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Back Pain

Updated 02 October 2018

What is back pain?

Backache is second only to headache as the most common cause of pain.

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Alternative names: Back ache, backache

Back pain, including lower back pain (LBP) or what doctors refer to as lumbar pain, is an aching, tight, stiff, burning, throbbing or pulling sensation along the spine.

Multiple factors at play

It’s a symptom of a number of processes, and not a disease, and is the most common musculoskeletal disorder in the world. It’s often difficult to find the exact cause of and treatment for back pain.

As such, it remains an enigma for many patients and doctors. Back pain is also one of the most expensive, disabling and poorly managed healthcare disorders across the globe, and one that makes many of us panic at the slightest onset. 

In South Africa, 60–80% of people get back pain at some stage of their lives. In up to 90% of cases, including where there’s nerve-root irritation, the pain will clear up within two months – with or without medical treatment. 

Currently, one of the main causes of back pain in South Africa is the obesity epidemic, although multiple factors are usually at play.  

Of all the types of back pain, the Global Burden of Disease 2010 study found that lower back pain causes more global disability than any other condition. In the 2016 Global Burden of Disease study, researchers found that countries with ageing populations, such as Germany and Japan, suffer more from back pain than, say, Kenya and Angola, where the incidence is lowest. South Africa is somewhere in the middle. See graph below.




The causes and contributing factors of back pain, as well as the perception of pain, is unique to each individual and the context they find themselves in. For this reason, back pain should be managed on an individual basis.  

For instance, one person may have a herniated disk and experience excruciating pain, while another with the same condition may experience only mild discomfort.

This is why pain perception is increasingly considered in treatments. Similarly, a muscle strain may take weeks to repair in one person visiting a variety of specialists; in another, it will heal on its own within a few days. 

To ensure that each individual is given the best possible care, doctors need to take a bio-psycho-social approach in the diagnosis and treatment of back pain.

The occurrence of back pain can be categorised as follows:

  • Acute back pain, the most common form, starts suddenly and lasts less than six weeks.
  • Sub-acute back pain lasts up to 12 weeks.
  • Chronic back pain lasts more than three months and is present all the time.
  • Recurrent acute back pain may occur if the cause of the pain isn’t addressed. You may have periods of acute pain, along with pain-free intervals. 

Types of back pain

The spine, one of the strongest parts of the body, consists of bony vertebrae that are joined together by cushioning discs. These make the spine flexible, forming an inward curve at the neck, and another in the lower back. 

The spine is held together by strong tendons that connect muscle to bone, and ligaments that connect bone to bone. Large, powerful muscles assist further to hold the spine in position. The spinal cord – a bundle of nerves – runs down the length of the spinal column. 

Back pain can originate in any of these parts. When the specific cause of the pain cannot be identified, it’s often referred to as “non-specific” back pain.

1. Mechanical back pain

Mechanical back pain (axial back pain), which accounts for 97% of cases, is where the source of the pain may be caused by an injury to the spinal joints, discs, vertebrae, or soft tissues. 

Types of mechanical back pain include: 

  • Irritated, stretched or pinched nerves
  • Muscle, ligament or tendon strain or sprain
  • Herniated (slipped) disc
  • Fractured vertebrae
  • Degenerative disc disease
  • Diseases such as spondylolysis or spinal arthritis
  • Deformities that you’re born with, e.g. scoliosis or kyphosis

2. Inflammatory back pain

Inflammatory back pain is generally characterised by pain that’s exacerbated by rest and relieved by activity, and which is often accompanied by early-morning stiffness. 

This type of back pain is associated with hard-to-diagnose medical conditions such as rheumatoid arthritis, ankylosing spondylitis, psoriatic arthritis, inflammation of the bowel (as in the case of Chrohn’s disease and ulcerative colitis), and reactive arthritis. 

3. Back pain caused by disease

Pain that occurs anywhere along the spine and which is constant, severe and nocturnal, without an obvious cause, needs to be seen to immediately to exclude a malignant or infective cause.

