New Year New Goals!
It’s the start of the year so you know what that means, its time for New Years Resolutions! The start of the year always seems
14 January 2025
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Establishing the cause of someone’s back pain is an area of healthcare that leads to much debate and that is rife with misinformation. You may well have heard several phrases bandied around when it comes to the causes of back pain. Here are some… “it’s a slipped disc”, “you’ve pulled a muscle”, “something’s out of place”, “your pelvis is misaligned”, “I’ve trapped a nerve”. If I asked you to rate these in terms of which of these sounds most threatening, I would imagine that “you’ve pulled a muscle” would be somewhere close to least threatening and “it’s a slipped disc” or “I’ve trapped a nerve” would sit further up the list of more threatening.
Low back pain is one of the leading causes of disability worldwide. Musculoskeletal conditions, of which low back pain is the most common, are estimated to cost the NHS £5 billion annually, and are a leading cause of time off work.
The good news is that less than 1% of cases of back pain are likely to be due to something serious, for example, a spinal fracture, an infection, cancer, or compression of the nerves of the spinal cord (which might for example affect an individual’s bladder, bowel or sexual function). These more serious causes of back pain tend to be referred to as “red flags”, and as physiotherapists we are trained to assess for when these rare things might be present. Of course, in these instances establishing what’s likely to be causing back pain is not only possible, but also essential.
Back to the cause of the pain. When, as is more often the case, back pain is not due to something serious, it is worth thinking of back pain less as a categorizable disease, and more as a normal part of being human and moving about in our environment. The back is made up of muscles, ligaments, joints, bones, discs and nerves. All of these interact in complex ways and an acute (typically less than 6 weeks) episode of back pain might be due to a strain or injury to any of these structures. These acute episodes of back pain, not due to anything serious, are often referred to as mechanical low back pain, and this just means that it’s nothing serious, that there’s no significant abnormality of the nerves (more about this below) and that it’s not another special category of back pain called inflammatory back pain (sometimes called “Ankylosing spondylitis”). The hard bit is to determine exactly which of these acutely injured structures is at fault. Whether it is the world’s top neurosurgeon, the best physiotherapist there is, or the most skilled of osteopaths and chiropractors, establishing the exact structures that have been injured is almost always not possible. And the good news is that it doesn’t seem to matter in terms of an individual’s likelihood of getting better. If we take X-rays or other types of scans, such as MRIs, of the spine of people without back pain, it is more common to find disc bulges, disc degeneration, or degeneration of the joints, than not. In fact, in adults, we are likely to find these “abnormal” structural changes in more than 8/10 people who don’t have any pain… surely, therefore, these changes are a normal part of a naturally maturing spine.
It would seem reasonable to assume that the severity of an episode of acute back pain would provide an indication of the severity of the underlying problem, however, this is often not the case. Most back pain, even when it starts off as very severe, gets better with simple strategies such as taking painkillers, trying to keep moving, keeping calm and a positive attitude. Annoyingly, about one in 3 people will have a recurrence of their back pain within the next year of having an acute episode. In this instance, it’s important to think about all the factors that might be contributing to an increased risk of recurrence. It’s important to think broadly here. Muscle strength and how conditioned our backs are to what we need then to do, is likely to be important, but so are our stress levels, how anxious we’re feeling, and importantly what we think, or are led to think, might be causing our back pain. Telling a patient that their back or pelvis is out of alignment, or that their discs have slipped, and that these things need to be put back into place, is not only inaccurate (there is a huge amount of research to support this, and incidentally, when you ask a bunch of clinicians to try and establish any of these so called structural abnormalities, none of them come up with the same conclusions), but it has also been shown to increase the chances of developing chronic (pain that lasts for more than 3 months) back pain. That’s right, people’s beliefs about what’s causing their back pain, are in themselves a contributor to how likely they are to get better.
That doesn’t mean that some of the treatments we offer, such as hands on therapies (including massage or manipulation), won’t help to reduce your pain in the short term. They can often be a useful addition to a management programme that is underpinned by a robust assessment (both the talking bit and the testing bit), good explanation and understanding of the problem, graded exercise, a positive view of the problem, and consideration of other important lifestyle factors that might be contributing to the problem.
Back to identifying different causes. Aside from the more serious causes of back pain, everything I’ve discussed above (the so-called mechanical causes of back pain that are almost always benign) has been in relation to when back (and not leg) pain is the main complaint. So, what about when the main problem is leg pain (+/- back pain) that is caused by a problem in the back. Is that always “sciatica”? (The short answer is no), and how will this affect the likelihood of recovery?
“Sciatica” refers to when the nerves that come from the spine are irritated, which commonly causes pain anywhere from the buttock down to the foot. The telltale signs the nerve is irritated is that patients may also describe that they’ve got funny feelings in their leg(s), which may include pins and needles or numbness, and/or that the pain is brought on when we put the nerves on a stretch. As clinicians, we refer to this type of pain as radicular pain (another name for sciatica). When that radicular pain is also associated with changes in nerve function (reflexes, sensation or muscle strength) we then call this radiculopathy. Both radicular pain and radiculopathy are sciatica, and once again, this type of back related leg pain, more often than not, resolves over time. It sometimes takes a little longer, and as clinicians we might want to monitor it a little more closely, as in a few cases, this type of problem may require us to think about onward referral for scans, with a view to considering spinal injections, or rarely surgery.
Just to add another layer of complexity, sometimes pain in the leg (usually the upper leg), that is coming from an irritation or injury of any of the structures we mentioned as part of “mechanical low back pain”, is not sciatica and is what we refer to as referred pain. This is also known as “somatic referred” pain, which in the literal sense means “referral from the body structures”. This is also nothing serious, and, you guessed it, will normally improve with the strategies we described above.
I’ve not spoken much about a few other categories of back pain. Namely, things like spinal stenosis (narrowing of the spinal canals that can sometimes cause pain and alterations in nerve function), sacroiliac joint pain (often wrongly identified as the cause of an individual’s pain… this is where people might be told, incorrectly, that their pelvis is out of alignment) and inflammatory causes of back pain (where the immune system goes a bit wrong and causes inflammation). These are also rare, but a good clinician will know how to identify the signs and symptoms that these things might be implicated.
As you can see, identifying the cause of back pain is not a random art and the good news is that most back pain gets better with simple and non-invasive solutions. Namely, movement & exercise (“motion is lotion”), pain control (which might include painkillers, ice/heat packs, or hands on therapies), and the psychological and social factors (including thoughts, attitudes and beliefs about the back pain) that are known to influence the likelihood of getting better.
In summary, here are some take home messages (you might also want to look at this wonderful infographic that helps to summarise what I’ve discussed above see https://www.bmj.com/content/bmj/suppl/2017/01/06/bmj.i6748.DC1/beri151216.w1.pdf2):
Here at SHP Health, as experts in musculoskeletal, based on the beautiful Denbies Wine Estate in the market town of Dorking, our knowledgeable, skilled and friendly team are committed to helping you understand the cause of your back pain and the likely contributing factors, and to helping you on the road to recovery.
References:
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