Scheuermann disease is also a common condition that leads to a hunched appearance and spinal pain.
(D) A flat back reduces lumbar lordosis and can affect the balance of the spine.
(E) Scoliosis is a common musculoskeletal disorder with a rotational (twisted) component of the spine.
Summary
Postural assessment can help chiropractors identify risk factors for low back pain and determine appropriate action.
Postural alignment is not perfectly symmetrical.
Some postures may increase the risk of spinal pain and discomfort, and prolonged posture without movement is a risk factor for pain.
7) Disc herniation
Lumbar disc herniation is common and is divided into 4 stages: 1) bulging, 2) protrusion, 3) extrusion, and 4) sequestration. In a study of asymptomatic persons aged 60 years or older, 36% had a herniated disc, 21% had spinal stenosis, and more than 90% had a degenerated or bulging disc. The most common disc herniations occur from C5 to C7 of the cervical spine (neck) and L4–L5 and L5–S1 of the lumbar spine (low back). Studies have shown that 85–90% of the cases of painful lumbar disc herniations will resolve within 6–12 weeks and without medical intervention.
Spontaneous resorption of herniated lumbar discs has been reported in numerous studies. In one study, spontaneous resorption of the herniated disc was found in all patients in an average of 8 months. The rate of spontaneous regression was found to be 96% for disc sequestration, 70% for disc extrusion, 41% for disc protrusion, and 13% for disc bulging. Patients with disc extrusion and sequestration had a significantly higher possibility of having spontaneous regression than did those with bulging or protruding discs. Some of the signs and symptoms of a lumbar disc herniation include:
Low back pain.
Limited movement bending forwards.
Pain exacerbation with straining, coughing, and sneezing.
Pain intensified in a seated position as the pressure applied to the nerve root increased.
Symptoms worsen with leg straightening.
Back pain that radiates into the front thigh.
Weakness in hip flexion, knee extension, and adduction.
Back pain that radiates into the buttocks.
Back pain that radiates into the outside thigh, outside calf, and the top of the foot.
Buttock pain that radiates into the back of the leg, calf, and bottom of the foot.
Summary
Lumbar disc herniations are common and can take a long time to heal.
Spontaneous regression can happen, but don’t give up!
Image A shows the classification of lumbar disc herniation; bulge, protrusion, extrusion, and sequestration. Image B is a 43-year-old female patient with lumbar disc herniation. The initial MRI showed that the L5/S1 disc was hugely herniated. Image C shows after 1 year of conservative treatment, the L5/S1 disc herniation was significantly reduced and absorbed.
8) Causes of lower back pain
Low back pain symptoms can derive from many potential anatomic sources, such as nerve roots, muscles, fascial structures, bones, joints, intervertebral discs, and organs within the abdominal cavity. Muscle tension and spasm are among the most common symptoms in those with low back pain. In other cases, low back pain can be attributed to specific conditions such as;
Radicular pain that radiates from the low back and into the buttocks and legs Disc herniation is the most common cause, and inflammation of the affected nerve is the most common cause.
Lumbar facet pain usually presents with low back pain and stiffness, with or without referred pain to the thigh or groin and is not usually below the knee. Pain increases with extending backwards, twisting, side bending, walking uphill, waking up from bed, and trying to stand after prolonged sitting.
Sacroiliac joints (SIJs) are well recognised as a source of pain in many individuals who present with chronic low back pain. It usually worsens in a sitting position and with postural changes.
Lumbar spinal stenosis is usually due to age-related changes in the spine. The most frequent symptoms are central low back pain, referred leg pain, muscle weakness, tingling, pins and needles, numbness, and an altered sensation of feeling. Bending forward, sitting, stooping, or lying can all ease the discomfort, while prolonged standing or leaning backwards can aggravate the pain.
Discogenic pain often presents with radiating pain into the buttocks and legs. This pain can be experienced either on one side or both, but without leg pain. Individuals often experience a sitting intolerance.
Myofascial back pain is a type of pain that refers to a muscle or fascia. It is often associated with muscle strains, tightness, and spasms.
9) What can I do to help my low back pain?
Yoga practice, including yoga postures, yoga breathing, and meditation, has been shown to improve heart rate variability and reduce chronic low back pain.
Intensive chiropractic care in the initial pain relief phase is effective for chronic low back pain. Once maximum benefits have been reached, maintenance chiropractic may be beneficial to maintain the benefits and reduce pain levels.
For chronic low back pain, trunk strengthening (abdomen, pelvis, and low back) is effective for long-term pain management.
Diaphragmatic breathing exercises are effective in reducing pain and improving function in those with chronic low back pain.
During an episode of low back pain, the best thing you can do is carry on with your daily life and stay as physically active as possible.
If you have severe acute back pain, you should avoid lifting heavy objects and take care when bending down.
Getting into the following position (picture to the right) can help ease severe pain. Lie on your back and put your lower legs on a raised platform high enough so that your knees are bent at a 90-degree angle.
Try to continue with your normal daily life and don't spend too much time sitting in one position at work.
Gentle exercise, such as walking or cycling, is a great option that may offer pain relief.
Hot water bottles or heat packs are effective ways to relieve acute low back pain.
Anti-inflammatory medications such as ibuprofen can help, but they should only be used for a short period of time.
Staying active, avoiding prolonged rest, and using heat or anti-inflammatory medications can also help manage symptoms. Focus Chiropractic Abingdon, also provides a holistic approach to managing low back pain, focusing on conservative treatments and personalised care.
For those in need, visiting a chiropractor in Abingdon or seeking Abingdon chiropractic services can provide significant relief and support in managing low back pain. Whether it's through chiropractic treatment or lifestyle adjustments, chiropractic care aims to improve overall well-being and reduce the impact of low back pain.