Back pain - tips and tricks to getting better and when to see a doctor

Symptoms and signs of back pain include:

• Pain or soreness in the back

• Back stiffness

• Tingling in the back or down the legs

• Being unable to stand straight without discomfort

• Being unable to bend from side to side, or bend forward properly

• A general reduction in back movement

Causes and triggers of back pain

There are multiple causes of back pain, and these can be categorised in different ways, so we find it easiest to consider this by looking at which part of the anatomy is affected.

Muscle injury

This is the most common cause of back pain, especially low back pain - often called mechanical back pain. It usually relates to a sprain or strain on a muscle or ligament, and it causes aches or spasms in certain movements. It usually starts to improve after 3 to 4 days, but may take a bit longer.

You may be able to recall an injury that triggered your back pain, perhaps a house move where you were lifting boxes or furniture, or it might have been a sporting injury or an awkward weight lift at the gym. It can even occur from tripping on the kerb or missing a step in a flight of stairs. Your job may involve a lot of lifting or twisting ( such as delivery drivers, clerical staff or nurses) and poor technique or lifting a load that’s too heavy is often responsible for these injuries.

Coughing fits can also cause you to strain the muscles that either surround your spine or between the ribs (the intercostal muscles). Obesity and a sedentary job or inactive lifestyle are other common risk factors for muscle injury, due to additional load and lack of support in the back and core muscles.

Nerve problems

Trapped nerves are common, and usually get better on their own. Sciatica is a condition where the sciatic nerve gets inflamed and trapped or irritated as it passes from the lower spine, through the pelvis, to each leg. Symptoms include low back ache and burning or shooting pain across one buttock, down the back of the thigh and sometimes to the outside of the lower leg or foot. It might also cause a temporary numbness in the leg. It’s worse when bending the leg, and most people have less pain when standing than sitting. It’s also often worse when it first starts, when it can cause spasms of pain.

There’s often no underlying cause of sciatica - it may become inflamed after injury or overuse, and some people seem more vulnerable to it. It can sometimes be the result of a compressed nerve from a slipped disc, bone spur (notch of bone on one of the vertebrae) or spinal stenosis, where the space for the spinal cord to fit within one of the vertebrae narrows.

Cauda equina syndrome is a serious nerve problem where all of the nerves in the lower spine are compressed, leading to worsening weakness and numbness in the legs, sciatica in both legs, possibly a lack of sensation around the buttocks and back passage, and loss of control of the bladder or bowel. This is a medical emergency, requiring urgent medical attention to prevent permanent disability.

Slipped disc

It’s common for the soft cushion between each vertebrae to get compressed, causing it to bulge to one side - known as a slipped disc. This can reduce cushioning, causing pain in itself, and it can compress nerves coming from the spinal cord, causing painful conditions like sciatica. Your cushioning reduces with age, so this is one risk factor, and obesity is another, as additional weight puts more strain on the discs.

Inflammatory conditions

Ankylosing spondylitis is an autoimmune condition that causes lower back pain, and typically starts in the late teens to early 30s. It’s lifelong and can run in families. You might notice morning stiffness, where it takes 30 minutes or more before you can get out of bed and start the day, and loss of lower back flexibility over time. Care needs to be taken with regular stretching and prescribed medication is often needed to avoid long-term problems such as fusing of the lower spine or neck.

Rheumatoid arthritis is another long-term inflammatory condition that can affect the spine, especially around the neck.

Poor bone health

The vertebrae are vulnerable to breakdown, where the structure of the bone becomes less dense and strong. This occurs in a condition called osteoporosis, and puts you at risk of compression fractures. A lack of calcium and vitamin D over a lifetime can contribute to reduced bone density, along with being both overweight and underweight, long-term alcohol excess, smoking and age. Medications can also reduce bone health, such as long-term corticosteroid use.

Spinal osteoarthritis is a wear and tear arthritis that can affect the cartilage cushions in your spine and neck, and put you at risk of spinal stenosis.

