Low Back Pain: Causes and Approaches to Care

Low Back Pain is a very common problem. Some of the most common causes include a sprain, strain, degenerative disc disease, or degenerative joint disease.

"Oh, my aching back!"

Back Strains and Sprains 

These injuries are often due to the following: Repetitive motion (doing the same thing over and over again using your back), poor body mechanics and posture, heavy lifting, standing for a long time, being overweight, having weak back, abdominal or thigh muscles (usually due to lack of exercise) or caused by a "traumatic" injury (for example contact sports, a fall or car accident). It is important to note that low back problems can be cumulative. That is, after using your back over and over and straining it a little bit each time (you are not aware of the strain), stress on the back builds up until suddenly a back problem and pain develop. This is common for medical people who end up lifting patients (although they have developed devices to help do this now). NEVER LIFT A GROWN PERSON BY YOURSELF UNLESS IT IS A DIRE EMERGENCY. OSHA (the Occupational Safety and Health Administration) has some more specific recommendations regarding weight limitations when lifting.

General Approaches to Back Strains and Sprains May Include:

• ​Rest

• Ice packs (first 72 hours), heat applications (after 72 hours)- 15 minutes each time 3-4 times daily.

• Relaxation techniques

  -Deep breathing exercises - This helps release endorphins in your brain, which are"feel good" hormones. This technique is practiced by taking a deep breath through your mouth using your diaphragm muscle located just beneath your lower ribs (instead of using neck, shoulder and upper chest muscles), pausing and then releasing the breath through the mouth. Repeat this several times.

  -Guided Imagery - Think of a relaxing situation or a place you have been and focus on only that - focusing on texture, smells and visuals.

  -Use Mindfulness - This is when a person focuses on the present moment, feeling and experiencing the moment with awareness and acceptance, not judgment. This reportedly helps the fronto-limbic area of the brain, which is responsible, in great part, for emotional regulation and processing.

  -Try Progressive Muscle Relaxation Exercises: This is done by tightening muscle groups for eight seconds then relaxing them for several seconds: Begin with facial muscles, with the face, moving to the scalp - tighten muscles eight seconds, then relax; then the neck, doing with each muscle group of the chest, back, pelvis, extremities and so on. This releases some tension and stress. If you do not have time to move through all of your muscle groups, do this with those muscles you believe have the most tension.

  -Analytical Meditation - This meditation involves focus on an object or a concept and focusing on only that.

  -Body Scanning-Focus on a part of your body and feel relaxation, warmth, release of tension

• Warm bath with Epsom Salts

• Massage

• A back support (occasionally and short term)

• Physical therapy

• Practicing good posture 

• Acupuncture

• Using better body mechanics (learning how to improve body motion to avoid strain).

• Exercise (lack of exercise can make your back worse). Mayo Clinic has some good recommendations on its website - just be sure there are no contraindications. Check with your PCP, an orthopedist, or a physical therapist if you have any questions or concerns about it.​

• Assistive devices

• Needling

• Acupressure

• Yoga

• Psychological rehabilitation to help develop coping for pain

• Facet blocks (spinal injection of a long-acting anesthetic)

• Surgery - Spinal fusion

• Hydration

• Relaxing =music

Over-the-Counter Medicines

• NSAIDS - Anti-inflammatories - NSAIDs- ibuprofen (common: Advil, Motrin), Naproxen (Aleve), and Aspirin are quite effective in decreasing pain and, in many cases, are the first-line medications for pain caused by inflammation. In the case of ibuprofen, an adult can take 200 mg to 400 mg every 6 hours for mild to moderate pain and swelling, and 600 mg every 6 hours for moderate pain.  

