One of the most common conditions in the developed world is back pain, especially low back pain. It is estimated almost 80% of the adults in America have had significant back pain at some point in their life. Specialists who treat pain will often quip that it is likely 100% of adults have back pain issues at some point, it’s just that the other 20% won’t admit it.

Why do people get back pain?

Like many issues surrounding pain, the nature of our experience is complex, and we are continuing to better understand how pain works at a molecular level. However, the anatomy and biomechanics surrounding some types of back pain are better understood. All the load in your body above the hips is carried by the spine. People in modern societies have increased rates of obesity, spend a lot of time hunched over in chairs or perform repetitive manual labor which increases load on the vertebral bodies. These vertebral bodies are separated by shock absorbers, called intervertebral discs. Humans are also living a lot longer, and over time these discs dry out. Besides the discs, the actual bones in your spine (and your whole body to some extent) break down as you age, becoming more brittle. For these reasons, you will often see elderly more hunched over and losing height compared to when they were younger. Besides the bones themselves, the connective tissues, and more importantly muscles on the back, as well as abdomen normally help take stress off the spine. But over time, these supportive structures may atrophy or become smaller from disuse, which puts further stress on the spine.

What are some common causes of back pain?

The most common reason people have back pain are from myofascial strains. With myofascial strains, the muscles that would normally protect the back twitch and spasm after some insult – it could be something simple like sleeping in a bad position, or lifting something heavy when your muscles are not ready for it. Despite just affecting the muscles/connective tissues, even these strains can be quite disabling and people sometimes have to even take time off work for them.

Of course, sometimes the cause of back pain lies in the spine itself. Fractures can occur that may or may not require further treatment. On one end of the spectrum, very young people, particularly female gymnasts can injure a portion of the spinal vertebral body in what is called spondylolysis, a type of stress injury. On the other end of the spectrum, elderly with more brittle spines can have the vertebral body itself crushed down resulting in compression fractures. Many fractures can be treated conservatively with physical therapy but unstable fractures will usually require surgical treatment.

Some of the more painful causes of back pain are when nerve roots are involved. Often this occurs from disc herniation or “slipped” discs, where the herniated portion can result in local inflammation that is suffocating the nerve root. Pinched nerves near the spine can result in radiating or referred pain depending on the location involved. At first this can manifest as some numbness and tingling. If left untreated, this could even lead to extremely painful shooting sensations, and even sometimes weakness.

What to do when you have back pain?

Back pain usually gets better on its own, but sometimes you need to seek professional treatment. If the pain is worsening or incapacitating in any way, then seeing a qualified specialist may be a good idea. If you have any more alarming symptoms such as sudden weakness, loss of bowel or bladder control, or shooting pain down your leg, then a more urgent consultation may be necessary.

What can you do to treat back pain?

Sometimes it’s not enough to just wait for the pain to go away. Luckily, there are many treatment options for back pain because it is such a common condition. It is important to note though that the only consistently proven treatment for back pain, regardless of cause, is physical therapy. Because of this, any time you see a provider for back pain, you will likely be referred to physical therapy. Insurance companies may not even consider further options until you have tried physical therapy.

Physical medicine

Besides physical therapy, abdominal/core strengthening and stretching exercise have been shown to be beneficial to treat back pain. There is evidence that activity such as yoga or pilates may be helpful. Many people find massages, foam rollers, and heat packs successful in relieving their pain as well, but the results may be temporary. Given the relative lack of side effects, a trial of all or some of these interventions may be a good idea to treat back pain. There is also some limited evidence for use of osteopathic manipulation and chiropractic treatment. However, studies are controversial regarding safety and efficacy of these interventions, especially chiropractic treatment – thus insurance coverage may be limited.

Medications

Again, most back pain can be treated with physical therapy, and physical interventions but sometimes medications can be used in adjunct. Acetaminophen (Tylenol) or NSAIDs such as Ibuprofen can be used as needed for significant pain. Excessive use of Tylenol could result in liver or kidney issues, followed by withdrawal headaches. Excessive use of NSAIDs can result in acid reflux or even GI bleeding thus, despite being over the counter their use is not without side effects. Creams containing lidocaine, camphor, menthol, or some combination thereof have also been helpful with little side effects since they act locally. Some formulations may however stain clothes. These creams include Bengay, Tigerbalm, and Biofreeze.

Some providers may prescribe opioids for back pain but there is no evidence to show that their use is effective in treating any kind of back pain except for very limited circumstances such as cancer-related pain, thus the practice has been frowned upon. Retrospective analysis reveals that opioid overprescribing in the 1990s and 2000s may have lead to an opioid epidemic particularly in certain midwestern states.

When the pain comes from a pinched nerve with particularly referred shooting pain, sometimes certain medications may be prescribed. Please see my post on how to treat nerve pain for more information regarding this kind of pain.

Injections

When the back pain is more disabling, potentially shooting down legs, and more conservative measures are not helping, a physician may offer certain spine injections. Most of these injections involve injecting steroids mixed with an anesthetic to numb the pain and decrease inflammation around the damaged nerve. They are especially useful in certain cases of herniated discs (“slipped discs”), sacroiliac (SI) joint pain, and facet-mediated (also known as Z joint or zygapophyseal joint) pain.

With facet-mediated pain (or facet syndrome), an anesthetic injection may also be given to perform a medial branch block to numb the nerve that powers or innervates the facet joint. If this is successful, then you may later be offered a radiofrequency ablation, where this nerve area is burned off to allow for more long term pain relief.

Surgery

For certain refractory cases, unstable fractures, and any significant neurologic involvement, surgery may be either the best option – or sometimes the last resort. Surgery can involve opening up the spinal canal or spaces around the nerve roots in case of pinched nerves. Surgery may also involve placing hardware around the spinal column to allow for better spinal stability. In some cases, even surgery is not helpful and people consider placing spinal cord stimulators and intrathecal pain pumps to allow for direct treatment to the spinal cord.

Complementary and Alternative Medicine

I will say it again – the only consistently proven treatment for back pain as well as most sources of pain is physical therapy and exercise – including both general activity and some more specific exercise such as yoga. But pain is complex and everyone is different. Thus we look for other treatments that are helpful to some people. Nontraditional treatments include transcutaneous electrical nerve stimulation (TENS) and acupuncture. Both of these treatments have some evidence to show they are helpful in treating patients especially with radicular pain. However, despite more interest in nonwestern medicine over the last few decades, there is still little evidence for most nontraditional treatments. There is little to no supporting evidence to support reiki, various herbal remedies, homeopathy, special massage techniques, traditional chinese medicine (TCM), qigong, and naturopathy. There is much heightened interest recently regarding cannabis and especially CBD-formulated health products. However, a combination of legal and regulatory issues has made their research difficult. But you don’t need to spend a lot of money or time to get some benefits from some of these treatments. Try meditating for ten minutes or less, or try something like watching a Tai Chi video on Youtube. Everyone is different. Some of the pain relief may be temporary, some may be long term. You have to try some of these treatments to find what works for you.