Back pain

What is back pain?

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Acute Back pain

Acute back pain can be caused by a sprain or strain in the back. It is so common it should be seen as an annoying but normal part of life. It is likely to improve within a short period but can take up to 6-12 weeks.

80% of the adult population in this country will have a significant episode of back pain in their life. Around 10% of the population have back pain at any one time.

It can come on quite suddenly, or over time, and can be caused by lifting or moving awkwardly, which can be extremely distressing and can sometimes stop you carrying out your everyday activities. However, more often than not, acute back pain comes on without any specific injury to your back.

You will often hear that the best thing you can do for back pain is to lie down and rest.However, inactivity will prolong the episode of back pain.

Persistent Back pain

Persistent back pain can refer to recurrent back pain or pain that has lasted for several weeks and it can have a big impact on your day-to-day life.

Persistent back pain can range from a mild pain or ache, to a more severe pain. This can depend on a variety of things, such as general health and fitness, whether you have had back pain before and how happy you are at home or work.

Persistent back pain may require treatment such as medication or physiotherapy. In most cases though, your back will settle to a manageable level itself. It is important that you keep active and continue as normal, but if your pain is severe and unrelenting then you should seek medical advice.

Sciatica

Sciatica is a common term used to describe pain into the leg. Many things can contribute to pain in the leg but true sciatica is a nerve pain that travels from your back or buttock towards your foot (usually going below the knee). Nerves are like the wiring system in the body. They tell the muscles in the leg what to do and they also pass messages from the leg to the brain. You can experience either pain, pins and needles, numbness, weakness or a combination of these. With significant sciatica the leg pain tends to be worse than the back pain. This can be caused by narrowing affecting the nerve in the back due to a disc bulge or other age related changes. We no longer use the term slipped disc, this is misleading as they do not slip in and out and cannot be pushed back in. But positively with time the majority of disc bulges and episodes of sciatica improve themselves.

Key Facts

  • The majority of people are much better after 3 months. Unfortunately some people take longer to recover but pain levels are very often up and down.
  • It is normal to have some flare ups of pain when you are recovering. A small proportion of people can have flare ups for a year afterwards.
  • Regular exercise may reduce the risk of nerve pain and help reduce the likelihood of future problems. Cardiovascular exercise specifically can reduce our pain levels by 20%.
  • The less you use your back the more deconditioned and sensitive it can become. A gradual return to normal activity is important.

Diagnosis

In the initial stages a GP can help manage sciatica. The diagnosis is made largely from the symptoms and the initial examination.

Simple tests of the function of the nerve including strength, reflexes and sensation will help identify which nerve is likely to be causing the pain.

The amount of pain is not a good indication of the underlying cause. Nerve root pain can be very varied and at times severe. Understanding the facts about sciatica can help an efficient recovery. Distress and fear can often make pain worse.

An MRI is not needed in the early stages as symptoms are likely to improve; it is unlikely to change your management and does not provide a prediction of your outcome.

If symptoms have persisted for a significant amount of time and have not responded to conservative management, then an MRI scan at that stage can be useful to aid further management.

Spinal stenosis

Spinal stenosis is a term used to describe a narrowing of the spinal canal which gives rise to symptoms of irritation of the spinal nerves. Spinal stenosis is a common problem particularly affecting people in their 60s and older.

What are the symptoms of spinal stenosis?

The symptoms experienced are predominantly those of leg pain and can affect one or both legs but back pain can also be felt. Symptoms can occur in standing and walking and cause discomfort, numbness, weakness or feelings of unsteadiness in the legs. Some people will also experience pain in lying and leg cramps, particularly at night.

Claudication is the term used by doctors for pain and/or weakness of the legs that gets worse on standing and walking. Common causes are vascular, due to narrowing of the blood vessels in the legs or spinal due to a reduction in the space for spinal nerves to pass through.

Typically, walking distance and/or ability to stand still is reduced, due to increasing symptoms into the legs which results in the need to stop. Most people with spinal stenosis find that sitting down or leaning forward enables them to recover so that they can then walk again. Usually patients have no pain in the leg when sitting. This is because the space around the nerves is reduced when you are upright, but increases on sitting.

What causes spinal stenosis?

As part of the aging process we develop natural changes in the lower back.

These changes can sometimes lead to a partial narrowing or a “stenosis” of the space available to the nerves.

This may give rise to the symptoms associated with lumbar spine stenosis although not everyone with these changes gets symptoms. There is ongoing research into spinal stenosis; it is thought that by doing regular exercise that you enjoy can help you manage your symptoms.

