• Introduction
• Symptoms
• Causes
• Diagnosis
• Treatment
• Prevention
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Introduction

Back pain is a common condition that affects most people at some point during their life. Most cases of back pain are associated with pain and stiffness in the lower back.

Types of back pain

Back pain is classified in two main ways:

• specific back pain – pain that is associated with an underlying health condition or damage to the spine
• non-specific back pain – where the pain is not caused by serious damage or disease, but by sprains, muscle strains, minor injuries or a pinched or irritated nerve

Causes of specific back pain include:

• sciatica – a condition caused by a nerve in the back (the sciatic nerve) being irritated or compressed
• slipped disc – where one of the discs of the spine (see below) splits and the gel inside leaks out
• ankylosing spondylitis – a condition where the joints at the base of the spine become inflamed

This article focuses on non-specific back pain.

Back pain can also be classified according to how long the symptoms last. For example:

• acute back pain – the pain does not last longer than six weeks
• chronic back pain – the pain lasts for more than six weeks

The structure of the back

The back is a complex structure consisting of:

• 24 small bones (vertebrae) that support the weight of your upper body and form a protective canal for the spinal cord
• shock-absorbing discs (intervertebral discs) that cushion the bones and allow the spine to bend
• ligaments that hold the vertebrae and discs together
• tendons to connect muscles to vertebrae
• the spinal cord which carries nerve signals from the brain to the rest of the body
• nerves
• muscles

The lumbar region

The lower part of your back is known as the lumbar region.  It is made up of 5 vertebrae: L1, L2, L3, L4 and L5.

The lumbar region supports the entire weight of your upper body (plus any extra weight that you are carrying).  It is under constant pressure, particularly when you are bending, twisting, and lifting.  This is why most cases of back pain develop in the lower back.

How common is back pain?

Back pain is a very common condition and can affect adults of all ages.

It is estimated that one in five people will visit their GP in any given year because of back pain. And 80% of adults will experience at least one episode of back pain at some time in their lives.

Chronic back pain is less common than acute back pain, but it is still very widespread.  Chronic back pain is a very common cause of long-term disability (after arthritis). After stress, it is the leading cause of long-term work-related absence. A recent study found that one in every 10 people reported having some degree of chronic back pain.

The rates of reported cases of back pain have increased over the past 40 years – a trend that is seen in almost all Western nations. There are a number of theories to explain the rise in the number of cases.

One theory is that the rates of obesity, depression and stress are now higher than they were in the past. These conditions are all risk factors for chronic back pain. Another theory is that people are now more willing to report symptoms of pain to their GP than they were in the past. See Back pain - causes for more information.

Outlook

The outlook for back pain can vary considerably between individuals. Some people have minor episodes of acute back pain before making a full recovery.

Other people have long periods of mild to moderate back pain that are interrupted by periods of severe pain, which makes them unable to do their normal daily activities.

An Australian study which looked at people who visited their GP because of back pain found that:

• 40% were completely free of pain within six weeks
• 58% were pain-free within 12 weeks
• 73% were pain-free within one year

Psychological and social factors play an important role in the expected outlook for back pain, particularly for chronic back pain.

For example, people who have a positive frame of mind and report enjoying a good quality of life tend to make a faster recovery than those who report symptoms of depression and are unhappy with one or more aspects of their life.

Treatment options for back pain include painkillers, spinal manipulation, acupuncture and exercise classes. Some cases of chronic back pain may also benefit from additional psychological treatment for the reasons discussed above.

Symptoms

The most common symptom of backache is a pain, tension, or stiffness in the lower back.  The lower back, between the bottom of your ribs and the top of your legs, is usually affected.

Other symptoms of backache can include:

• muscle spasms – involuntary tightening and relaxing of your muscles
• pain that travels from your lower back down your buttocks and into your legs – this is usually a sign of sciatica
• a reduced range of motion in any actions that involve your back – for example, you may find it difficult or painful to bend over to pick things up

When to seek medical advice

The majority of cases of back pain will usually get better without you having to consult your GP or another healthcare professional.

