Lower back pain is very common and can generally be classified into acute lower back pain and mild to moderate lower back pain. It is not always possible to make a precise diagnosis of a specific back injury or condition which might be causing lower back pain. However, this should not prevent the back pain from being managed or treated.
It is often possible to make a diagnosis for patients with the following conditions:
- Fractures through direct trauma. There is often soft tissue injury associated with this kind of injury also.
- Nerve route compression with pain radiating down a specific part of the leg.
- Spondylolysthesis or stress fracture of the pars interarticularis.
- Spinal canal stenosis (more usually seen in older athletes)
The above conditions are thought to account for less than 10% of lower back pain. Back pain can be categorized into severe or acute low back pain and mild to moderate low back pain. Most people have mild or moderate low back pain.
Acute low back pain
Severe low back pain usually comes on suddenly and caused by a minor movement such as bending over. The pain may increase over a couple of hours as inflammation develops. The pain is usually in the lumbar area of the spine but can radiate into the buttocks.Patients who have chronic or long standing back problems can often suffer from bouts of acute low back pain.
What can be done for acute or severe lower back pain?
The patient is usually encouraged to get into a position of least pain. Suitable positions may be lying on the back (supine), on the front (prone) or on the side. Whatever the most comfortable position for the patient is best.
If it hurts don’t do it. Avoid movements or positions that make the pain worse.
Bed rest may help but not for more than two days as resting for too long can make back injuries worse. Often movement is needed after the initial pain and inflammation has gone.
Taping the lower back can relieve pain and give support, as can use of a specialist back support belt or back brace.
The doctor may prescribe NSAID’s (non steroidal anti inflammatory drugs) to relieve pain and muscle spasm.
Electrotherapy can be used to relieve pain. For example TENS (electrical stimulation) or magnetic field therapy or ultrasound therapy may be helpful.
Avoid sitting in the same position for long periods of time.
Very light massage techniques may help reduce pain.
Use of an inversion table to apply gentle traction may also help relieve symptoms.
Once the severe back pain symptoms have gone then the patient is usually treated as if having mild to moderate back pain and more intensive treatments can be started.
Mild or moderate low back pain
Mild or moderate lower back pain is the type of pain that would be associated with chronic or long term back problems. Longer term back pain is usually caused initially by an injury, usually to the joints in the back but over time other structures in particular soft tissue such as muscles contribute to the pain.Muscles will tighten up in response to a back injury and if left they can tighten weaken or adaptively shorten causing changes in posture or movement which then also make the condition worse.
Symptoms of moderate low back pain
- An aching pain that may be constant or come and go.
- Pain may be on either side, both sides or in the middle. A common complaint is that the pain is in a band all the way across the lower back.
- There may be pain in the buttocks or hamstrings as well.
- A reduced range of motion.
- The ‘slump test’ may increase pain or show restricted movement.
- Tenderness over the spinus processes.
- Hypo mobility (lower than normal mobility) in one or more of the intervertibral segments.
- Muscle spasms in the lower back and buttocks.
Treatment of mild to moderate low back pain
- IIdentify possible causes including:
- Hyperlordosis (increased curve in the lower back)
- Scoliosis (an S shaped spine)
- Poor posture while sitting.
- Poor posture while standing.
- Pelvic instability.
- Bad lifting techniques.
- Sleeping in a bed that offers poor support.
- Reduce pain and inflammation through ice, NSAID’s, electrotherapy and rest.
- Restore full range of movement.
- Increase flexibility and strength.
- Return to full sports specific fitness.
Because there are so many causes of back pain and so many back pain conditions and injuries no single treatment programme is going to work for everyone. Some methods may work best for some people, most would benefit from a combination of treatment methods and approaches.
REHABILITATION
The following guidelines are for information purposes only. We recommend seeking professional advice before beginning rehabilitation.
Aims of rehabilitation:
- Reduce pain and swelling.
- Modify activities to reduce stress on the lower back.
- Improve mobility and flexibility of the back.
- Strengthen any weaknesses.
- Reducing pain and swelling
If you have suffered a sudden sharp onset of pain then treat the injury as acute. Apply ice or cold therapy for 15 minutes at least 3 times a day. This can be increased every hour for the first 3 to 5 hours following injury if possible.
Rest. If necessary in bed but bed rest for more than a day or two will cause significant weakening of muscles and is to be avoided if possible.
Try and assume a position or posture that is not painful. The psoas position may be comfortable (lie on your back with your feet resting on a chair or similar so the knees are at 90 degrees).
The acute stage of this injury may last up to 48 hours if you have looked after yourself. If not it may be longer.
After the acute stage (usually 48 hours) wear a heat retainer or lumbar support.
Modifying activities to reduce stress on the lower back:
- Many back injuries are not caused directly by sport but by every day activities such as sitting badly or lifting with poor technique. Poor sporting technique needs to be identified.
- Sitting in a slouched position may feel comfortable but it is taking the stress off the back muscles and onto the ligaments. Eventually the ligaments will become damaged. Always try to sit upright with a natural curve in the lower spine rather than slouching to flatten the lower spine.
- When lifting heavy objects try to bend the knees rather than the back. Contract the stomach muscles when lifting and try to keep the shoulders and back upright rather than bent over. Again, try to maintain a natural curve in the lower spine. The spine is far stronger when in its natural position.
- If you compete in a technical event that puts stress on the spine then ensure
- You use the correct technique.
- See a good coach if you haven’t already done so.
Improving mobility and flexibility:
If you have suffered a back injury in the past, muscles are likely to go into spasm, weaken or tighten up. In addition there may be scar tissue where the injury has healed. The scar tissue will be inelastic. The result of all this may mean an imbalance of muscles in the back resulting in further problems. It is important to improve the mobility of the spine and flexibility of the muscles involved and return them to their original condition.
Mobility exercises can begin as soon as pain will allow.
Exercises should be done 3 times a day for the first 5 days of rehabilitation and at least on a daily basis after that.
Strengthening exercises:
Strengthening exercises can be done on a daily basis as soon as pain will allow. If it hurts to perform them, do not continue. This may be 48 hours after injury or up to a week or more depending on severity.
It is important to identify any particularly weak muscles. A good sports therapist / equivalent can advise as to which muscles need strengthening in particular.
In general the abdominal muscles or stomach muscles are usually in need of strengthening. Good abdominal strength can take up to 30% of the stress off the lower back.
Other exercises to strengthen the lower back muscles are also important but strengthening the back muscles in isolation when they are already tight can only increase problems long term.
Increase the intensity or number of repetitions of each exercise gradually, when you can comfortably manage the current workload. There is no need to increase every day!
Strengthening exercises should be combined with mobility and flexibility exercises and continued long after you feel the injury has healed.