How is spinal stenosis diagnosed?

Most people see their GP first who can usually make a clinical diagnosis based on what you tell them. The GP will be able to advise on first line management such as medication and exercise which is key to managing the condition. Depending on your symptoms you may be referred to a hospital specialist, who will assess and possibly request an MRI scan.

What is the prognosis of spinal stenosis?

The outlook is unpredictable, but a general rule can be applied that with respect to symptoms:

  • 1 in 5 will improve with time,
  • 3 in 5 will stay the same,
  • 1 in 5 will worsen with time. We have no way of predicting who will get worse. Worsening typically will cause a decrease in walking distance.

 

When to seek medical advice

Many patients have a combination of back pain, leg pain, leg numbness and weakness. These symptoms can be distressing for you but don’t necessarily require emergency medical attention.

A rare but serious back condition, Cauda Equina Syndrome, can lead to permanent damage or disability and will need to be seen by an Emergency Specialist Spinal Team.

Please seek urgent medical advice and attend the Emergency Department if you experience any of the Cauda Equina Syndrome warning signs below:

  • Loss of feeling/ pins and needles between inner thighs or genitals
  • Numbness in or around your back passage or buttocks
  • Altered feeling when using toilet paper to wipe yourself
  • Increasing difficulty when you try to urinate
  • Increasing difficulty when you try to stop or control your flow of urine
  • Loss of sensation when you pass urine
  • Leaking urine or recent need to use pads
  • Not knowing when your bladder is either full or empty
  • Inability to stop a bowel movement or leaking
  • Loss of sensation when you pass a bowel movement
  • Change in ability to achieve an erection or ejaculate
  • Loss of sensation in genitals during sexual intercourse

There are other rare but serious causes of back pain and you need to seek medical advice if:

  • you feel generally unwell and suffer symptoms such as fever, night sweats or unexplained weight loss
  • you experience pain at night, possibly worse than during the day that prevents you from sleeping due to increasing pain and/or difficulty lying flat.

If any of these symptoms occur, you should contact your GP.

Managing Back Pain

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Treatment

When you have back pain it is crucial for you to keep moving. It will not do any harm – remember, the spine is a strong structure designed to move.

Movement, little and often at first, is something you can do that contributes to your back getting better. Part of that process is allowing time for the body’s natural healing to occur and this will be much better if you continue to move, even if this causes some discomfort.

Significant evidence-based changes have been made to the way back pain is managed in the NHS.

Better understanding of back pain through research has highlighted other factors that can influence any episode of back pain. These include stress, anxiety, poor sleep and poor general health. It is important to recognise how these factors could be influencing you and look at how you may need to make changes.

Through this website we are supporting the county’s GPs in giving you the help you need to manage your own back. After all, back pain is so common, you’re likely to have episodes of acute pain on and off throughout your life.

Your GP will help guide your recovery and prevention of further back pain by using the right pain killers as needed, along with some good advice. When you need extra help, they can help you decide what’s best for you.

For further advice and exercise please download the following leaflet:

Guide to back pain and what you can do about it (Hyper link

https://www.mskdorset.nhs.uk/wp-content/uploads/2020/04/Start-Patient-Leaflet-Apr19-FINAL.pdf

As mentioned in the above leaflet MRI scanning for patients with back pain alone is rarely indicated, will not change the treatment and does not predict your long term outcome.

For those who really struggle to self-manage their back pain long term and it remains severe and significantly effecting function you may be referred on to a spinal service. If it is felt appropriate you may then be referred on to a pain service who can consider multidisciplinary pain management strategies to help improve your long term management.

In line with NICE guidelines spinal surgery is not recommended for the management of back pain alone.

Managing with Sciatica

Nine out of 10 cases of sciatica will improve without any specialist treatment. More than seven out of 10 patients will report improvement within four weeks.

Keeping active is very important, but it may often be necessary to take pain killers to allow you to do this.

You shouldn’t be afraid of masking the pain, as keeping active will not do you any harm.

Using over the counter medication such as Paracetamol or Ibuprofen. An ‘umbrella ‘ of pain relief using a combination of tablets is often more helpful than trying to rely on just one type of medication.

Painkillers like paracetamol will ease the pain, but need to be taken regularly in order to control the pain. Always follow the instructions on the packet.

