Back pain

Sciatica

Back pain is sometimes linked with pains in the legs, called sciatica. The sciatic nerve runs from the spine to the leg and pain can be felt anywhere from the buttock to the big toe. Sciatica can be caused by a 'slipped' or prolapsed disc in the spine, which may press on a nerve, causing pain that can take six weeks or more to settle down. You may also notice weakness of the muscles in your leg. If you lose bladder or bowel control, you should see your doctor urgently as this may indicate a more serious problem.

Spondylosis

Persistent back pain sometimes occurs with arthritis of the facet joints and degeneration of the discs. As we grow older the discs in the spine become thinner and the spaces between the vertebrae become narrower. Spurs of bone (osteophytes) may form at the edges of the vertebrae and facet joints. This usually affects the lower back (lumbar spondylosis) or the neck (cervical spondylosis). These changes are very common and can sometimes cause back pain, though they may not cause any pain at all.

Spinal stenosis

Occasionally back pain is associated with leg pain that comes on after a few minutes' walking. This may be caused by spinal stenosis – the narrowing of the spinal canal caused by osteophytes, a prolapsed disc and/or thickening of one of the main spinal ligaments. This causes squeezing of the spinal cord or nerves.

You will probably feel pain in the thigh or the lower leg. You are also likely to have either numbness or pins and needles. Symptoms often affect both legs but one may be worse than the other. The pain usually eases after rest, and some people have less discomfort if they walk a little stooped.

Very rarely, spinal stenosis can result in loss of bladder or bowel control; if this happens you should see your doctor straight away.

Other causes

Other causes of back pain include:

• bone problems such as a fracture – often linked to thinning of the bones (osteoporosis)
• infection
• a tumour
• inflammation, as in ankylosing spondylitis, where the spinal ligaments may harden (calcify), forming new bone which may eventually cause the vertebrae to join (fuse) together.

Symptoms similar to spinal stenosis can be caused by narrowing of the arteries in the legs, but this is a very different condition that requires different treatment, so your doctor will need to rule this out. A CT or MRI scan will show if there is any narrowing of the spinal canal or thickening of the spinal ligaments.

If you have severe or persistent back pain your doctor may recommend a combination of the following treatments:

• exercises to improve strength and flexibility, or a physiotherapy programme tailored to your needs
• therapies including transcutaneous electrical nerve stimulation (TENS), hot packs and acupuncture – which can help with pain relief
• manipulation (most often carried out by chiropractors and osteopaths), which may include gentle or more vigorous movements and can help to clear up a spell of back pain
• injections or drug treatments
• attending a pain management programme
• surgery – rarely needed (probably in less than 1% of all cases of back pain).

For severe sciatica, your doctor may suggest an injection into the tender area, or into the space around the spine, or the facet joints. Sometimes x-ray images are used to allow more precise placement of the needle.

Your doctor may recommend low-dose amitriptyline. And occasionally, drugs such as gabapentin or pregabalin may be recommended. These drugs work by relaxing the muscles and reducing nerve irritation. They may need to be taken for six weeks initially and sometimes longer. As with all drugs, there can be side-effects, so they will not be suitable for everyone; you should discuss this with your doctor.

Surgery

Surgery isn't needed for most back problems. An operation may sometimes be needed for spinal stenosis or for severe sciatica to remove a large piece of slipped disc that is pressing on a nerve, although most doctors would recommend trying other measures first – including physiotherapy or injections. Urgent surgery may be needed if you lose bladder or bowel control.

Most back pain improves with simple measures, and the following advice should also help to prevent back pain becoming persistent:

• Don't rest for too long – muscles and bones will become weaker the longer you are inactive. Avoid the most painful activities at first, but increase your activity level gradually and get back into your normal routine as soon as possible
• Painkillers such as paracetamol or ibuprofen can be taken regularly for the first few days, or they can be taken before exercise so that you can get moving again without too much pain. Don't wait until the back pain is very bad before you take the painkillers.

In the longer term, think about what you can do to reduce the risk of further back problems:

• Start some specific back exercises and aim to be more active generally. Regular exercise will strengthen the muscles that support your back and reduce the risk of further problems.
• Learn to lift things correctly – when lifting something from the floor, keep the weight close to your body and bend your knees.  
• Avoid bending over for long periods.
• Try to maintain good posture when sitting at home, at work, or in the car.
• Find ways of dealing with stress – stress leads to muscle tension which can cause or increase pain.
• Keep to a healthy weight – this will reduce back strain.
• Don't smoke – it makes exercise more difficult and hinders the healing of body tissues. 

Exercise

It can be tempting to avoid exercise because of back pain. Yet exercise is the most important way you can help yourself if you have back pain. Inactivity will mean that muscles become weaker and your back will be less able to withstand the knocks and jolts that are part of daily life. So what started as a simple strain can turn into a persistent problem. Starting some gentle exercise at an early stage can help to prevent this vicious circle.

Another reason for exercising is that physical activity releases endorphins – 'feel-good' hormones which act as natural painkillers. And exercise can also help you lose weight or maintain a healthy weight, which will reduce the strain on your back.

The three main types of exercise are:

• stretching exercises for the back and leg muscles – to improve flexibility
• strength, stamina and stabilizing exercises for the back, stomach and leg muscles
• exercise to improve your general fitness – any exercise that makes you out of breath.

Stretching exercises

Strength, stamina and stabilizing exercises

A physiotherapist may give you specific back exercises to do, but can also adapt exercises to suit your needs – for example, if you have joint pains in other parts of your body. A physiotherapist will also be able to advise you if you are thinking of taking up a new sport or activity where the right training or technique may be crucial to avoiding injury.

It's normal for your back to feel a bit sore for the first few days of exercise, but don't give up. It's important to exercise regularly to keep your back in good health. Taking some painkillers before exercising can help to overcome any early difficulties.

Diet and nutrition

There are no particular diets that have been shown either to help or prevent back pain. However, if you are overweight you should consider a weight-reducing diet and exercise that will help you to lose weight. This will reduce the strain on your back.

Pain management programmes

A pain management programme may help you to control and live with your pain. Exercise and regaining your physical confidence are important aspects of the pain management approach, along with learning about the physical and psychological factors that contribute to pain. Pain management programmes are generally outpatient group sessions. They are usually run by a team of health professionals, often led by a physiotherapist.

There are also a number of self-help groups who can advise you on managing your back pain.

• BackCare runs local group meetings with exercise classes and discussions
• The Pain Relief Foundation provides a range of useful resources
• The Expert Patient Programme provides education and support – contact your Primary Care Trust for details.

Supports, aids and gadgets

If you have long-standing back pain you may need to change the way you do things. If you enjoy gardening try using long-handled tools to avoid too much bending. A variety of gadgets are available to help with jobs around the home. Visit your local Disabled Living Centre or ask an occupational therapist for advice.

Back supports to lean against can help your posture when sitting at home, at work, or in the car. We don't recommend corsets – it's better to strengthen your back by doing exercises than relying on corsets.

Sleep

Many people with back pain feel that a medium-firm mattress gives better support. A mattress that sags will tend to strain your back. However, the mattress should be soft enough to mould to the shape of your body at the shoulder, waist and hip, as well as being firm enough to support your spine.

Work and back pain

We recommend that you try to stay at work, or get back to work as soon as possible, though this will depend on your circumstances and the demands of the job. Discuss any difficulties with your foreman or manager.

If you need further support to continue in your job, a Disability Employment Adviser can usually help – either with work assessment or retraining. Simple adjustments to your workplace may be all you need. You can contact an adviser via your local Jobcentre Plus office.