Cancer

Vertebral bones are the most common place for cancers to spread (metastasise) to, causing severe back pain that won’t improve and it may wake you at night. You may be more aware of this if you have already been diagnosed with cancer, but it may also be the first sign. Night sweats, immense fatigue and unintentional weight loss are all added signs to get this checked out.

Lung, breast and gastrointestinal cancers are the most common to spread there. Smokers are at high risk of lung cancer, and therefore spinal deposits of cancer, and the elderly are also at highest risk of cancer overall, and therefore spine metastases.

Spinal fractures

Significant injury such as from impact sports or a road traffic collision can cause vertebral fractures. Pathological fractures relate to either very mild injury or no particular injury at all. They occur because of poor bone health, and alert a doctor to an underlying problem that needs investigating, such as cancer. Compression fractures usually occur as a consequence of spinal osteoporosis, where the bone loses density and becomes more crumbly, making it vulnerable to fractures.

Infection

We have a pair of kidneys with each one sitting on either side of the back, by the flank. A kidney infection called pyelonephritis can cause kidney pain, where you may also have blood in your urine, passing it with more urgency or frequency, and a fever. Kidney stones can also cause a searing back and abdominal pain, usually leaving you doubled over in spasms, and they can cause blood in the urine.

Much less commonly, a spinal abscess from bacteria or tuberculosis (TB) can cause back pain and a reluctance to move the back, possibly with a fever.

Dissecting aorta

People describe a searing or ripping pain in their back and across their chest if this occurs. It’s where a layer in the lining of your aorta, the biggest blood vessel in your body, comes apart and blood that should be transported from the heart to the rest of the body starts leaking out. This is a medical emergency and requires urgent hospital treatment.

Severe symptoms

General principles apply for back pain when it should be something you discuss with your doctor. If there is severe pain or weakness, or the pain is associated with concerning symptoms such as fever, unintentional weight loss, night sweats, a traumatic injury (such as falling from chair height), or pain that feels out of proportion with an injury or suspected diagnosis then you should see your doctor for review urgently.

Pain and stiffness can often shortly occur after a muscle injury to the back. Paracetamol is a safe and sensible place to start when reaching for back pain relief, with relatively few risks or side effects, if taken as instructed. It’s well-tolerated and may be sufficient for occasional mild pain that occurs for just a brief time. It’s also safe in pregnancy. It should be avoided by those with a known liver condition who have been told not to use it.

NSAIDs (non-steroidal anti-inflammatory drugs) can help to relieve the swelling and inflammation that causes back pain and loss of function, especially in musculoskeletal injuries. NSAIDs include ibuprofen and aspirin, and stronger versions are available on prescription. Taken regularly for a week or so, NSAIDs can be very effective. They should be taken with food to minimise any irritation to the stomach lining or increasing reflux issues. The anti-inflammatory element of NSAID medications increases throughout the first week, so will continue to give added benefit with regular usage.

NSAIDs should be avoided in pregnancy, and in those with NSAID-sensitive asthma, a long-term kidney condition, on certain medications or those with a stomach ulcer. Aspirin is not suitable for those under 16.

A proton pump inhibitor (PPI) may be recommended by your doctor or pharmacist to protect the stomach lining if recommending regular NSAID medications. These are available on prescription or to buy at the pharmacy, such as Nexium Control (contains esomeprazole) or Pyrocalm tablets (contains omeprazole).

Anti-inflammatory gels can be a good alternative if you would rather not take tablets . You could try creams or gels that contain anti-inflammatory agents, such as Voltarol Back and Muscle Pain Relief 1.16% Gel, containing diclofenac. Be careful to not take anti-inflammatory topical creams alongside anti-inflammatory tablets, as these can lead to increased risk of side effects and problems.

First things first - we’d recommend starting with some good old-fashioned stretching exercises if the cause is musculoskeletal back pain. For the majority of mild back pains, this may be all that is needed and even if you need other techniques or medication, moving and stretching is essential throughout your road to recovery. You should avoid complete bed rest with back pain as this stiffens muscles up and can set up new problems in your surrounding joints. Try to move little and often, with gentle stretches for the back, neck, shoulders, waist and legs, to avoid further stiffness, pain and difficulty in recovering.