Anti-inflammatories like ibuprofen can help with swelling, and therefore help you move more freely. Follow the instructions on the packet and discuss using them safely with a pharmacist, especially if you have any underlying health conditions

Up to date guidelines can be found on the NHS website:

https://www.nhs.uk/medicines/ibuprofen-for-adults/

https://www.nhs.uk/medicines/paracetamol-for-adults/

For up to date guidelines on the government about Ibuprofen use and Coronavirus (COVID-19)

https://www.gov.uk/government/news/ibuprofen-use-and-covid19coronavirus

Nerve pain control: In line with NICE guidance doctors can prescribe drugs to help reduce nerve pain e.g. Amitriptyline, or Gabapentin.

Your GP or physiotherapist will be able to recommend activities that will help you keep moving and stop your muscles getting out of shape

It’s normal to feel some discomfort during recovery – but this is not harmful.

For further information and exercises please refer to the Sciatica Information leaflet.

If the sciatica is severe, not responding to conservative measures and MRI scan shows a reason for the symptoms a caudal epidural could be used. A caudal epidural is a steroid injection into the back to help with leg pain.

Surgery for sciatica may be considered in the most severe cases but all conservative efforts should be exhausted in the first instance. Any surgery would only be considered if felt appropriate by the surgical team.  The surgery will be aiming to help reduce the leg pain.

Managing spinal stenosis

This condition is a ‘quality of life’ issue. If your symptoms are acceptable to you then no interventions may be needed. Most specialists would suggest you start with simple less risky treatments first.

Firstly:

  • Improving spinal mobility (especially bending), strength & overall fitness.
  • Pacing
  • Improving pain control.

Back Exercises will help keep your spine mobile and strengthen muscles. Ideally you should do these daily. These should include movements such as bending forward in sitting or standing whilst rounding your back. This movement can also be used for symptom relief, enabling you to continue with your chosen activity i.e. walking. Night pain and cramp can also be relieved by hugging one or both knees in towards your chest. Keeping the hips mobile is also beneficial.

Pacing refers to modifying activity levels to avoid the over/under active cycle through balancing activities throughout the day or week. Pacing means breaking your day into chunks of activity and rest, so that activities are spread out.  It means not doing too much when you are feeling good or too little when you are not feeling so good.

Static cycling little and often to start with. Patients can often cycle with much less leg pain than when they walk. The use of an exercise bike can enable improvement in fitness and leg muscle tone. Start with just two or three minutes twice a day, and increase the time a little every few days.

Walking as tolerated. Walking up to symptom threshold then just a little further despite the pain will often improve walking distance over time.  You may  benefit from using a walking aid if appropriate.

General Strengthening If we have pain when doing physical activity we tend to do less.  Reduced activity deconditions us.. This in turn can make our pain worse and so we do less activity, leading to a spiral of decline in function and walking. Progressive resistance training, using weights or body weight to improve muscle strength, may effectively reverse functional decline and improve functional outcomes in older adults. Such as repeated sit to stands (without using your hands), mini squats, mini lunges and using the stairs more often.

Balance exercises can enhance your walking and reduce your risk of falls. Such as standing in a semi tandem or tandem foot position (one foot in front of the other) with or without hand support. Reduced balance is linked to poor walking ability in patients with spinal stenosis.

If you are overweight then you may be advised regarding weight loss strategies.

Some patients may improve by the above measures. If any further intervention is indicated the above advice is still relevant as ensuring you are as fit as possible means that any further intervention would be safer and likely to result in a better outcome.

Exercise leaflet for the management of spinal stenosis. Please contact your healthcare professional or refer yourself to physiotherapy for further advice and guidance.

Simple pain control: Using over the counter medication such as Paracetamol or Ibuprofen. An ‘umbrella ‘ of pain relief using a combination of tablets is often more helpful than trying to rely on just one type of medication.

Painkillers like paracetamol will ease the pain, but need to be taken regularly in order to control the pain. Always follow the instructions on the packet.

Anti-inflammatories like ibuprofen can help with swelling, and therefore help you move more freely. Follow the instructions on the packet and discuss using them safely with a pharmacist, especially if you have any underlying health conditions

Up to date guidelines can be found on the NHS website:

https://www.nhs.uk/medicines/ibuprofen-for-adults/

https://www.nhs.uk/medicines/paracetamol-for-adults/

For up to date guidelines on the government about Ibuprofen use and Coronavirus (COVID-19)

https://www.gov.uk/government/news/ibuprofen-use-and-covid19coronavirus

Nerve pain control: In line with NICE guidance doctors can prescribe drugs to help reduce nerve pain e.g. Amitriptyline, or Gabapentin.