Metabolic disorders such as osteoporosis and diabetes, infections such as urinary tract infections (UTIs), tuberculosis and meningitis, and cancer tumours (either benign or malignant) can all cause back pain. 

Red alert: Contact your doctor immediately if back pain occurs with bladder or bowel dysfunction. Other red-flag symptoms are shooting pain, fever, tingling limbs, pain that becomes worse when you sit down, or pain as a result of trauma suffered to the back or neck accompanied with back pain.

Common back pain sites 

1. The neck

Any pain that stretches from the base of your skull to your shoulders, and which spreads to your upper back or arms, is regarded as neck pain.

Symptoms of neck pain include stiffness that makes it difficult to turn your head, tightness, or a sharp pain in one spot. 

The muscles in your body usually relax when they’re not being used, but your neck muscles never stop working because they’re permanently tensed to support your head. 

Injuries that cause neck pain include whiplash, pinched nerves, injured discs, sprains and strains, repetitive strain injury, and damage to the spinal cord. Whiplash injuries can sometimes become chronic and cause you to develop what’s known as whiplash associated disorder.

2. The upper and middle back

Pain located in your thoracic vertebrae (the area between the base of your neck and the bottom of your ribcage) is less common because you don’t use this part of your back as much as your upper or lower back. 

Back pain felt in this area is typically caused by irritated muscles in the upper back, either because they have lost strength, or are overused. It can also be due to natural degeneration as joints age, or it may stem from neck pain or stiffness, or sudden injury. 

3. The lower back

Lower back pain, or lumbago, is the most common type of back pain, affecting up to 80% of people at some point in their lives.

This is because this part of the back carries the weight of the upper body, and bends and twists more. Pain is felt between the bottom of your ribcage and the top of your legs, and symptoms include tension, stiffness, aches, pain and soreness. 

4. Buttocks and legs (sciatica)

Caused by irritation or compression of the sciatic nerve, this type of back pain typically radiates from the lower back and moves down the leg to the calf, and sometimes right into the foot. 

The pain level can vary from mild (including numbness and pins and needles) to extremely painful (e.g. sharp, burning or shooting pain).  

Is it back pain or kidney pain?

People often wonder whether sudden back pain could be a sign that there’s something wrong with their kidneys. Here’s a quick guide (but always consult a doctor to be sure): 

Back pain

Kidney pain

Pain is not constant or increases with movement.

Pain is constant or comes and goes in waves (pain is mild with infection and severe with kidney stones).

Pain in the lower back.

Pain occurs higher up, between the lower ribs and hips, on the flanks and/or in the groin area.

No vomiting, nausea or fever.

Vomiting, nausea and fever may be present.

Muscles are tender to the touch.

Muscles are not tender to the touch, but pressure applied to an infected kidney is.

The outlook for back pain

Ageing, a sedentary lifestyle, poor posture, obesity, genetic factors, an adverse work environment, pregnancy, smoking, and psychological factors (including depression) can put you at risk of back pain. 

These are easily avoided through better lifestyle choices. For instance, strengthening the core muscles (both abdominal and gluteal) can result in up to 70% reduction in the recurrence of back pain. 

Important note:

When it comes to diagnosing back pain, medical professionals now prefer to take an integrated approach that considers your entire lifestyle and health profile, including psychosocial factors such as too much focus on pain, fear of re-injury, anxiety and depression.

This provides an opportunity to guide and encourage self-care, which in turn lowers the high cost of treating back pain.

Back pain course and prognosis

How long your back pain will last depends on what’s causing the pain and what you’re doing to fix it. 

Remember that acute back pain is a symptom of something else that is wrong. Most of the time, the pain results from injury to bones, ligaments and muscles in and around the spine. Chronic back pain is often a result of multiple different factors – including social, psychological and physical – that interact and cause the pain.  

