Lower back pain: symptoms and treatments

What is lower back pain?

Lower back pain, or lumbago, refers to discomfort in the lumbar region. It is one of the most common medical issues and a major reason for doctor visits, medication use, and work absences. The pain can range from dull to sharp, sometimes alternating with periods of relief, or manifesting as a burning sensation. Severe cases can severely impair a person's quality of life. Lower back pain can be either acute or chronic, and in serious cases, it can be disabling, affecting daily activities and overall well-being.

How common is it and who does it affect?

Lower back pain affects people of all ages and backgrounds. Research shows that:

• 9 out of 10 people experience back pain at least once in their lives.
• 5 out of 10 working adults seek medical attention for back pain annually.
• In the U.S., 95% of people have suffered from back pain at least once.

Among the various types, lower back pain is the most prevalent, followed by cervical pain (neck pain) and thoracic pain (upper back pain or dorsalgia).

What are the causes of lower back pain?

Most people experience lower back pain from everyday activities - like picking up something heavy or twisting awkwardly. It can also develop gradually from repeatedly doing things that stress your back's muscles, discs, and joints over time. What makes this type of back pain tricky is that it's often hard to identify exactly what's causing it. Just because you feel pain in one spot doesn't necessarily mean that's where the problem is - the pain location doesn't always match up with what's actually hurting.

Doctors call this "non-specific back pain" because they can't point to one exact cause. This is different from "specific back pain," which is less common and happens when doctors can identify a precise reason for the pain, like a herniated disc or pinched nerve.

Types of lower back pain:

Depending on how symptoms appear and how long they last, lower back pain can be classified as acute or chronic.

Acute lower back pain (or acute lumbago) is pain in the lumbar area that appears suddenly and abruptly, lasting no longer than 6 weeks.

Chronic lower back pain (or chronic lumbago) is pain in the lumbar area that appears gradually and lasts at least 12 weeks.

Furthermore, depending on the cause of lower back pain, it can be further classified as specific lower back pain and non-specific lower back pain.

What are the causes of specific lower back pain?

Back pain caused by a specific condition is often referred to as specific lower back pain. Conditions causing lower back pain are:

• Herniated disc, disc protrusion, and other disc disorders
• A herniated disc occurs when the nucleus pulposus of an intervertebral disc tears through the fibrous ring walls and protrudes, reaching and irritating the nearest spinal nerve roots.
• Conditions such as sciatica, lumbosciatica, crural neuralgia, and cauda equina syndrome are all related to herniated discs and characterized by lumbar pain.
• Vertebral fractures
• These are generally the result of traumas to the back due to falls or repeated microtraumas over time (stress fracture).
• Osteoporosis is another important risk factor for this type of injury.
• Spinal column infections
• These are infectious processes that can affect the vertebrae (spondylitis), intervertebral discs (discitis), or both structures (spondylodiscitis).
• Spinal, vertebral, or other types of tumours
• Spinal neoplasms affect the spinal cord parenchyma.
• Vertebral tumours affect the vertebrae (and can involve the spinal cord through compression).
• Multiple myeloma is among other types of tumours.
• Ankylosing spondylitis
• It's a chronic rheumatic disease, autoimmune in nature.
• Initially affects the spine (primarily the lumbar region).
• Can later extend to affect the eyes and cardiovascular system.
• At the vertebral level, it's responsible for inflammatory processes that result in the fusion of joints between vertebrae.
• Lumbar spondylolisthesis
• It's a spinal column alteration characterised by abnormal slipping of a lumbar vertebra onto the lumbar vertebra below.
• Can be congenital or due to trauma or continuous abnormal stress on the lumbar region.
• Visceral conditions Including:
• Kidney stones.
• Renal colic.
• Kidney infections.
• Gynaecological conditions (pregnancy, spontaneous abortion, ovarian cysts, endometriosis, uterine fibroids, ovarian cancer, etc.).

Photo by Kenny Eliason on Unsplash

What are the risk factors for lower back pain?