However, there are a number of warning signs, known as ‘red flags’, which may indicate that your back pain is actually caused by a more serious condition. These include: 

• a high temperature (fever) of 38C (100.4F) or above
• unexplained weight loss
• inflammation or swelling of your back
• constant back pain that does not ease after lying down or resting
• pain that travels to your chest or pain high up in your back
• pain down the legs and below the knees
• a recent trauma or injury to your back
• loss of bladder control
• unable to pass urine
• loss of bowel control
• numbness around the genitals, buttocks or back passage

Contact your GP immediately if you have any of these symptoms listed above.  If this is not possible, you can telephone NHS Direct Wales on 0845 4647.

Also seek medical advice if you are experiencing back pain and:

• you are under 20 or over 55 years of age 
• you have taken steroids for a few months
• you misuse drugs
• you have cancer, or you have had it previously
• you have a weakened immune system as a result of chemotherapy treatment or medical condition such as HIV or AIDS.

Also ask your GP if your symptoms fail to improve within three days or you have persistent pain that lasts longer than six weeks.

Causes

Your back is a complex and delicate structure that is made up of a combination of bones, muscles, nerves and joints. Therefore, it does not take a significant injury or damage to disrupt the normal workings of the back and trigger an episode of back pain.

Back pain can be triggered by everyday activities at home and at work, or by poor posture. For example, back pain can occur as a result of:

• bending awkwardly
• lifting, carrying, pushing or pulling incorrectly
• slouching in chairs
• standing or bending down for long periods
• twisting
• coughing
• sneezing
• muscle tension
• over-stretching
• driving in hunched positions
• driving for long periods without taking a break

You may also experience occasional episodes of back pain as a result of the normal ageing process of the spine, which can temporarily disrupt the normal function of your back.  Sometimes, you can wake up with back pain and have no idea what has caused it.

Risk factors

Risk factors for back pain include:

• being 20 to 50 years of age – for reasons that are not fully understood, most cases of backache affect young and middle-aged adults
• being overweight or obese – extra body weight places more strain on the bones, muscles and joints of your spine
• smoking – it is uncertain as to whether this is a result of tobacco smoke damaging the tissue of the back or due to the fact that smokers tend to have unhealthier lifestyles than non-smokers (or it could possibly be a combination of both)
• being pregnant – as with being overweight, the excess weight of carrying your baby can place additional strain on your back       
• depression (see below)
• the long-term use of medications that are known to weaken bones, such as corticosteroids
• stress – it is thought that people who are under stress may unknowingly tense the muscles in their back, which could trigger an episode of back pain 

Depression does not directly cause back pain but it can be a major contributing factor. Many people with back pain and depression can fall into a vicious cycle. The pain makes them feel depressed, which means that they exercise less and do not take part in everyday activities. 

The lack of physical activity and exercise means that the symptoms of back pain persist, which in turn makes symptoms of depression worse.

Having a job (or regularly taking part in an activity) that involves a large amount of lifting, twisting, sitting down or repetitive motion can increase your risk of developing back pain. Taking part in an activity that exposes your back to prolonged vibration, such as driving a lorry or using a pneumatic drill, can also put you at risk.

Diagnosis

Your GP will be able to diagnose back pain by discussing your symptoms with you and by examining your back.

There is usually no need for tests, such as X-rays or MRI scans, when diagnosing back pain. If you have simple back pain, tests are not always helpful because they do not often show anything unusual.

Your GP will only refer you for an X-ray or MRI scan if you have associated symptoms that suggest that you may have a more serious condition, such as loss of bladder control or unexplained weight loss.

Back-related conditions that can be diagnosed using an MRI scan include:

• cancer of the spine
• infection
• fracture
• ankylosing spondylitis – a chronic (long-term) condition that causes pain and inflammation of the joints and the tissues around them
• cauda equina syndrome – a rare and serious condition where nerves inside the spine are compressed, leading to a loss of bladder and bowel function

You may also be referred for a MRI scan if spinal surgery is being considered (see Back pain - treatment for more information about spinal surgery).

Treatment

Acute back pain

Most cases of acute back pain can be treated using a combination of medication and self-help techniques. These are discussed below.

Medication

The painkiller paracetamol is usually recommended as the first treatment to try for back pain.

If paracetamol does not control your pain, non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen, may be used instead.

Common side effects of NSAIDs include:

• indigestion
• stomach ulcer (a sore in the lining of the stomach)

In some people, particularly those who are 45 years or older, NSAIDs have been known to cause bleeding inside the stomach.

