By Dr. Dineshani Hettiarachchi Sirisena Low back pain is extremely common and experienced by people of all ages. If you have low back pain, you are not alone. About 80% of adults experience low back pain at some point in their lifetime. It is the most common cause of job-related disability and a leading contributor to missed work days. As we celebrate Backcare Awareness Week in October, we spoke to University of Colombo Faculty of Medicine Department of Allied Health Sciences senior lecturer Dr. Romain Perera (MBBS, PhD). Low back pain was responsible for 60.1 million disability-adjusted life years in 2015, an increase of 54% since 1990, with the biggest increase seen in low-income and middle-income countries. Disability from low back pain is highest in working age groups worldwide, and is especially concerning in low-income and middle-income countries where informal employment is common and possibilities for job modification are limited. According to Dr. Perera, most episodes of low back pain are self-limiting and resolve in less than three months with little or no consequences. However, for some patients (23%), recurrent episodes are common and recurrences may persist throughout their lifetime. It is a complex condition affecting all aspects of life with multiple contributions in the form of psychological, social, and biophysical factors. Symptoms of low back pain Symptoms range from a dull ache to a stabbing or shooting sensation in your lower back and/or buttocks. Sometimes, the pain may spread down the legs. The pain may make it hard to move or stand up straight. Acute back pain comes on suddenly, often after an injury from sports or heavy lifting. Pain that lasts more than three months is generally considered chronic. Causes of low back pain Acute low back pain is mainly caused by mechanical damage to spinal structures or surrounding tissues such as muscles and ligaments (strains and sprains). The damage may be caused by activities such as awkwardly bending, heavy lifting, and hard pulling that twist the spine. However, even normal daily activities such as sitting, standing, and carrying a normal backpack can strain your back if you continue to engage in the same activity for a prolonged time, day after day. The risk increases with incorrect posture and heavy loads. Acute low back pain may resolve gradually over a few weeks. However, acute pain may progress to a chronic state if the damage to the spinal structure continues or if the damaged tissues do not get enough time to heal. Chronic low back pain often becomes complex with the involvement of unfavourable psychosocial and biophysical factors. Usually, it is difficult to identify the specific cause for the pain once it becomes chronic. Sometimes, back pain may be related to a pinched sciatic nerve due to a herniated disc (slipped disc). Such pain is called sciatica and typically radiates from the lower back down the back of the thigh and calf. The degree of the pain may vary from mild to excruciating, which feels like an electric shock when you cough, sneeze, bend, or sit for a prolonged time. Mild sciatica gets resolved with time. Sometimes, severe sciatica is accompanied with numbness and muscle weakness of the leg, and difficulty in bowel and bladder control. There are some serious causes of chronic low back pain which need immediate identification and management. Malignancy, vertebral fracture, infection, or inflammatory disorders such as axial spondyloarthritis are the main ones, but are seen in only a small proportion of cases with low back pain. Risk factors of low back pain

• Increasing age
• Female gender
• Overweight and obesity
• Lack of exercise
• Smoking
• Psychological factors such as depression and fear avoidance (fear of pain leading to avoidance of activities)
• Chronic diseases such as diabetes, asthma, and hyperlipidemia
• Heavy physical work
• Incorrect posture while sitting, standing, walking, and lifting

When to see your doctor

• If the back pain is severe and does not improve with self-care measures
• Severe back pain after a fall or injury
• Pain spreading down one or both legs, especially below the knee
• Pain associated with numbness or weakness of the leg muscles
• Loss of bowel or bladder control
• If the patient has a history of cancer, osteoporosis, steroid use, or excessive drug or alcohol use
• Unexplained weight loss
• Back pain associated with fever

Diagnosis of low back pain Your doctor will ask you a series of questions and carry out a thorough physical examination to assess the problem. The assessment is targeted at identifying the underlying cause for the pain and excluding serious causes of chronic back pain. The severity of pain, impairment of body functions, limitation in carrying out daily activities, and restrictions on participating in social and work-related activities will be assessed. Routine imaging (X-ray or MRI of lumbar spine) is not recommended unless there is a strong suspicion of a serious condition (progressive neurological symptoms, spine fracture, malignancy, spinal tuberculosis, etc.) causing the back pain. The radiological features of disc degeneration and disc herniations are common findings even in people without back problems and so are not the best way to explain your back pain. Treatment Treatment may vary depending on the severity of the problem.

