Back Pain
What Is Acute Low Back Pain?
Acute low back pain (LBP) is defined as low back pain present for up to six weeks. It may be experienced as aching, burning, stabbing, sharp or dull, well-defined or vague. The intensity may range from mild to severe and may fluctuate. The pain may radiate into one or both buttocks or even into the thigh/hip area. Low back pain may begin following a strenuous activity or jarring trauma, but often is seemingly unrelated to a specific activity. The pain may begin suddenly or develop gradually. At least 80% of individuals experience a significant episode of LBP at some point in their lives. At any given point in time, at least 15% of individuals report that they are experiencing LBP. Some consider the symptom of LBP to be a part of the human experience.
What Causes Acute LBP?
The exact source of acute LBP is often difficult to identify. In fact, there are numerous possible pain producers including muscles, soft connective tissue, ligaments, joint capsules and cartilage and blood vessels. These tissues may be pulled, strained, stretched or sprained. Additionally, annular tears (small tears that occur in the outer layer of the intervertebral disc) can initiate severe pain. Even if the actual tissue damage is minor, and likely to repair quickly, the pain experienced may be quite severe. No matter which tissue is initially irritated, a cascade of events occurs which contributes to the pain experience. Numerous chemical substances are released in response to tissue irritation. These substances “stimulate” the surrounding pain-sensitive nerve fibers, resulting in the sensation of pain. Some of these chemicals trigger the process of inflammation, or swelling, which also contributes to pain. The chemicals associated with this inflammatory process feed back more signals which perpetuate the process of swelling. The inflammation attributable to this cycle of events may persist for days to weeks.
Muscular tension (spasm) in the surrounding tissues may occur resulting in a “ trunk shift” (the body tilts to one side more than the other) due to muscular imbalance. Additionally, a relative inhibition or lack of the usual blood supply to the affected area may occur so that nutrients and oxygen are not optimally delivered and removal of irritating byproducts of inflammation is impaired.
How Long Will it Last?
The good news is that even if the exact source of pain is not determined, usually the acute pain subsides spontaneously over time. The originally irritated tissue heals. Fifty percent of episodes nearly completely resolve within two weeks, and 80% by six weeks. Unfortunately, the duration and severity of a single episode cannot be predicted based on the onset, location of pain or even the initial severity. Excruciating initial pain may resolve within several days, while moderate or mild symptoms may persist for weeks. However, up to 30% of individuals will
experience recurrent pain or develop persistent pain in the future.
Is Acute LBP Dangerous?
The seriousness of LBP is relative. The symptoms of acute LBP are usually benign and self limited. Even a ruptured disc has a chance of improving without surgery. Rarely, however, LBP is caused by a more serious process such as a fracture, infection or cancer. This is more common in individuals over age 50, those with a history of cancer, those with severe pain at rest, with associated fever, with underlying medical problems such as diabetes, heavy alcohol or drug use, long time corticosteroid use, or osteoporosis. Pain in the legs, weakness, or difficulty with bowel or bladder control warrant prompt medical evaluation. For all cases of pain lasting longer than six weeks, medical evaluation is advised. Some of the best advice for treatment for acute LBP is to continue to remain active “as tolerated”. Continuing to perform everyday activities may seem counterintuitive, and the natural inclination may be to stay in bed or “freeze”, to guard and avoid activity. Yet, activity keeps blood and nutrients flowing to the affected area, inhibiting inflammation and reducing muscular tension. Many individuals with LBP find that they can perform their usual, but more controlled cardiovascular activities (such as walking) in spite of the pain and often feel better after the activity. More vigorous or uncontrolled activities such as weight lifting or competitive or contact sports are inadvisable while pain is severe. There is no reason to completely avoid stretching muscles and tissues in the legs and back during an acute episode, but stretching should not cause more severe pain. Local application of heat or ice can temporarily reduce pain and heat may facilitate stretching, but does not necessarily speed long term recovery.
How Is it Treated?
