Back pain: cause, symptoms and treatment

Back pain is one of the most common complaints. 80% of the world's population suffers from back pain once in their lives. Back pain is also a major cause for being absent from work. Although back pain is found among all age groups, it mostly affects people between the age of 35 and 55. Experts state that back pain is associated with bone, muscle and ligament problems.

Lower back pain may be caused by lumbar vertebrae, vertebrae, intervertebral disk, ligaments between vertebrae and intervertebral disks, spinal cord and nerves, spinal muscle, abdominal and pelvic organs pathology, and skin problems around spine area.

Causes of back pain

Spinal cord is a structure consisting of muscles, ligaments and tendons, which anatomically divided into segments. Any of these components may cause back pain if there is a problem.

Tension, stretching is the most common causes of back pain:
 - Muscle stretching
 - Ligament tension
 - Muscle spasm

Movements that could result in muscle stretching and tension:
- Lifting heavy goods without purpose
- Lifting very heavy goods
- Sudden and awkward movements

Structural problems - structural problems listed below may also cause back pain

 - Ruptured disc - Each vertebrae of our spinal cord is surrounded with discs. If one of the discs is ruptured, then the pressure on the nerve will cause back pain.
 - Bulging disc – As with ruptured disc, bulging disk may also cause back pain by pressing nerve.
 - Sciatic nerve – compression of sciatic nerve by ruptured disk or bulging disk cause acute and burning pain running (radiating) from the buttock through the back surface of the thigh down to the lower part of the leg.
 - Arthritis - Arthritis affects mostly the hip, lumbar, knee joints and joint of hand.
 - Pathological spine curvature - Spinal cord has a natural and pathological curvature; natural lordosis, natural kyphosis, pathological lordosis, pathological kyphosis and scoliosis. When the natural curvature is lost, the back pain is inevitable. For example, during the scoliosis the spinal cord is being bent to the side.
 - Osteoporosis – in osteoporosis spinal bones and vertebrae become fragile and porous, which often results in fragmentary fractures.

Below are other causes of back pain

 - Horse -tail syndrome (Cauda equina syndrome) – horse tail is mass of nerve roots that branches off the lower end of the spinal cord. Patients with horse-tail syndrome experience dull pain in lower back and upper buttock and numbness in buttock, genital and hip areas. In some cases, problems with urinary excretion and defecation are also observed.
 - Cancer of the spine – tumor could lead to back pain by compressing the nerve in the spinal cord
 - Infection diseases of the spinal cord - if the patient has back pain symptoms along with high fever, this could be because of infectious disease of the spine.
 - Other infectious diseases - infectious diseases of the pelvic (in women), bladder or kidney infections can also cause back pain.
 - Herpes Zoster - Depending on damaged nerve, this infection can also cause back pain.
 - Poor bed – The risk of back pain is high if your mattress does not support your body's specific curvature and keeps your spine straight.

Daily activities and improper posture

Back pain may also occur as a result of our daily activities or improper posture. These include:
 - Leaning forward awkwardly;
 - Pushing an item;
 - Pulling an item;
 - Carrying an item;
 - Lifting goods;
 - Standing for a long time;
 - Bending for a long time;
 - Spinning
 - Coughing
 - Snoring
 - Straining muscle
 - Excessive stretching
 - Leaning your neck forward excessively, for example when driving or using a computer;
 - Continuous driving

Risk factors

Conditions that contribute to the cause and development of the disease are called risk factors. For example, obesity significantly increases the risk of developing type 2 diabetes. Hence, obesity is considered the risk factor of type 2 diabetes.

The following are high risk factors that increase the risk of back pain

 - Hard mental work
 - Pregnancy
 - Sedentary lifestyle
 - Age - (elderly people are more likely to have back pain than young people and children);
 - Anxiety
 - Depression
 - Gender – back pain is more common amongst women than men:
 - Obesity and excessive weight
 - Smoking
 - Tiresome, purposeless physical exercise;
 - Tiresome physical work.

Signs and symptoms

The main symptom of back pain is pain in the lower part of the back, sometimes radiating into the buttocks and to the legs.  Back problem could lead to pain in a various parts of body, depending on the compressed nerve.  In many cases, the symptoms disappear on their own.

If any of the following symptoms are accompanied by back pain, be sure to consult your doctor

 - Weight loss;
 - Increased temperature (fever);
 - Inflammation on the back (redness, swelling);
 - Continuous back pain: pain that does not ease by lying down and resting, radiating to the lower parts of the body (legs);
 - Pain that spreads from knee downwards;
 - Recent back injury or trauma
 - Urinary incontinence – involuntary urination;
 - Difficult urination;
 - Fecal incontinence – loss of bowel control. Involuntary fecal elimination;
 - Numbness in the genital area (sensation disorder);
 - Numbness around the anus area (sensation disorder);
 - Numbness in the buttocks (sensation disorders).

According to the British National Health Service (NHS), the following group of people should seek medical advice when feeling back pain.
 - Persons under the age of 20 and over the age of 55;
 - Patients receiving steroids for several months;
 - Those with drug addiction;
 - Those with cancer;
 - People who have weakened immune system.

Diagnosis

The doctor can diagnose back pain after a physical examination and short clinical story, and in most cases imaging is not required. If there is any suspect to the spine pathology, then additional analysis may be required.

Investigations such as X-ray or other imaging examinations as CT scan or MRI may be indicated for the confirmation of disc, nerve, tendon, and other problems.

X-ray - can confirm if the patient has arthritis or bone fractures. It is not an ideal test to detect muscle, spinal cord, nerves and discs related problems.
MRI or CT examinations - are indications for disc hernia, tissue, tendon, nerves, ligaments, blood vessels, muscle and bone problems.
Electromyography or EMG - measures muscle response to a nerve’s stimulation of the muscles. The test is used to help detect nerve compression as a result of a disk hernia or stenosis.