Recent evidence indicates that risk factors for non-specific lumbar back pain are:

• Excessive physical exertion or unusual activities, such as:
• Lifting objects that are too heavy
• Sudden movements with the back
• Unnatural back twisting
• Maintaining an upright posture for many consecutive hours
• Sedentary lifestyle and lack of motor stimuli (this could be due to staying still for a prolonged period of time, both when sitting and standing)
• Obesity
• Anxiety and stress
• Poor quality of night sleep
• Fear of performing certain movements
• Smoking

Other risk factors include:

• Practicing sports like horseback riding, where the risk of falls is high.
• Weight lifting, where incorrect technique can favour the appearance of herniated discs
• Genetic predisposition for certain conditions (e.g., ankylosing spondylitis)

Why does back pain mainly affect the lumbar region?

The lower back is particularly vulnerable to pain because it bears the brunt of body weight during movements like lifting. This biomechanical aspect explains why lower back pain is more common than pain in other parts of the spine. The lumbar region is structurally stressed more than the cervical or thoracic regions, making it a frequent site for issues. The combination of weight-bearing responsibilities and the strain from various activities makes it prone to injury, justifying the higher incidence of pain in this area.

Fun Fact: The lumbar vertebrae are larger and sturdier than other vertebrae because they bear the most weight, especially during lifting. This evolutionary adaptation helps the lower back manage the heavy loads it regularly encounters, offering better structural support and durability.

What are the symptoms?

The most common type of lower back pain is often associated with:

• Local rigidity. The muscles are often contracted, giving the patient a sensation of stiffness
• Reluctance to move due to pain. The patient knows, for example, that bending will hurt, so they avoid doing it
• Difficulty moving due to pain. Movement causes pain, which restrains the patient's movements

If lower back pain is related to a specific health condition (specific lower back pain), clinical symptoms may include:

• Pain, tingling, and/or sense of weakness in a thigh, leg, and/or foot
• Limping
• Loss of anal and/or bladder sphincter control
• Muscle atrophy in the lower limbs
• Fever
• Unexplained weight loss

How does lower back pain presents itself?

Depending on the cause, pain related to lumbar back pain can be piercing, burning, or dull; moreover, it can be constant or alternate between phases of severe intensity and apparent remission.

Complications of non-specific lower back pain

Severe lower back pain can make the most basic movements difficult, which can compromise the patient's quality of life.

Chronic or recurrent lower back pain can also impact the individual on a psychological leve as the patient feels limited in their daily activities.

When should you worry about lower back pain?

You should contact your doctor if:

• The pain is very acute, sharp, and debilitating
• The pain doesn't decrease despite rest
• You have fever
• You experience limping and/or loss of anal or bladder sphincter control
• You have sexual dysfunction
• You experience unexplained weight loss

How to diagnose it?

It's important to note that in most cases, non-specific lower back pain isn't anything serious. With that said, diagnosis typically begins by taking a thorough medical history and carrying out a physical examination.

In most cases, these two approaches are sufficient to establish the nature of the pain.

In some circumstances, further investigation may be needed, particularly when a specific condition is suspected to be causing your lower back pain. In these cases, depending on what emerges from initial investigations, diagnostic tests might include:

• Imaging diagnostics (X-rays, MRI of the spine, and sometimes even CT scans)
• Blood tests
• Electromyography and nerve conduction studies

Clinical diagnosis (medical history and physical examination) should always precede instrumental investigation, because numerous studies have shown that there isn't always a direct correlation between lower back pain and conditions like hernias, disc protrusions, disc degeneration, or spinal arthritis, which are very common in completely asymptomatic patients, especially in certain age groups.

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What are the treatment options for lower back pain?

Treatment for lower back pain varies depending on the cause.

Non-specific lower back pain tends to resolve spontaneously; You just need a bit of patience. However, experts believe that without a change in daily habits, relapses are very likely, and the pain could become chronic/persistent.

Specific lower back pain is different: in this instance, it's necessary to identify the triggering cause and implement targeted therapy, which may include medications and/or surgery.

How to relieve lower back pain?

