In the Spotlight
Managing Your Lower Back Pain
Colin L. Fernandes, MD (Harvard-trained pain specialist. He currently serves as Director of the Pain Service at the VA Hospital in Martinez, CA.)
Anthony J. Mariano, PhD (Clinical Director of Pain Services at the VA Puget Sound Health Care System in Seattle, WA)
If you are reading this, chances are you have experienced low back pain. More than half of the population will have low back pain at some point in their lives. Typically the pain is nagging, and sometimes sharp. It may lessen and go away, but it could also return. Low back pain may cause you to feel like something dangerous is happening in this part of the body, but generally, the pain is not life-threatening. Most acute low back pain will improve within four to six weeks. If you also have high fever, unexplained weight loss, history of cancer, or loss of bladder or bowel control with onset of low back pain, seek immediate medical attention.
There are many causes for low back pain:
- Myofascial - pain arising from "soft tissue" muscles and ligaments in the back
- Arthritis - overgrowth and inflammation of the bones and joints in the spine
- Disc Degeneration - with wear and tear, the discs (which are cushions between bones in the spine) can decrease in size, weaken, and bulge
- Irritation of nerves exiting the spine - often called "sciatica"
In many cases, your doctor will not be able to definitively point out the cause, or there may be more than one reason for the pain. Mental health conditions could affect low back pain. Anxiety and Post Traumatic Stress Disorder (PTSD) can cause aggravation of symptoms. When there is activation of the body's "fight or flight" nervous system, muscles may go into spasm and pain can worsen.
There is little agreement between pain symptoms and findings on an X-ray or Magnetic Resonance Imaging (MRI). In an important medical study published in 1994, investigators looked at the discs of 98 people who did not have back pain. More than half of these people had bulging discs. Many other studies have shown people with severe pain have normal test results.
Medical tests cannot tell if your pain is "real." Your pain is real if you say it is. This is why medical providers rely more on your history and physical examination than on imaging results. At your medical visit for low back pain, your provider may ask you questions about your general health, mood, sleep and lifestyle that may seem strange but that information is important. The treatment for low back pain typically involves some combination of the following:
- Physical Therapy - Including teaching better posture, breathing techniques and development of a home exercise program
- Medications - Including non-steroidal anti-inflammatories, muscle relaxants, nerve medications and opioids (strong painkillers like vicodin and morphine)
- Procedures - Including injection of steroid anti-inflammatory medication into the spine (often called "epidurals" or "nerve blocks")
- Psychotherapy - To help with sleep, anxiety, PTSD, depression, and coping with pain
- Chiropractic Manipulation
- Surgery - In a few specific cases, surgery is appropriate as an emergency or as the best treatment. It should never be considered a "last resort" given the significant risks
The media often reports the promise of new developments. One example includes gene therapy to stall disc degeneration. While these are indeed exciting, they are unlikely to make it to clinical practice for a while. You cannot afford to wait for a "medical miracle" before you get on with your life, if you have low back pain now.
The goal of treatment of low back pain is pain reduction, not elimination. More importantly, your provider will attempt to help you improve your day-to-day functioning.
In summary, low back pain is common and has multiple, often puzzling, causes. A treatment plan typically involves a variety of strategies. The goals are aimed not only at pain reduction but at improving your functioning so you can get on with your life.
Bielanski TE, Nashelsky J. Clinical inquiries. What is the prognosis for acute low back pain? J Fam Pract 2002; 51: 417.
Jensen MC, Brandt-Zawadzki MN, Obuchowski N, Modic MT, Malkasian D, Ross JS. Magnetic Resonance Imaging Of The Lumbar Spine in People Without Back Pain. New Engl J Med 1994; 331 (2): 69-73.
Don AS, Carragee E. A brief overview of evidence-informed management of chronic low back pain with surgery. The Spine Journal 2008; 8: 258-265
Updated/Reviewed: April 1, 2011