      Anti-inflammatories are always good medications to start with if you are having pain, especially pain from inflammation (almost all pain has some element of inflammation). BUT on a long-term basis, these medicines can cause gastric ulcers and bleeding as well as kidney and blood pressure issues, so beware - alternate your pain medications (NSAIDS) if possible - ibuprofen to Tylenol or a prescription medicine. Speak to your PCP about this. Additionally, consider taking a stomach acid-reducing medicine (common: omeprazole/Prilosec or famotidine/Pepcid and others) while taking NSAIDs. Remember: Aspirin thins your blood and can make you bleed more easily.

• Acetaminophen (common: Tylenol), on the other hand, is not an anti-inflammatory but, instead, a pain reliever. It has a different mechanism of action than those of anti-inflammatories: It stops pain transmission in the nervous system. It is also a good medication for pain, but used long term, it can cause stomach and liver problems. Again, consider alternating this with ibuprofen every few weeks or speak to your PCP about getting another prescription pain medication.

  
  

• Lidocaine patches

  
  
  
  

​Prescriptive Treatment

• High dose ibuprofen (800 mg)

• Opioids (short-term) - These are painkillers such as oxycodone or hydrocodone (combo opioids with Tylenol: Lortab, Percocet, and Vicodin) and Tramadol (i.e., Ultram). Because these are highly addictive, they are not the drug of choice for long-term pain

• Muscle relaxers (common: Flexeril/cyclobenzaprine, Skelaxin, Methocarbamol)

• Amitriptyline (tricyclic antidepressant) - Especially for pain with related neuropathy

• Gabapentin, Pregabalin (common: Lyrica) - Thought to block pain neurotransmission/

       messages from getting to the brain (antiseizure medications) - (not recommended for disk herniation)

Problems can occur within the vertebral column itself, which consists of the bones that protect the central nerves that take messages back and forth from the rest of the body to the brain (and vice versa). Two common examples of this are degenerative disc disease and degenerative joint disease, which are discussed in the following.

​​Degenerative Disc Disease 

Degenerative disc disease occurs when the cushioning discs between the vertebrae gradually deteriorate, leading to pain and reduced flexibility in the spine. These discs act as cushions that give our backbone flexibility and help prevent the bones of the spinal column from rubbing against each other. When those cushions start to give out in the lower back, it often causes low back pain and sometimes lower extremity pain, due to compression by the bones on the nerve that extends from the spinal nerve to that extremity.

The problem here is that, in many cases, disks tend to erode with use over time. They suffer from wear and tear and start becoming dried out due to normal loss of hydration. And, no surprise, it tends to occur more in older adults. In addition, it occurs more frequently in smokers, those with arthritis, and as the body's alignment changes.

Degenerative disk disease can cause temporary mild dysfunction and pain, or it can progress to severe pain, instability, and restriction of movement. In the case of a herniated disk ("slipped disk"), the disk starts bulging outside of the disk space and causes pain and pressure on surrounding nerves. This often causes a great deal of localized pain in the area where the disk is located, and it can cause pain, numbness, and weakness in the buttocks, hip, or thigh (sciatica) - even traveling down the leg to the foot. A slipped disk can occur in the upper extremities and related disks as well, but it is far more common in the lower back or lumbar region.

It can be diagnosed through various means such as an X-ray, CT, or MRI.

Many treatments, remedies, and approaches for degenerative disc disease are similar to those for sprains and strains

General approaches to degenerative disc disease:

• Ice Packs (usually initially for the first 48-72 hours) Use for 15-30 minutes about three times a day. Note: Be sure to wrap the ice because direct and prolonged application of ice can cause tissue damage

• Heat (Warm moist heat - 15 minutes, about three times a day)

• Hydration

• Relaxation techniques (lots of instructions online - like deep breathing, meditation, guided imagery).

• Yoga- guided

• Tai Chi - guided

• Counseling

• Quit smoking

• A healthy diet (an anti-inflammatory diet that particularly recommends that you eliminate processed foods)

• ​Pain clinics help diagnose pain and take a holistic approach to treatment and care. They have providers who help diagnose painful conditions, prescribe medications, give injections, provide physical therapy, occupational therapy, and provide other approaches to pain, like cognitive behavioral therapy (mental health approach), to help alter the perception of and tolerance to pain. This is an ideal approach to hard-to-control chronic pain.