Medication: Both acetominophen and nonsteroidal antiinflammatory drugs (NSAIDs) are analgesics (pain relievers) which are known to provide effective reduction of acute LBP. NSAIDs also inhibit the above described inflammatory process described earlier. These medications should be used only as prescribed by a physician. NSAIDs are associated with possible side effects in certain individuals and risk for such effects increases when used for prolonged periods. The more common side effects include excessive bruising and bleeding, and stomach upset irritation, with kidney and liver problems possible with sustained use. “Muscle relaxants” are medications that do not actually relax skeletal muscle. However, they do calm or sedate the central nervous system and can be useful to facilitate sleep and secondarily reduce contributing emotional or muscular tension in the setting of severe pain. These medications must be used under the direction of a prescribing physician. Narcotics (also called opioids) are strong pain
relievers and do reduce the symptoms of acute LBP. Because narcotics are sedating, they can be useful to facilitate sleep during the first few nights of symptoms. Long term use of narcotics is associated with undesirable side effects including physical dependency, sedation, depression, constipation, increased sensitivity of pain sensitive fibers, and interruption of restorative sleep cycle. Narcotics should only be used as prescribed by and under the direction of a physician. Treatments Other Treatments: Physical therapy modalities such as ultrasound, electrical stimulation, traction, mobilization, and chiropractic manipulation can provide temporary relief, but are not proven to improve long term recovery. Acute LBP usually resolves spontaneously and in most cases, as long as activity can be maintained, formal therapy may not be required. If the pain is severe, participation in activities is impaired or if motion is significantly restricted, a physical therapist can provide additional education and advice regarding strategies for restoring motion, resuming activities, preventing deconditioning and achieving a position of comfort during sleep. For those with persistent or recurrent LBP a medical evaluation is indicated and a physical therapist supervised exercise program is likely advisable. The goal should always be towards developing and transitioning to a fully independent home or health club exercise regimen. Emphasis will likely be placed on optimizing trunk or “core” strength and improving general flexibility and cardiovascular endurance. Spinal Injections: Spinal injections are generally not considered an appropriate treatment for acute, self-limited LBP. There are several injection options for persistent or recurrent pain, including epidural steroid, facet joint and trigger point injections, which can be determined following a comprehensive medical evaluation.
Do I Need an X-Ray or MRI?
In most cases of acute LBP diagnostic testing is not required. X-rays or other diagnostic tests may be advised in cases of pain associated with severe trauma, history of cancer, fever, diabetes, other medical problems, illicit IV drug use, age over 50, bowel or bladder dysfunction, nocturnal pain or osteoporosis. Various types of imaging tests an be obtained. These include regular x-ray, bone scan, computed tomography (CT) scan, and magnetic resonance maging (MRI). The choice of test depends on what medical condition your physician suspects. It is important to realize that the “final” diagnosis is based on a combination of history, physical examination and diagnostic testing, not imaging tests alone.
What is Chronic Pain?
Low back pain is considered to be chronic if it has been present for longer than three months. Chronic low back pain may originate from an injury, disease or stresses on different structures of the body. The type of pain may vary greatly and may be felt as bone pain, nerve pain or muscle pain. The sensation of pain may also vary. For instance, pain may be aching, burning, stabbing or tingling, sharp or dull, and well-defined or vague. The intensity may range from mild to severe. Many times, the source of the pain is not known or cannot be clearly defined. In fact, in many instances, the condition or injury that triggered the pain may be completely healed and undetectable, but the pain may still continue to bother you. Even if the original cause of the pain is healed or unclear, the pain you feel is real. It is your health care provider’s job respect your experience of pain, regardless of its cause.
What Causes It?
Chronic low back pain may be caused by many different sources. It may start from diseases, injuries or stresses to many different structures including bones, muscles, ligaments, joints, nerves or the spinal cord. The affected structure will send a signal through nerve endings, up the spinal cord and into the brain where it registers as pain. Many different theories try to explain chronic pain. The exact mechanism is not completely understood. In general, it is believed that the nerve pathways that carry the pain signals from the nerve endings through the spinal cord and to the brain may become sensitized. Sensitization of these pathways may increase the perceived pain out of proportion to the source of the pain. Stimuli that ordinarily are not perceived as painful, such as light touch, can be amplified or changed by these sensitized pathways and experienced as pain. Sometimes, even after the original injury or disease process has healed, sensitized pathways continue to send signals to the brain. These signals feel just as real and sometimes worse than the pain caused by the original injury or disease process. Imagine an old television set or computer screen on which the same image is continuously projected. This image is eventually “burned” into the screen. Even when the screen is turned off, the image can still be seen on the screen. In the same manner, after the original source of pain is healed or no longer present, chronic pain patients may continue to feel pain. Although this is an over simplification of what may happen in chronic pain, it helps explain the basic concept.
How Is Chronic Low Back Pain Diagnosed?
