Managing Back Pain

General Medical

Dr. Sam Hay

Serious pathology in patients presenting with low back pain includes malignancy, spinal fractures, cauda equina syndrome (CES), infection or aortic aneurisms. Spinal malignancy and vertebral fracture are the most frequent serious pathologies of the spine. If you’re an Aussie, then you’re almost certain to suffer a bout of back pain at some stage in your life, in fact 80% of us do. It’s just far too common, associated with more global disability than any other condition. 

The back is a complex region. Lots of bones, ligaments, tendons and muscles are carefully packed together to provide the central ‘core’ that holds us up. The back is involved in every movement we make - every step, twist, reach, or lift we do. It’s no wonder it gets injured so often!

But it’s the complexity of the whole back region that makes diagnosing the exact cause, and then targeting treatment all the more challenging for health professionals. Is it a slipped disc?  A pinched nerve? A strained muscle or a twinged ligament?

Or does it have nothing to do with the back itself?

Thankfully, there’s a different way to look at it. Most of the time, it doesn’t actually matter what the exact underlying issue is. Most of the time, we can manage back pain in roughly the same way – focusing on a more global approach, rather than drilling down to treating one exact problem.

Waving the red flag

Whilst most of the time the exact diagnosis isn’t a priority, sometimes it is.

So what should we look out for and when should we be alarmed? If you’re wincing with your ‘bad back’ and any of these pop up, then you need to see your doctor pronto.

  • Major trauma - This seems obvious, but if you’ve got a sore back after a fall, car accident, or sporting injury then a fracture needs ruling out.
  • Fever - Onset of back pain with general body aches and fevers could indicate an infection. Blood supply into the vertebrae is not great, so infections here can be hard to treat. They can be more common after serious infections elsewhere in the body too. Taking drugs that suppress your immune system? Then your risk is even higher.
  • Redness or swelling over the back - Once again an infection could be looming.
  • Cancer history - The reality is many cancers can spread, and bones like the vertebrae or lower ribs are common sites for cancer metastases. So if you’ve had a nasty cancer in the past, check with your doctor about the need for special scans.
  • Sudden weight loss - Back pain with weight loss could point to a cancer issue unfortunately.
  • Loss of bladder or bowel function - If the nerves to the bladder or bowels are affected then people can find it hard to empty, or even the opposite – they lose control. This can occur slowly with some conditions, or rapidly with the dangerous cauda equine syndrome. Either way, it’s an emergency.
  • Numbness in the ‘saddle area’ - Can’t feel your bum? Then this could be bad news – another symptom of the dangerous cauda equine syndrome.
  • Numbness, tingling, and weakness below the knees - These are the classic symptoms of a ‘pinched nerve’. The spinal nerves exit the spine at each level, supplying the muscles and skin down the leg in an ‘onion layer’ like pattern. When pinched, symptoms occur where the nerve goes. Classically people feel shooting sharp pains, or maybe a dull background ache. Tingling or pins and needles may also occur in the same region, plus people might have trouble walking due to muscle weakness. The lowest discs, joints and nerves are the most likely to be effected – which means people suffer these symptoms below the knees.

So what can most people do?

My first advice is to seek out a bloody good GP who can coordinate a rehabilitation treatment plan for you. Once you’ve had a good think with your doctor and ruled out the red flag issues, then you're most probably going to fall into the big bunch of back pain sufferers where we can manage back pain in roughly the same way. The bulk of evidenced based treatment options available to you require hands on therapy -and that means you will a good allied health provider who specialises in musculoskeletal rehabilitation.

But who to choose? 

I prefer the physiotherapists, however, there are a good number of chiropractors and osteopaths out there who can offer evidence based care as well. Any of these experts will be able to provide a full assessment and tailor a management plan for you – drawing on the wide range of treatment options. At the core of any management plan will be the need to address underlying postural, strength, flexibility, and endurance issues with how your back and overall body works.

So just what is proven to help?

There are numerous ways to skin a cat, and managing back pain is no different. But there are a number of methods that have been proven to work, and many that haven't.

  • Multidisciplinary rehabilitation - Many cooks make light work, and that certainly applies to managing back pain. Seeing a team of people who tailor a program for you is proven to be highly effective for managing back pain. Each program will draw on elements of the options below. Your GP should be able to point you in the right direction, but many local rehabilitation hospitals, physiotherapists, and even gyms offer these services – do some googling!
  • Exercise - There's good evidence that a consistent exercise regime is effective for managing back pain. Your physio or exercise physiologist can help tailor a program for you, but swimming and walking are definitely on the list.
  • Local hands on therapy - Whilst evidence can vary from low to moderate effectiveness, we do know that in the right hands massage and focussed joint mobilisation are effective treatment options for you. The big 'whacks and cracks' that you hear some therapists perform can be dangerous for some, so be wary if they're being offered, especially as the only treatment option...
  • Psychological support including mindfulness strategies - Pick a well trained therapist such as a psychologist and these strategies can be incredibly powerful, and thankfully the evidence supports this. At the very least, download some mindfulness apps to your phone, or choose a well respected book from the bookstore. However, practice makes perfect – it's something you really need to repeat regularly to have effect.
  • Acupuncture - Unfortunately evidence is limited, but there seems to be some benefit.
  • A bit outside the box - There's a small amount of evidence that tai-chi is effective, and a moderate amount of evidence that yoga can help your back pain. These strategies certainly incorporate other health advantages, particularly with regard to practising mindfulness.

At the end of the day, there are a number of treatment options you can choose from. When we look at all of these, the magnitude of pain benefit is generally small to moderate, and generally only for the short term. When we consider their ability to help you return to a normal day’s activity ('function') – the overall effects of all these modalities is a bit worse.

Can my mattress help?

There are many out there who believe that certain mattresses can help their back pain, with hard mattresses commonly believed to have a positive therapeutic effect. The term “orthopaedic mattress” was “invented” in the seventies after a survey of Orthopaedic Surgeons – but it doesn't actually have a medical meaning or defined standard. Mattress companies make big bucks from advertising and marketing their products, claiming endless medical benefits with little more than anecdotal evidence in the form of customer quotes.

It's estimated that 30% of mattresses are sold for 'back pain'. Looking at the cold hard facts, we are still truly unable to advise patients on what is the best mattress, or even if mattresses have any real effect in the first place! Maybe a medium-firm mattress is better than a firm mattress, but even that research was sketchy.

So will anything actually work to prevent back pain?

The only methods currently proven to work to prevent back pain in the first place are regular exercise, or exercise plus education. By education, we mean regular attention to lifting and exercise techniques that reduce unnecessary strain and load on the back. Other interventions such as back belts and innersoles for your shoes are useless.

What about standing desks?  

More research is required to answer the question about standing desk effectiveness – but we are at least pretty sure they will do no harm.

The low down

Managing back pain for most needs time, a team approach, and above all a tailored plan that suits you individually. Start with your GP who can help you rule out those red flags, plus steer you in the direction of allied health specialists that can provide good quality and evidenced based treatments.

BMedSci, MBBS(Hons), FRACGP, GDipSpMed, DCH
Director Your Doctors®


Please note: Dr. Sam's blog is general advice only. For further information on this topic please consult your healthcare professional.

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