• Hydrotherapy and/or warm baths with Epsom Salts

​Over-the-Counter Medications

• NSAIDS - Anti-inflammatories - NSAIDs- ibuprofen (common: Advil, Motrin), Naproxen (Aleve), and Aspirin are quite effective in decreasing pain and, in many cases, are the first-line medications for pain caused by inflammation. In the case of ibuprofen, an adult can take 200 mg to 400 mg every 6 hours for mild to moderate pain and swelling, and 600 mg every 6 hours for moderate pain.  

Anti-inflammatories are always good medications to start with if you are having pain, especially pain from inflammation (almost all pain has some element of inflammation). BUT on a long-term basis, these medicines can cause gastric ulcers and bleeding as well as kidney and blood pressure issues, so beware - alternate your pain medications (NSAIDS) if possible - ibuprofen to Tylenol or a prescription medicine. Speak to your PCP about this, and also, consider taking a stomach acid-reducing medicine (common: omeprazole/Prilosec or famotidine/Pepcid and others) while taking NSAIDs. Remember: Aspirin thins your blood and can make you bleed more easily.

• Acetaminophen (common: Tylenol), on the other hand, is not an anti-inflammatory but, instead, a pain reliever. It has a different mechanism of action than that of anti-inflammatories: It stops pain transmission in the nervous system. It is also a good medication for pain, but used long term, it can cause stomach and liver problems. Again, consider alternating this with ibuprofen every few weeks or speak to your PCP about getting another prescription pain medication.

  
  

Topical:

• Diclofenac/Voltaren (an anti-inflammatory) - topical

• Icy Hot (menthol and methyl salicylate, which is related to aspirin)

Considered Natural and Herbal Approaches

• ​Capsaicin (also over-the-counter)-topical

• Turmeric/curcumin

• Ginger

• CoQ10

• Glucosamine

• Boswellia/curcumin combination

• Peppermint

​Prescriptive Treatment:

• Opioids (short course) are painkillers (such as oxycodone, Percocet, Vicodin, Lortab, and others). Because these are highly addictive, they are not the drug of choice for degenerative disc disease.

• Steroid injections at the site of a joint problem can reduce swelling and inflammation

• Steroids have lots of potential side effects, from ulcers to diabetes, to hypertension to insomnia, and sometimes downright psychosis, but they are great anti-inflammatories. Sometimes healthcare providers prescribe a low dose to use over the long term, but because of the potential side effects, it is good to look at some of the alternatives.

• Muscle relaxers (common: Flexeril/cyclobenzaprine, Skelaxin, Methocarbamol)

• Amitriptyline (tricyclic antidepressant) - Especially for pain with related neuropathy

• Gabapentin, Pregabalin (common: Lyrica) - Thought to block pain neurotransmission/

       messages from getting to the brain (antiseizure medications) - especially good with                 neuropathy (not recommended for disk herniation)

If you develop sudden weakness, numbness and tingling, or loss of bladder or bowel control, see a healthcare provider right away (ER)!! 

Low Back Pain

PLEASE NOTE: There are many potential causes of low back pain. If you develop acute low back pain, or your back pain is severe or ongoing, it may be more than meets the eye. Back pain can come from urinary tract infections to other, more serious kidney problems. It can be from shingles, and even abdominal issues like pancreatitis, a peptic ulcer, or even an aortic aneurysm, which is rare but does happen.

The discussion above, Low Back Pain: Causes and Approaches to Care, is here for you to consider different problems and paths to management. It is not here to take the place of your healthcare provider. If you have any questions or concerns, and/or if you're experiencing back pain without a known injury, it's important to consult a healthcare provider to determine the underlying cause, especially if the pain is severe. Pain is always a signal that something isn't right.

If you have any questions about your pain, see a healthcare provider. Treat early.