Preventing back pain

Back pain is a universal phenomenon. In the United States, up to 84 per cent of the population would have experienced an episode of back pain during their lifetime. In Malaysia, a study carried out in 1988 showed that 10.9 per cent of men and 19.5 per cent of women surveyed had had back pain in the preceding one week.

Why do you get back pain?

The human backbone (vertebral column) consists of 33 bones called vertebrae. In between the vertebrae are softer intervertebral discs, made of a gel-like material in the middle surrounded by a tougher fibrocartilage outer layer.

The discs enable the spine to be able to twist and turn. At the back of the spine runs the spinal cord with nerves going to the arms and legs.

The whole vertebral column is stabilised by ligaments and muscles.

Any pathology affecting the bones, nerve, discs, ligaments and muscles may give rise to pain. So potentially, there are numerous causes of back pain.

Common causes of back pain include degenerative disc disease, facet joint arthritis or a herniated/prolapsed disc ("slipped disc").

Wear and tear can lead to degenerative disc disease, or the breakdown of the spinal discs, with small cracks and tears and/or loss of fluid in the discs. This can lead to other changes, including the formation of bone spurs.

Degenerative disease of the spine is also called "spondylosis", so "lumbar spondylosis" means degenerative disease in the lower spine.

When there is too much wear and tear on the disc, the outer covering of the disc can become weak or torn and the soft gel inside the disc extrudes out (thus "slipped disc"). If the herniated disc touches a nerve, it can cause leg pain.

Facet joint arthritis occurs in the joints connecting the vertebrae to one another (facet joints). This can lead to bone spurs around the joint and may cause low back pain.

However, degenerative disc disease, facet joint arthritis, bone spurs and herniated discs are part of the ageing process and are frequently seen on x-rays or MRIs, even in people with no low back pain.

Less common but more serious causes of back pain include vertebral fracture due to osteoporosis, ankylosing spondylitis (a type of arthritis), spinal infection, tumour and cauda equina syndrome (where the spinal cord is compressed).

Having mentioned all that, it must be emphasised that in 90 per cent of cases, back pain is not associated with serious pathology; rather, it is due to sprains or minor injuries to the muscles, ligaments or tendons in the back. Thus, spontaneous resolution of the symptoms is usually the rule.

When should I see a doctor?

As the vast majority of cases of back pain resolve spontaneously, it may not always be necessary to see a doctor. Even if you do see a doctor, he/she may not immediately order x-rays or scans of your back.

For example, if there is a herniated disc seen on the scan, it may well heal over time because the body breaks down and absorbs the excess disc material and water within the disc, relieving pressure or irritation on the nerve.

However, there are several warning signs, known as "red flag" signs, which may indicate that your back pain is caused by a more serious condition. Therefore, you should see the doctor if you have numbness or weakness in your legs, have problems with bowel or bladder control, have a fever or feel sick in other ways, take steroid medicine, such as prednisolone on a regular basis, or have a history of cancer or osteoporosis.

Medical advice should also be sought if the back pain does not improve with rest or a change in position, and is so severe that you cannot perform simple tasks or if your back pain does not start to improve within three to four weeks.

For the majority of cases of non-specific/musculoskeletal causes of back pain, the current recommendations are that you remain active; most experts now agree that staying in bed, lying down or being inactive for long periods is bad for your back. Recovery is just as rapid and complete without bed rest.

Keeping active under such circumstances will not cause deterioration in the back pain. If the back pain is severe, bed rest may be necessary, but usually for no more than a day. The aim is for a rapid return to the normal activities of daily living.

There may not be any need to take much time off work either. White collar office workers may be able to go back to work promptly. Those with more manual jobs should still be encouraged to get back to work, but perhaps on light duties until the back pain is better.

Your doctor may prescribe simple painkillers such as paracetamol, or non-steroidal anti-inflammatory drugs (NSAIDs), which can be taken on a short-term basis for symptomatic relief of the pain.

Once the pain is resolving, exercises can be started.

How can I prevent further back pain?

For people with non-specific back pain, exercises such as back flexibility and strengthening exercises combined with general fitness/aerobic exercises, have been shown to reduce the rate of recurrence of low back pain. Exercises that strengthen the abdomen/torso, hip and pelvic muscles are particularly useful ("core strengthening", Pilates, McKenzie method, Alexander techniques, are some examples).

Some examples of exercises that can be done at home are listed below:

1. Back exercises in 15 minutes a day, from the Mayo Clinic:

2. Good and bad exercises for low back pain, from WebMD:

3. Lower back pain exercises, from NHS UK:

It is also important to avoid activities that involve repetitive bending or twisting and high-impact activities that increase stress on the spine.

In addition, people with low back pain should learn the right way to bend and lift.

For example, lifting should always be done with the knees bent and the abdominal muscles tightened to avoid straining the weaker muscles in the lower back. People who sit or stand for long periods should also change positions often.

In conclusion, remember that back pain is common but self-limiting in most cases. However, please see a doctor if there are any "red flag" signs which may suggest a more serious cause for the back pain. Exercise and ergonomic adjustments to activity may help prevent recurrences of back pain.