As mentioned earlier, chronic low back pain is defined as back pain that lasts longer than three months. During the evaluation of chronic back pain, it is important to rule out any injuries or disease processes that could place you at risk for further injury if not treated or addressed. Clarification of the diagnosis is a key step in creating a pain management program. A good patient history and a thorough physical examination by a well-trained clinician are the most important aspects of the evaluation. Serious injuries and illnesses can often be diagnosed or ruled out based on the history and physical examination alone. However, lack of a definite diagnosis does not necessarily mean more testing is needed. Needless tests do not add anything to what your health care provider has already discovered in his or her physical examination. (In fact, unnecessary testing is not only expensive, but it could expose you to unnecessary risks or radiation.) If your health care provider feels that more testing is needed based on your history and physical examination findings, he or she will discuss with you the appropriate tests to be ordered. Testing may include blood tests, radiography (X-ray films), bone scans, computed tomography (CT) scans, magnetic resonance imaging (MRI), diagnostic injections, electromyography (EMG) and many other specialized tests. Many times, the exact cause of the pain is still not well defined at the end of the evaluation. Nevertheless, an evaluation is successful if it has ruled out those processes that could place you at risk if not treated.
What Treatments Are Available?
Treatments for chronic back pain can vary greatly depending on the type and source of the pain. If a treatable source of the pain is found, then the underlying process should be treated. When the underlying cause is either not known or not treatable, then the symptoms are treated. The goals of the treatment are to reduce pain, improve quality of life and increase function. Treatment for chronic pain includes several different general categories. These categories include physical therapy, medications, coping skills, procedures and complementary medicine
treatments. Your health care provider will tailor a program involving a combination of these general options which best addresses your needs. Physical therapy includes patient education and a variety of stretching and strengthening exercises, manual therapies and modalities (ice, heat, transcutaneous electrical nerve stimulation [TENS], ultrasound, etc.) to treat pain. Active therapies which you can continue on your own, such as exercise and strengthening, usually have the most permanent and long lasting effects. Exercise and strengthening are designed
to increase stability and strength around the structures in the back that are being stressed. They also work to avoid deconditioning that results from decreased activity. Exercises are tailored specifically to your abilities and the type of back pain being addressed.
Treatments…Continued
Medications used for treatment of pain are multiple and varied. They fall into several different categories. Both non-narcotic and, rarely, narcotic pain medications may be used in the treatment of chronic back pain. Nonsteroidal antiinflammatory drugs (NSAIDs) are helpful with pain control and may help reduce inflammation. (See the NASS Patient
Education Brochure on NSAIDs for more information on their proper use.) Muscle relaxants can also help with chronic pain and may enhance the effects of other pain medications. Nerve stabilizing drugs (antidepressants and antiseizure medications) are used to treat nerve-mediated pain. All these medications have different potential side effects and interactions and should be carefully monitored by your health care professional. Coping skills are extremely important in the management of chronic back pain. Chronic pain directly affects all areas of your life. Pain affects mood, and your mood affects your ability to cope with pain. Pain also affects how you interact with other people. For this reason, learning appropriate coping skills for dealing with anxiety, depression, irritability and frustration can be invaluable. Visiting a trained pain specialist, psychologist or psychiatrist greatly enhances the treatment of chronic back pain. (See the NASS Patient Education Brochure on Back Pain and Your Emotions for more information.) Procedures ranging from minimally invasive injections to surgery may be used in chronic pain. Sometimes, implantable devices are beneficial in treating chronic pain. You should discuss the potential risks and benefits of any procedures considered with your health care provider. Often a second opinion is beneficial. Complementary medicine also provides a variety of treatments often helpful in the treatment of chronic pain. These treatments include acupuncture, dry needling, nutrition, magnets and many others. It is important for you to discuss these treatments with your health care provider. It is important to be sure that any complementary medical interventions work well with your other treatments. Make certain you fully understand any treatment option that you are given. Ask questions if something is not clear. The North American Spine Society also offers a wide range of patient education brochures on spine procedures to help you be an informed participant in your care.
Four out of five adults will experience an episode of significant back pain sometime during
their life. Not surprisingly, back pain is one of the problems most often seen by health care
providers. Fortunately, the majority of patients with back pain will successfully recover and
return to normal social and work activities within 2-4 months, often without treatment.
In 1979, the major professional organization specializing in pain—the International
Association for the Study of Pain—introduced the most widely used definition of pain: “an
unpleasant sensory and emotional experience associated with actual or potential damage, or
described in terms of such damage.” This pain is a complex experience that includes both physical
and psychological factors.