 

Some patients’ leg pain can lessen with appropriate medication. It may take a few months before it is clear if these simple measures are helpful. Remember it may hurt, but you won’t cause yourself harm!

Secondly:

If indicated spinal injections of steroid & local anaesthetic can also help some patients’ symptoms. They are helpful for leg pain rather than back pain.

These injections are usually requested by the hospital specialist. In Dorset they currently occur in a theatre setting under x-ray guidance.

Thirdly:

For a small number of patients with disabling leg pain surgery may be an option, however is not suitable for those with back pain alone.

At work

You are better continuing with activity, including work, even if you are still in some pain. People who remain active have far better outcomes than those who don’t.

If you are struggling with back pain:

  • Inform your manager
  • Keep mobile
  • Stay at work as long as possible, this helps with your rehabilitation and recovery
  • Use pain killers to help you carry on – it’s the movement that will get you better, and the pain killers will allow you to move better by reducing your pain not masking it..
  • Seek professional advice if you are unable to manage

If you have to go off work sick, use that time to get your back better – this might mean going out for walks, to the shops, etc. Don’t feel that just because you are off work you should not keep active – you must!

Stay in touch with your workplace. Hopefully your employer will be trying to keep in touch with you as well. Be open-minded about getting back to work as soon as possible. This can be facilitated by changes to your normal job role, hours and even where you work.

The longer you remain off work the more difficult it becomes to get back to work.

Prevention and long-term management of back pain

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Keeping active

Regular exercise is vital in reducing back pain by toning your muscles and allowing your body to carry out daily tasks more easily. Government guidelines encourage us to perform at least 150 minutes of moderate intensity cardiovascular exercise (or 75 minutes vigorous i.e.: running, spinning) per week over a few sessions. As well as 2 days including some form of strength training and balance training (remember many exercises combine these i.e.: spinning is cardio and strength, yoga can be balance and strength).

People with good fitness levels tend to experience less back pain, so get out of the house and go walking, swimming or cycling for half an hour a day. Exercise classes such as yoga, pilates or going to the gym are also great for your back. Find something you can enjoy and stick with! Cardiovascular exercise is shown to decrease the pain you feel by 20% as well as improving your overall health and mental well-being.

We would also recommend some online exercise videos found on the NHS website (If you are new to the exercises build up gradually).

Keeping active is also good for you if you already have back pain. Even if exercising feels painful, it will not harm your back and keeping active is one of the best ways to allow your back to recover.

However, it is also important to gradually build yourself up from your starting point, working on strength and flexibility as well as cardiovascular (getting hot and sweaty) fitness.

  • Warm up – make time to warm up before exercise. Gently stretch both your upper and lower body to get your circulation going and to loosen up your muscles.
  • Right muscles – build strength in your legs and upper body so when lifting use the big muscles in your legs and arms that were designed to do the job efficiently – not your back.
  • Cool down – Gently stretching your muscles after exercise. It can loosen your muscles, helping to prevent stiffness later.

If you hurt yourself while exercising follow the advice earlier on in this resource and you should again improve but remember when building up exercise again, start slow and gradually build up to reduce the likelihood of further problems.

Managing back pain at work

Many people spend at least eight hours a day at work and there is a lot that you can do to reduce the likelihood of developing or help manage back pain better.

  • If you have to lift things at work plan the lift first, does it need to be done? Can you make it easier by dividing the load? Ensure you are strong enough for the task (by doing regular strength exercise)
  • If you work in a static job, seated or standing make sure your work set-up is correct for you.
  • Avoid prolonged static postures, for example sitting at a telephone station or VDU – take regular movement breaks.
  • Use equipment provided

At Your Desk

Working at a desk all day can be uncomfortable for your body as it was not designed to be still for prolonged periods of time.

  • Try to have your computer screen at eye level in front of you and your chair facing it.
  • Have your mouse and keyboard within easy reaching distance.
  • Take regular breaks and get up and walk around the office regularly, to stretch out your muscles and get things moving again.
  • If you are getting stressed or tense at your desk, take a break to relax your body and mind. Doing some abdominal breathing can help this relaxation.
  • Be active when you are out of work to compensate for the time you spend inactive at work.

Lifting & Handling 

When lifting and handling heavy goods you have to be fit/strong enough for the task.