If you are thought to have an increased risk of stomach bleeding, your GP may also prescribe an additional medication known as a proton pump inhibitor (PPI), which is designed to protect your stomach from the adverse effects of NSAIDs.

PPIs help to prevent stomach ulcers and internal bleeding by reducing the production of stomach acid. See Stomach ulcer - treatment for more information about PPIs.

Alternatively, you may be given a special type of NSAID known as a COX-2 inhibitor. It is specifically designed to have a less harmful effect on the stomach.

Common side effects of COX-2 inhibitors include:

• weakness
• fatigue
• dizziness
• headache
• nausea
• indigestion

COX-2 inhibitors are not suitable for pregnant women or those with a history of heart problems.

If a stronger painkiller is required then a mild opiate-based painkiller, such as codeine or tramadol can be used.

Common side effects of these types of painkillers include:

• nausea
• dizziness
• drowsiness
• dry mouth
• vomiting

If you have dizziness or drowsiness, do not drive or operate complex or heavy machinery.

Stronger opiates, such as morphine, are usually required only in the most severe cases of acute back pain. Due to their potential for addiction, they are only prescribed for the shortest time possible.

Common side effects of morphine include:

• constipation
• nausea
• vomiting

Due to these side effects, you may also be prescribed additional anti-emetics (medicine used to treat nausea and vomiting) and laxatives (used to treat constipation).

If you are also experiencing symptoms of muscle spasms, you may be prescribed a short course of a muscle relaxant, such as diazepam.  Common side effects of diazepam include:

• drowsiness
• dizziness
• loss of co-ordination

Do not drive or operate complex or heavy machinery when taking diazepam. Long-term use (more than five days) of muscle relaxants, such as diazepam is not recommended because they can be addictive.

Self-care

While acute back pain can be frustrating to live with, try to remain as positive as possible. There is a lot of research to suggest that people with a positive mental attitude tend to have quicker recovery times and are much less likely to progress from acute to chronic back pain.

If you have acute back pain, it is important to remain as active as possible. If you find it too painful to return to your normal daily activities immediately, pace yourself by carrying out your daily activities at a reduced level or a slower rate. Aim to do a little more each day. 

There is also no need to wait until you are completely pain-free before returning to work. Going back to work will help you to return to a normal pattern of activity, and it can often distract you from your symptoms of pain.

Many people with back pain find that using either hot or cold compression packs helps to reduce pain. You can make your own cold compression pack by wrapping a bag of frozen food in a towel. Hot compression packs are often available from larger pharmacies. You may find it useful to use one type of pack after the other.

Placing a small firm cushion beneath your knees when you are sleeping on your side, or using several firm pillows to prop up your knees when lying on your back, may help to ease your symptoms.

Chronic back pain

Your treatment plan

In 2009, the National Institute for Health and Clinical Excellence (NICE) issued guidelines about what treatments should be provided to people with chronic back pain. However, a number of back pain experts do not agree with NICE’s recommendations (see below).

NICE recommended that chronic back pain should be treated using painkilling medication and one of the following treatment options:

• acupuncture – fine needles are inserted into your skin at certain points on the body
• exercise classes – aerobic exercise, muscle strengthening and stretching
• manual therapy – your back is massaged or manipulated

If the treatments listed above prove to be ineffective, you may be referred for a combined programme of exercise and psychological treatment.

There is also a type of surgery called spinal fusion. However, it is usually regarded as a ‘treatment of last resort’ for people who fail to respond to treatment and who feel that chronic pain is making their life intolerable.

The various treatment options are discussed in more detail below.

Painkillers

As with acute back pain, a step-wise approach to pain management is recommended for chronic back pain.  You will first be given a mild painkiller and only ‘step up’ to a stronger painkiller if it proves to be ineffective.

The usual steps are:

• paracetamol
• NSAID or COX-2 inhibitors, possibly in combination with paracetamol
• mild opiate-based painkillers, such as codeine or tramadol

If you need to take NSAIDs on a long-term basis, you will probably be prescribed a proton pump inhibitor (PPI) to protect against stomach bleeding.

Tricyclic antidepressants

If painkillers are not effective, you will probably be prescribed an additional medication called tricyclic antidepressants (TCAs). TCAs were originally designed to treat depression, but they have subsequently proved to be effective at treating some cases of chronic pain.