A cold compress is a good idea in the first few days after a flare-up or injury. A bag of frozen peas wrapped in a towel will help to reduce the initial wave of inflammation and swelling that can add to pain. You should only use a cold compress for a maximum of 20 minutes at a time and never apply ice directly to your skin. Deep Freeze can be applied to the injured area to have the same effect, or creams or gels containing menthol.

A warm compress is helpful once inflammation has settled after the first few days, as it helps the muscles relax, prevents stiffness and eases pain. A hot water bottle also does the job well – use a towel to avoid causing any skin damage – or certain creams and gels can cause a local heat, such as Deep Heat heat patches or capsaicin cream, the substance that gives chilli peppers their heat.

A professional massage or manipulation can help ease aches and pains in the back and improve movement. This is best done by a professional who understands anatomy and injury. A sports therapist, physiotherapist, chiropractor or osteopath are all highly trained, with the latter two working specifically with back problems and alignment. They can also advise on stretches to alleviate pain and rehabilitate, and exercises to prevent future back pain or injury.

With sciatica symptoms, once you’re over the initial spasms of pain, stretching out the hamstring muscles at the back of your thighs helps to ease the sciatica with time, and can prevent it in future.

A TENS machine (transcutaneous electrical nerve stimulation) can help relieve pain by providing small electrical impulses to the lower back area, giving a mild tingling sensation and reducing pain signals to the brain. It’s a good idea to try if you have long-term back pain.

Acupuncture has evidence to back its role in short-term relief of chronic back pain, and it may allow a little more movement to encourage further rehabilitation and repair. Tiny needles are inserted to the skin and muscles, which is thought to release natural painkillers in the body called endorphins.

CBT and mindfulness may help to treat the brain’s interpretation of pain, if your back pain lasts several weeks or months. Sometimes our bodies malfunction to continue making us think we’re in pain, even after we’ve recovered from the initial injury. So CBT (Cognitive Behavioural Therapy) or mindfulness can be beneficial in reducing your sensitisation to chronic pain and thereby dampening its impact.

Taking care of your mental health is essential with injuries that are slow to recover, as chronic back pain can take its toll. Consider what you enjoy and what helps you relax – music, reading, catching up with friends – and work on releasing those natural painkillers, the endorphins. Be aware that low mood, anxiety and depression can sometimes set in with chronic pain. See your doctor if you think your condition is affecting your mental wellbeing.

Core strength and conditioning can help with longer term back pain, and help to prevent future injuries. Pilates, yoga and weight training can all help to build up core muscles, including the paraspinal muscles that hug the spine, and flexibility to keep the spine supple. They also improve posture, which helps if you sit at a desk for long periods or have a physical job requiring lots of lifting.

Most cases of back pain are nothing to worry about and will improve within a few days or weeks. There are certain circumstances when you should seek medical attention, and you may need this urgently:

• if your back pain started after a significant fall or accident

• if you have a history of cancer

• if you have back pain together with unintended weight loss, extreme fatigue or night sweats, a chronic cough, a change in your bowel habit or a lump in your breast, or if you are a long-term smoker

• If you have severe back pain, or intense back pain that wakes you at night

• if you have sciatica affecting both legs, numbness around your bottom or problems with your bowel or bladder control

• if you are aged under 45 and get severe back pain and stiffness first thing in the morning, every morning, lasting for 30 minutes or more, and this has persisted for 3 months or more

• if your back pain has not started to improve after 6 weeks

If your doctor thinks there is a serious or life-threatening condition, they will refer you directly to your hospital. Otherwise, they will examine you and discuss the next steps for your road to recovery. Most commonly your doctor will refer you to a physiotherapist for more specialist management, as this is one of the best ways to improve your back pain and muscle strength, and prevent further injury.