  • Whether it is a heavy stacks of paper in an office or machinery – power through your legs and arms to lift – it is safe to lift without bracing your back or keeping it overly straight
  • If possible, use lifting and moving equipment such as a trolley to aid you.
  • Test the weight of an unknown item you are about to lift if able by pushing it with your foot. This way you know what to expect.
  • Always plan ahead to ensure that where you are moving the item to is clear and uncluttered – this avoids having to hold the item for longer than needed.
  • Most importantly do regular exercise that keeps you strong enough for activities such as lifting.

On Your Feet

If your job requires you to be on your feet all day, then it’s likely you will at some point have suffered from aches and pains, it is important to try and keep moving and walking around and to sit every so often.

  • As with all jobs, getting regular exercise and keeping fit outside of work will greatly improve the strength of your body and reduce your chances of getting back pain.
  • Take regular breaks to stretch your muscles – this will prevent stiffness and keep your circulation going.

Managing back pain at home

Whether you’re out in the garden or cleaning the house – what you get up to at home can often have an impact on your back.

But by following some simple tips and advice you can manage better around the house and garden

Gardening & DIY 

For many people, gardening is an enjoyable hobby.

Some general tips when gardening:

  • Take a moment to warm up
  • Digging – take a wide stance and let your leg muscles do the work. If necessary, lever the spade using your foot if the soil is dense and heavy.
  • Moving tubs – roll them onto their outer rims to avoid lifting as they are often very heavy and more than you would normally lift.

If carrying, the following tips should help:

  • Ensure you’re wearing loose, casual clothing and sensible shoes
  • Lift close to the body and pick up and set down using the powerful leg and arm muscles.
  • Plan movements of compost bags/soil/chippings using wheels wherever possible
  • Wheelbarrows – don’t overload as these can be awkward to move

When bending:

  • Loosen with some repeated bends first.
  • Combine with bending the knees into a squat if easier, or bend your knees as far as possible with one foot in front of the other (lunge)
  • Otherwise go down on one knee or both
  • Take regular breaks changing position going for a short walk or stretching (time can fly when you are having fun in the garden!)
  • If you are tired, STOP for a break instead of pressing on (there’s always tomorrow, pace yourself)

Around the House

Back pain affects around 8 out of 10 of us at some time. During an acute flare of back pain you may have to pace your activities better and reduce the amount that you do, but it is important to keep moving and not stop completely. Activities around the house such as cleaning and hoovering require good range of movement and strength in our bodies. It is important that we use exercise to enable us to have the required range of movement and strength, so that we can carry out these activities and remain independent. Using the tips above for gardening can also make activities within the house easier.

Understanding the complexity of pain and other influencing factors

Understanding the complexity of pain and other influencing factors

What we have learnt through research is that pain, especially persistent pain is more complex than just what is going on locally to where you feel the pain. It can be affected by many things including poor sleep, poor general health, reduced fitness, stress, past experience of pain and our beliefs about pain and our physical structure.  The links below provide some insight into understanding pain, understanding your own beliefs around your pain and then looking at positive changes you can make that can in turn have a positive effect on your pain and levels of function.

Understanding pain in less than 5 minutes 

Separating fact from fiction

Facts about back pain and exercise 

Sleep and pain

10 things you need to know about your back 

Why things hurt 

Tame the Beast 

Pain Tool Kit 

Pain-ed

 

Abdominal breathing, relaxation and sleep

Stress and tension are common with persistent pain. For some it may be part of the underlying cause for many it’s a consequence as pain itself causes more stress and anxiety. What we know is that if we can use tools to help reduce our muscle tension and stress this can help with pain, sleep and function. Below are links you may find useful

Abdominal breathing 

Online video describing abdominal breathing 

Headspace 

Breathe2relax. This is an APP specifically for abdominal/diaphragmatic breathing – go onto your smart phones APP store for more details

Sleep well with pain

Below are links to local services that can help with aspects of physical and mental health that you feel may be impacting your pain and general health.

Live well Dorset – Weight management, stop smoking, exercise advice, lifestyle change 0800 8401628/ 01305 233105

Steps to wellbeing – for help with feelings of anxiety, depression, bereavement and trauma/PTSD

Welcome to the moodzone – for help with self-management of stress, anxiety and depression

Dorset Pain Management Service website – This website contains a lot of further information and links about pain and also gives you the opportunity to see if you feel a referral to the Pain Service may be beneficial for you.

Understanding persistent pain – this booklet is commonly used by the Dorset Pain Management Service.

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