• Remain active and take advice from your doctor on the nature of the back pain and self-care measures. These are beneficial in both acute and chronic back pain
• You may need specialised exercise therapy and cognitive behavioural therapy, especially if you do not respond to self-care measures
• Drugs are prescribed for pain relief, but should be taken as prescribed under close supervision of the doctor
• Physiotherapy might also help in relieving the pain
• Surgery as treatment is recommended in a limited number of cases and is usually offered only in certain serious conditions leading to severe disability

Self-care measures

• Avoid bed rest, stay active, and continue with the usual day-to-day activities
• Cold packs can be used to relieve pain in the initial two to three days after getting the pain by placing on the area for up to 20 minutes several times per day
• After two or three days, heat therapy can be used to relieve pain. Some safe effective options are hot showers or baths, warm compresses, hot water bottles, heat wraps, and heating pads
• Application of topical pain relieving gel, cream, or ointment
• Maintain good posture while standing, walking, and sitting
• If pain increases despite these measures, contact your doctor or physiotherapist

Prevention You can prevent back pain by improving your physical fitness and maintaining the correct posture and movements.

• Exercise regularly – low-impact aerobic exercises such as walking and swimming can increase overall strength and endurance. Special abdominal and back muscle (often called core muscles) exercises can strengthen your core, which acts like a natural corset for your back. Flexibility exercises involving your trunk, hips, and thighs improve balance and stability. It is always better to get advice from your doctor or physiotherapist when selecting the best exercises for you
• Maintain normal weight for your height (body mass index: 18.5-23 kg/m2) – if you are overweight or obese, you may need to start diet control and regular exercises to reduce your weight
• Maintain good posture – good posture reduces the strain on your back. When standing, don’t slouch; keep your head straight and your shoulders and back and relaxed, pull in your abdomen, keep your feet about hip-distance apart, balance your weight evenly on both feet, and keep your legs straight but knees relaxed. When sitting, don’t hunch your back or stick your chin forward. Keep your neck straight and tuck the chin in. Keep your shoulders relaxed and back straight. Keep the elbows at the sides making an L-shape with your arms. You may need to choose a chair with an adjustable seat with good back support and an armrest. You can place a pillow or a backrest in the lower back region if your back does not comfortably meet the chair. Keep your knees at the same level as your hips or slightly lower. Keep the feet flat resting on the floor or on a footrest. Avoid standing or sitting for a long duration and change your position frequently, at least every half-hour Lift safely – plan the lift and do not lift or handle more than you can manage. Get help if you need to, especially for heavy loads. Keep your back straight while lifting and let your legs do the work. Keep the load close to your waist and keep a good hold of the load while maintaining a stable position without twisting.

Take home messages

• Low back pain is a disabling condition. Although most low back pain resolves over time with proper self-care measures, some patients experience recurrences despite the treatments.
• Routine X-ray/MRI scans of the lumbar spine is not recommended in diagnosing back pain
• It is difficult to identify a specific cause for most chronic pain and lifestyle modifications are helpful in managing pain
• Regular exercise, maintaining normal weight in correspondence to the height, and maintaining good posture can prevent low back pain

About the writer The writer, Dr. Dineshani Hettiarachchi Sirisena, is a family physician with a special interest in rare genetic diseases and regenerative medicine currently working as a lecturer at the Department of Anatomy, Faculty of Medicine, University of Colombo, Sri Lanka.