It is quite normal to have emotional reactions to acute back pain. These reactions can include fear, anxiety and worry about what the pain means, how long it will last and how much it will interfere with activities of daily living. Though it’s normal to avoid activity that causes pain, complete inactivity is ill-advised. Rather, it is important to take an active role in managing pain by participating in physician-guided activities. There are now accepted clinical guidelines for management of acute back pain (by definition, within the first 10 weeks of pain) and its associated stress. These guidelines emphasize:
- Addressing patients’ fears and misconceptions about back pain
- Providing a reasonable explanation for the pain as well as an expected outcome
- Empowering the patient to resume/restor normal activities of daily living through
simple prescribed exercises and graded activity. - This should be supplemented, when necessary, by complementary treatments such as analgesic medications, manual therapy and/or physical therapy for symptomatic relief.
Questions You Need to Ask
In order to minimize emotional distress, it is important to ask your health care provider questions about your back pain so you do not leave the office uncertain or anxious. Understanding your pain will help decrease your anxiety. Keep in mind that, if your pain lasts more than 2-4 months (which is usually considered a normal healing time for most back problems), your condition may become chronic. Chronic pain can be associated with even greater psychological distress.
During the acute period, feelings of helplessness, stress and even anger towards your health care provider (for not relieving your pain) may occur. In order to help allay this distress, you need to be sure that your health care provider is attending to all of your important physical and psychological needs. You and your health care provider should do the following:
- You should express your concerns about your pain symptoms. It is normal for patients to fear serious disease or disability. Be certain that your health care provider addresses your
fears through appropriate medical evaluation and explanation. - Be certain that your health care provider fully explains what is being looked for or
ruled out during these evaluations and tests, and make sure you get the results in terms
you can understand. - If your health care provider recommends staying active, be certain that he or she discusses
with you how to stay active safely. - Inform your health care provider of any functional difficulties your pain is causing
(eg, problems with bending, lifting, etc.) and identify with him or her ways to overcome
these difficulties. Also have your health care provider address any problems you have
performing your normal work activities. - The information you receive about your diagnosis and prognosis should be clear to you.
Make sure you understand the natural progression of back pain, what “improvement” can be expected and when it is likely to occur. - Whenever any recommendations are made, be sure that you or your health care provider
writes them down so you can review them after leaving the office.
All of these recommendations are intended to reduce the emotional concerns and stress most
patients experience with pain. If you are not satisfied with the treatment and explanations you
receive, consider getting a second opinion from another health care provider. Anxiety and stress
can actually increase your pain and reduce your pain coping skills.
Relationship Between Stress and Pain
It is important to remember that there is a dynamic relationship between your state of mind
(eg, stress level) and your physical condition (eg, pain). Pain can cause stress, which causes more pain, which causes more stress, and so on. The more chronic this vicious cycle becomes, the
more likely your emotional distress will increase. This cycle can be very difficult to break.
Emotional suffering can lead to loss of sleep, inability to work as well as feeling irritable and helpless about what can be done. You may feel desperate and attempt to relieve the pain at any cost including the use of invasive medical procedures. Although invasive approaches may be beneficial for some conditions (such as a herniated disc), often they can be avoided if stress and pain are managed at an early point in time.
Education and reassurance from your health care provider goes a long way in preventing or
relieving a great deal of stress and anxiety. You also need to be proactive about your condition
and treatment. These naturally occurring feelings of anxiety and stress may cloud your judgment.
Your goal is to avoid getting into a chronic pain cycle. Reassurance from your health care provider that the pain is only temporary can go a long way to help you avoid becoming preoccupied with pain, and prevent unnecessary worry about the symptoms.
Psychological Interventions for Back Pain
Fortunately, there are a number of psychological therapies that have been successfully used in the management of pain and anxiety. These include stress management, relaxation training, biofeedback, hypnosis and cognitive-behavioral therapy (a method to reduce feelings of doom and helplessness). There are also medications available to help with sleep problems, anxiety and depression. Such comprehensive pain management programs, when integrated with your medical care,
have proven to be quite successful.
Your health care provider can refer you to a psychological management program if it is appropriate. Participation in such a program does not mean the pain is “all in your head” – it is meant to teach you methods to cope with and control the pain. Remember, pain is a complex experience that includes a close interaction of physical and psychological factors! But together, you and your health care provider can help you manage and overcome your pain.