Basic facts about how long back pain lasts:

  • 90% of people with acute lower back pain recover over a period of six weeks. After this period, recovery tends to slow down.
  • 50% of episodes of acute lower back pain nearly completely resolve within two weeks. 
  • Up to 70–80% of affected individuals will have another back pain episode within a year.
  • Excruciating initial pain often resolves within a few days, while mild or moderate pain may persist for a couple of weeks.
  • All cases of back pain that last longer than six weeks need to be checked out by a doctor.
  • Back pain caused by an accident, and which results in substantial injuries, could become chronic. In other words, the pain may last more than three months.
  • How soon you seek treatment, as well as the quality of care, will affect your recovery rate.

Factors that make back pain better, or worse

Bed rest: You may feel like lying in bed until the pain goes away. However, staying in bed for more than a day could only make matters worse and reduce muscle strength in your back. Muscle strength can decrease by as much as 20–30% after only a week of complete bed rest. It generally takes much longer to regain the strength and function than it takes to lose it.

Certain exercises are best avoided while your back hurts. This includes exercises that round the spine and which reverse the natural lumbar curve, or which put stress on the lower spine, including toe touching, sit-ups, twisting the spine, double leg raises, spinning or cycling with a rounded back, and running.

However, studies overwhelmingly show that movement and exercise reduce all kinds of pain, including back pain. It strengthens the muscles and lubricates the joints, making it less likely that you’ll get reinjured or suffer joint pain. 

Exercise also releases natural pain-relieving endorphins, which can boost your mood. It also fights the inflammation associated with a number of painful conditions. By staying active, you keep the blood and nutrients flowing to the affected area, thereby controlling inflammation and reducing tension in the muscles. 

Getting quality sleep, using cold and heat therapies, using anti-inflammatory medication and plasters, stretching your hamstrings, and developing mechanisms for your brain to reduce or ignore pain signals can also help to relieve back pain. 

How long will it take to recover from back pain?

Researchers at NeuRA (Neuroscience Research Australia) have developed what’s known as the PICKUP (Preventing the Inception of Chronic Pain) model. This estimates how long people who have experienced lower back pain (LBP) for less than six weeks will take to recover by asking five simple questions. 

The questions were developed after studying 1 230 people with acute back pain, and was tested on a separate group of 1 530 individuals. The researchers found that, when doctors use this tool, it could reduce unnecessary interventions by 40% in primary care compared with a treat-all approach. 

The picture below shows what the calculator looks like:


Individuals who score 20% or lower can be confident that they have a good prognosis. Those with a score above 20% should consider more intensive management.

When can I resume normal activity?

This depends on the care you take and receive, as well as the type of injury and the cause. Research shows that it’s best to return to work as soon as possible. If needed, your work environment should be adjusted to prevent repeated injury.

Reviewed by general practitioners Dr Lienka Botha and Dr Suzette Oelofse, FX Health. April 2018

References:
- President of the South African Spine Society and neurosurgeon Dr Jacques du Plessis.
- KZN Department of Health
- Global Burden of Disease Study 2010
- How Back Pain Took Over the World.
- Diagnosis, Classification Management of Chronic Low Back Pain. From a mechanism based biopsycho-social perspective. Dr Peter O'Sullivan Specialist Musculoskeletal Physiotherapist. 
National Ankylosing Spondylitis Society (NASS). Differentiating inflammatory and mechanical back pain. 2012.
- Widespread Sensory Hypersensitivity Is A Feature of Chronic Whiplash-Associated Disorder but not Chronic Idiopathic Neck Pain. Clinical Journal of Pain, 21 (2) 175-181. Scott. D. et al (2005).

Image credits:

iStock

Global Burden of Disease 2010 study

Pickuptool

 

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Backache expert

Susan qualified as a Physiotherapist in 1990, and completed her master’s degree in Physiotherapy in 2013 at the University of Pretoria. She has a special interest in human biomechanics, as well as the interaction between domestic and work-related ergonomics.

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