If your back pain has been intermittent over a long period, or short-term but has no other concerning features, if it’s interfering with your job, hobbies or everyday activities, you should see your doctor. They will listen to your symptoms and what you’ve tried already, ask further questions and they will have a look at how you move, what brings pain on, and where the specific pain is.

Only rarely does your low back pain require referral to a specialist for further investigation and treatment. If they need specialist input, they may refer you to an orthopaedic or spinal surgeon, who deals with surgical bone and nerve problems, or a rheumatologist, who deals with medical inflammatory conditions and joint problems.

How can I prevent back pain?

The best way to prevent back pain is to keep your back strong and supple. Regular exercise, maintaining good posture and lifting correctly will all help. Other general points that are useful in preventing back pain include losing weight if overweight, wearing flat shoes with cushioned soles, avoiding sudden movements and staying active with regular exercise such as walking and swimming.

Posture tips

How you sit, stand and lie down can have an important effect on your back. When standing, keep as upright as possible with your head facing forward and your back straight. Balance your weight evenly on both feet and keep your legs straight. When sitting, make sure you sit upright with support in the small of your back. Your knees and hips should be level and your feet should be flat on the floor (use a footstool if necessary). Some people find it useful to use a small cushion or rolled-up towel to support the small of the back.

Adjusting your workplace set-up may improve posture to protect your back, such as keeping your computer screen at eye level, forearms and hands at waist height and rested on the desk, and hips, knees and ankles at right angles, with feet flat on the floor.

Sleeping tips

Make sure that your mattress is replaced at least every 10 years and that it is firm enough to support your body while supporting the weight of your shoulders and buttocks, keeping your spine straight. If your mattress is too soft, place a firm board (ideally 2cm thick) on top of the base of your bed and under the mattress. Your head should be supported with a pillow, but make sure your neck is not forced up at a steep angle.

Driving tips

Make sure that your lower back is properly supported. Position your wing mirrors correctly so you do not have to twist around and make sure the foot pedals are squarely in front of your feet and that your legs are not at an angle. If you are driving long distances, take regular breaks so that you can stretch your legs.

Exercise tips

Exercise is both an excellent way of preventing back pain and reducing back pain and exercises such as walking or swimming strengthen the muscles that support your back without putting any strain on it. Keeping supple and flexible is also very important, so activities such as yoga or pilates can help with this. (It is important that you carry out these activities under the guidance of a properly qualified instructor.)

Some types of exercises that are helpful in keeping the back strong and supple include;

Wall slides - stand with your back against a wall with your feet shoulder-width apart. Slide down into a crouch so that your knees are bent to about 90 degrees. Count to five and then slide back up the wall. Repeat five times.

Leg raises - lie flat on your back on the floor. Lift each heel in turn just off the floor while keeping your legs straight. Repeat five times.

Bottom lifts - lie flat on your back on the floor. Bend your knees so that your feet are flat on the floor. Lift your bottom in the air by tightening your stomach muscles while keeping your back straight. Repeat five times.

Lifting and handling tips

A major cause of back injuries and pain is lifting or handling objects incorrectly. Learning and following correct methods for lifting and handling objects can help prevent this, so always think before you lift a heavy object - can you manage the lift? Are there any handling aids you can use? Where is the load going?

Keep your feet apart, with one leg slightly forward to maintain balance, and then when let your legs do the work - bend your back, knees and hips slightly, but do not stoop or squat. Keep the load as close to your body for as long as possible with the heaviest end nearest to you

Avoid twisting your back or leaning sideways, particularly when your back is bent - your shoulders should be level and facing in the same direction as your hips; turning by moving your feet is better than lifting and twisting at the same time

Keep your head up - once you have the load secure, look ahead, not down at the load

Know your limits - there is a big difference between what you can lift and what you can safely lift. If in doubt, get help

Push rather than pull - if you have to move a heavy object across the floor, it is better to push it rather than pull it

Distribute the weight evenly - if you are carrying shopping bags or luggage, try to distribute the weight evenly on both sides of your body.