In the most common cases of lower back pain, the patient benefits from:

• Active rest
• This means avoiding all activities that evoke pain while staying in motion
• Complete rest is contraindicated, except in the first 24-48 hours after pain onset
• Resting actively allows tissues to recover while avoiding complications from complete physical inactivity (which would make tissues even more fragile and less tolerant to loads)
• Adopting pain-relieving postures
• When sitting or lying down, it's advisable to favor a neutral position of the spine
• It's also recommended to avoid staying still for long periods: for example, if you do desk work, it might be a good idea to take regular breaks for a short walk
• Applying cold or hot packs
• Ice packs have pain-relieving properties
• Hot packs relax the muscles
• Using self-heating patches
• Many products with these properties are available in pharmacies and drugstores
• Heat relaxes contracted muscles and alleviates pain symptoms
• Taking over-the-counter anti-inflammatory drugs
• Such as NSAIDs (e.g., ibuprofen) or paracetamol
• Indicated as needed when pain is very bothersome
• Despite being fairly common drugs available without prescription, it's still good to consult with your doctor before taking them

Can exercises help lower back pain?

If pain persists or recurs periodically, it's advisable to do physiotherapy exercises, preferably consulting a professional who will create a personalised functional rehabilitation program. Physiotherapy helps improve muscle tone, joint mobility, and general motor capabilities, thus promoting load tolerance of back muscles.

Other therapies that the physiotherapist might use include:

• Ultrasound
• Tecar therapy
• Laser therapy

Photo by Benjamin Wedemeyer on Unsplash

Is walking beneficial when you have back pain?

There is numerous evidence supporting the benefits of walking for people with non-specific lower back pain. As stated earlier, absolute rest is counterproductive (except in the very first days), while movements that don't excessively stress the spine are recommended and promote healing. Walking is an activity that gently stimulates the back, gradually reaccustoming it to load-bearing.

What to take for lower back pain?

In less severe cases of lower back pain, your doctor might recommend an NSAID, an anti-inflammatory drug that relieves pain. In these cases, using self-heating patches can also be beneficial.

In more severe cases, if indicated, anti-inflammatory therapies might involve the use of corticosteroids, (drugs with powerful anti-inflammatory action).

How to sleep with lower back pain?

There are certain positions that might lighten the weight on the back, promoting recovery and preventing annoying pain. According to experts:

• People who like sleeping on their back should place a pillow under their knees
• Those who prefer sleeping on their side should flex their hip and bring their knees to their chest, assuming the so-called fetal position (providing that it is not painful to put yourself in this position).
• Those who can only sleep on their stomach should place a pillow in the lower abdomen to promote neutral lumbar lordosis

Did You Know... In bed, the ideal positions for back health are:

• On your back, with a pillow under your knees
• On your side, with knees bent toward the chest and chin pointing downward

Specific lower back pain: what are the treatments?

In case of specific lower back pain, the treatment varies depending on the cause and severity of symptoms. To understand this concept, let's take herniated discs as an example: for the majority of patients (about 80%), personalised physiotherapy treatment is sufficient, while surgery is reserved for few selected cases.

Other therapeutic options can be:

• Physiotherapy and functional rehabilitation (e.g., most herniated discs)
• Antibiotic therapy (e.g., in case of bacterial infections)
• Chemotherapy (e.g., in presence of tumors)
• Surgery or other minimally invasive therapeutic techniques (e.g., severe hernias, tumors, severe vertebral fractures, visceral pathologies not responding to conservative treatments)

How long does lower back pain last for?

The prognosis for non-specific lower back pain is generally positive and the recovery times for most patients range between 2 and 6 weeks;

On the other hand, the prognosis and recovery times for specific lower back pain depend on the triggering cause; for example, in case of herniated disc (treated without surgical intervention), the healing process takes approximately 3 months.

What can you do to prevent lower back pain?

To prevent the most common forms of lower back pain, doctors recommend:

• Using appropriate technique for lifting weights and avoiding excessive back twisting
• Avoiding staying still for prolonged periods
• Recent evidence suggests there's no correlation between "bad" posture and lumbar back pain
• However, the back suffers if it receives few motor stimuli, such as when sitting for long periods or standing for a long time
• Exercising regularly and with proper modalities
• Physical inactivity and excessive sports practice are well established risk factors for lower back pain

Resources:

1. Back Pain Relief Products: Evidence-Based Treatments That Work - https://www.goodpath.com/learn/back-pain-relief-products
2. 7 Ways to Treat Chronic Back Pain Without Surgery - https://www.hopkinsmedicine.org/health/conditions-and-diseases/back-pain/7-ways-to-treat-chronic-back-pain-without-surgery
3. Back Pain - StatPearls - NCBI Bookshelf - https://www.ncbi.nlm.nih.gov/books/NBK538173/
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