If the doctor suspects infection, blood tests may also be required.

Methods of treatment
The vast majority of back pain disappears on its own without requiring any medical intervention. Usually the pain is relieved by painkillers or either hot or cold compress to the aching area. Short-term resting is useful. However, it may cause muscle weakness in the long run, which can further worsen back pain.

Usually back pain is divided into two types:
 - Acute - back pain starts suddenly and lasts for a maximum of 3 months.
 - Chronic - develops slowly over a long period of time and lasts for more than 3 months, causing long lasting problems.

If home treatment results are not satisfactory, your doctor may give the following advice:
- Medicines – a variety of painkillers, anti-inflammatory drugs, some types of anti-depressants.
- Physiotherapy - hot, cold applications, ultrasound and electrical stimulation, as well as some muscular relaxation techniques can help reduce pain in the muscles and soft tissues.

As soon as the pain decreases, the physiotherapist may recommend exercises to strengthen the spine and abdominal muscles. Methods that improve posture can also help.

Cortisone (hormonal) injection – when above listed treatments are not useful, or there is pain that radiates down, cortisone injection can be administered to the epidural zone. Cortisone has an anti-inflammatory effect. By reducing inflammation around the nerve root, it relieves pain. From the experience we may say that the pain may not return for 6 weeks after the cortisone injection.

Alternative (traditional) methods

Many people choose alternative treatment methods:
 - Osteopath – specializes in skeletal and muscle treatment.
 - Chiropractor – spine is the main target for joints, muscle and bone problems.
 - Shiatsu -is finger pressure therapy, where pressure is created in all energy lines of the body. The Shiatsu therapist treats with fingers, thumbs and elbows.
 - Acupuncture (needle treatment) - is a treatment that emerged in China, where the delicate needles are inserted into specific parts of the body. Acupuncture stimulates nerve and muscle tissue by releasing body's natural pain relievers - endorphins.

Experience has shown that these kinds of treatments have mixed results. Some people have good results after the treatment while others do not have the same effect.

TENS (transcutaneous electrical nerve stimulation) is a widespread treatment for patients with long term back pain. The TENS device transmits small electrical pulses to the body. Experts believe that TENS can block the returning pain signals to the brain by providing endorphin release in the body. TENS gives a variety of results: some do not see any effect, while others have certain effects. Pregnant women, people with epilepsy, with pacemaker and people with heart disease should not use TENS.

Special Non-Surgical Treatment - prolotherapy - is an injection treatment and is used to treat connective tissue and muscle-joint injuries. Injection accelerates process by repairing damaged and weakened tissue, relieves pain, and improves functionality.  Prolotherapy has several synonyms; sclerosant therapy, sclerotherapy, regenerative injection therapy, proliferative injection therapy and non-surgical ligament reconstruction.

Who should prolotherapy be done by? – Prolotherapy should be done by experienced doctor who specializes in this field.

Effectiveness of prolotherapy for back pain:

The efficacy of prolotherapy applied by the specialists to patients suffering from chronic back pain is 80% -90%.

Surgical intervention - Surgery is rare during back pain. If the patient has disk hernia, and if muscle weakness is observed, then surgical intervention might be necessary.

Surgical interventions include:
 - Fusion – technique that joins two vertebrae using bone grafting
 - Artificial disc – An artificial disk is placed between the two vertebrae.
 - Disc removal (discectomy) – removing part of the disc if it irritates or squeezes the nerve.
 - Partial removal of vertebrae- small part of the vertebrae can be removed if it compresses the spine and the nerves.

Prevention of back pain

Eliminating the risk factors means preventing back pain.

Exercise - regular physical exercise helps the body to strengthen, as well as reduce body weight. Experts recommend light aerobic movements.

There are two main types of sports for people to reduce back pain:

 - Core-strengthening exercises – movements that strengthen back and abdominal muscles, thus protecting the spine.
 - Flexibility- movements that increase elasticity in back, pelvis and spine muscles.
 - Smoking- the frequency of back pain in smokers for the same age, size and weight is much higher than non-smokers.
 - Body weight- risk for back pain may differ depending on gained weight in specific part of the body. The risk of back pain in people with obesity and with normal weight is questionable. Excess weight in belly and pelvis is a major risk for the back pain.
 - Standing position – make sure that pelvis area is not bent while standing. Stand straight; making sure the body weight is equally distributed to both feet, while holding your head straight along the spinal line.
 - Sitting position – for the correct sitting position you may need chair with a good support for your back, lap and rotating base. Keep your knees at the same position with pelvis and put your feet to the floor (if you are not reaching floor, place little box for your feet). You should sit perfectly even. When working with the keyboard, make sure that you place your elbows under the right angle.
 - Lifting heavy goods – the secret of protecting your back when lifting heavy goods, is thinking about your legs (not your back). In other words, during lifting heavy goods, use your legs more than your back. Keep your back straight as long as possible, and bend your knees slowly, keep the weight close to yourself and tilt your legs when changing the position of your back. The most important thing is not to straighten your legs before lifting goods, otherwise the main weight will be on your back.
 - Simultaneous lifting and rotation – if the good is heavy, ask someone to help you. Look forward while lifting goods, neither up nor down, by this you will support your cervical spine.  
 - Moving things – remember pushing is better than pulling
 - Shoes – flat shoes do not strain your back
 - Driving – supporting your back is very important. Adjust the side mirrors, so there is no need to turn around. During long drive give yourself short breaks and walk around.
 - Bedding – your mattress should hold your back straight and provide support to your back and pelvis. Use pillows that do not hold your neck under right angle.

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