Amitriptyline is a widely used TCA that is used to treat chronic back pain.  You will usually be prescribed the lowest possible dose to control your symptoms. If the medication is ineffective, your dose can be gradually increased. This approach will help to lower the risk of side effects.  Common side effects of amitriptyline include:

• dry mouth
• constipation
• sweating
• problems passing urine
• slight blurred vision
• drowsiness

If you experience drowsiness or blurred vision, avoid driving or operating heavy machinery. 

The side effects should ease after seven to 10 days as your body gets used to the medication. However, tell your GP if the side effects continue or become troublesome. It may be possible for you to switch to a different TCA that will suit you better.

There have been reports of people suddenly having suicidal thoughts when taking amitriptyline. If this happens to you, contact your GP or go to your nearest hospital immediately.

It may be helpful to tell a close friend or relative that you are taking amitriptyline and ask them to let you know if they notice any changes in your behaviour or they are worried about the way you are acting.

Avoid drinking alcohol while you are taking amitriptyline as the combined effects can make you feel very drowsy.

Acupuncture

Acupuncture is a form of ancient Chinese medicine which involves the insertion of very fine needles into the skin at certain points on the body.

Acupuncture is based on the belief that an energy or 'life force' flows through the body in channels called meridians. This life force is known as Qi (pronounced 'chee'). 'Blockages' in Qi can result in illness and pain. Placing needles at certain points around your body is thought to 'unblock' Qi and help relieve symptoms such as back pain.

However, many experts believe that the beneficial effects of acupuncture on chronic back pain (for which there is a reasonably good body of evidence) are actually due to the needles stimulating nerves and muscles while encouraging the body to release naturally occurring painkillers, known as endorphins. 

This view is backed up by a number of studies, which found that sticking needles in random locations around the body (sham acupuncture), rather than following the principles of traditional acupuncture, still had beneficial effects.

Ten sessions of acupuncture is recommended over a 12-week period. Side effects are usually mild and occur in about one in 10 cases. They include:

• pain where the needles puncture the skin
• bleeding or bruising where the needles puncture the skin
• drowsiness
• worsening of pre-existing symptoms

Some health boards offer acupuncture on the NHS, but provision can be sometimes patchy. Therefore, many people pay for private treatment. The cost of acupuncture varies widely between practitioners. Initial sessions usually cost between £35 and £60. Further sessions cost £25-50.

When choosing an acupuncturist (someone who practises acupuncture), make sure that they are registered with a recognised and reputable acupuncture organisation, such as the British Acupuncture Council or The British Medical Acupuncture Society.

See the Health topic about Acupuncture for more information and advice.

Exercise classes

If exercise classes are recommended to help treat your back pain, you will be offered eight sessions over a 12-week period. The classes usually take the form of group exercises, i.e. around 10 people under the supervision of a qualified exercise instructor.

You will take part in a range of exercises that are designed to strengthen your muscles and improve your posture. The exercises may include:

• aerobic activity – exercises designed to strengthen your heart and lower your blood pressure, such as jogging or swimming
• muscle strengthening
• stretching

Manual therapy

There are three main types of manual therapy:

• spinal mobilisation – force is applied to move one or more of your spinal joints within its normal range of position
• spinal manipulation – force is applied to move one or more of your spinal joints out of its normal range of position
• massage – the muscles around your spine are manipulated

Three main methods of treatment involve the use of manual therapy. These are:

Prevention

To avoid back pain, you must reduce excess stresses and strain on your back, and ensure your back is strong and supple.

If you have recurring bouts of back pain, the advice outlined below may be useful.

• Lose any excess weight  – you can use the body mass index (BMI) healthy weight calculator to find out whether you are a healthy weight for your height.
• Wear flat shoes with cushioned soles, as these can reduce the stress on your back.
• Avoid sudden movements or muscle strain.
• Try to reduce any stress, anxiety and tension.

Posture

How you sit, stand, and lie down can have an important effect on your back. The following tips should help you maintain a good posture. 

Standing

Standing upright, with your head facing forward and your back straight. Balance your weight evenly on both feet and keep your legs straight.

Sitting

You should be able to sit upright with support in the small of your back. Your knees and hips should be level and your feet should be flat on the floor (use a footstool if necessary). Some people find it useful to use a small cushion or rolled-up towel to support the small of the back.

If you use a keyboard, make sure that your forearms are horizontal and your elbows are at right angles.

Driving 

Make sure that your lower back is properly supported. Correctly positioning your wing mirrors will prevent you from having to twist around. Foot controls should be squarely in front of your feet. If driving long distances, take regular breaks, so that you can stretch your legs.

Sleeping

Your mattress should be firm enough to support your body while supporting the weight of your shoulders and buttocks, keeping your spine straight.  If your mattress is too soft, place a firm board - ideally 2 cm thick - on top of the base of your bed and under the mattress. Support your head with a pillow, but make sure your neck is not at a steep angle.

Exercise

Exercise is both an excellent way of preventing back pain and reducing any back pain you might have. However, if you have chronic back pain (back pain that has lasted more than 3 months), consult your GP before starting any exercise programme.

Exercises, like walking or swimming strengthen the muscles that support your back without putting any strain on it, or subjecting it to a sudden jolt.

Activities like yoga or pilates can help improve the flexibility and the strength of your back muscles. It is important that you carry out these activities under the guidance of a properly qualified instructor.

There are also a number of simple exercises you can do in your own home to help prevent or relieve back pain. 

• Wall Slides: stand with your back against a wall with your feet at shoulder-width apart. Slide down into a crouch so that your knees are bent to 90 degrees. Count to five, then slide back up the wall. Repeat five times.
• Leg Raises: - lie on the floor, flat on your back. Lift each heel in turn just off the floor while keeping your legs straight. Repeat five times. 
• Bottom Lifts: lie on the floor, flat on your back. Bend your knees so that your feet are flat on the floor. Then lift your bottom in the air by tightening your stomach muscles while keeping your back straight. Repeat five times.

At first, do these exercises once or twice a day, then gradually increase to six times a day, as your back allows.

These exercises are also useful for 'warming up' your back. Many people injure their back when doing everyday chores at home or work, such as lifting, gardening or using a vacuum cleaner. 'Warming up' your back before you start these chores can help prevent injury.

Lifting and handling

One of the biggest causes of back injury, especially at work, is lifting or handling objects incorrectly. Learning and following the correct method for lifting and handling objects can help prevent back pain.

• Think before you lift: can you manage the lift? Are there any handling aids you can use? Where is the load going? 
• Start in a good position: your feet should be apart, with one leg slightly forward to maintain balance. When lifting, let your legs take the strain - bend your back, knees and hips slightly but do not stoop or squat. Tighten your stomach muscles to pull your pelvis in. Do not straighten your legs before lifting as you may strain your back on the way up. 
• Keep the load close to your waist: keep the load as close to your body for as long as possible with the heaviest end nearest to you.
• Avoid twisting your back or leaning sideways, particularly when your back is bent. Your shoulders should be level and facing in the same direction as your hips. Turning by moving your feet is better than lifting and twisting at the same time. 
• Keep your head up: once your have the load secure, look ahead, not down at the load. 
• Know your limits: there is a big difference between what you can lift and what you can safely lift. If in doubt, get help.
• Push rather than pull: if you have to move a heavy object across the floor, it is better to push it rather than pull it. 
• Distribute the weight evenly: if you are carrying shopping bags or luggage, try to distribute the weight evenly on both sides of your body.

Preventing back pain in children

Back pain in secondary school-age children has been linked to heavy schoolbags and ill-fitting classroom seating. Nearly half of all teenagers in the UK have experienced occasional backache from carrying overloaded bags, poor posture and leading an unhealthy lifestyle.

The best schoolbag for your child is a well-designed backpack. This should be worn over both shoulders to balance out the weight. A heavy satchel or shoulder bag can put stress on your child's spine.

Encourage your child to exercise regularly or plan joint activities, such as a walk in the countryside or a trip to a swimming pool.

Selected links

NHS Direct Wales Encyclopaedia links

Acupuncture

Chiropractic

Osteopathy

Sciatica

External links

NICE guidelines: low back pain (PDF, 436kb)

BackCare

The British Pain Society

The Chartered Society of Physiotherapy

Back and neck pain British Brain and Spine Foundation

Welsh Backs