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The Management of Back Pain

This affects all of us.  You don’t have to be an athlete to suffer with back pain.  Sometimes, though, just having that basic information and knowing what to do about it can be a big help... 

As with all injuries, however, the importance of taking medical advice cannot be over-emphasised.  If there is any doubt at all, then it’s better to actually go to see a doctor, physician or even visit the nearest hospital.

On the following pages we will discuss:

  • Why the correct examination and diagnosis is vital in the management of lower back pain
  • Conditions that MUST be excluded in the initial examination
  • Basic anatomy
  • Injury to an inter-vertebral disc or facet joint
  • Dealing with sciatic pain
  • Related conditions:  Sacro-iliac pain
  • Postural considerations in the management of back pain


There are many types of back pain; and although most are able to be routinely treated and managed, it is essential to exclude the presence of any serious underlying pathology.

There’s nothing wrong with taking professional opinion so please don’t be afraid to do so.


The whole topic of back pain is huge nowadays.  From the sportsperson to the manual worker to the office staff, back pain is a common problem.  

Covering a broad spectrum of injuries ranging from a single specific incident or repetitive actions, to back pain of a non-specific origin, injuries to the spine and supporting muscles are common problems that can affect anyone. 

Treatment clinics are everywhere and back injuries are among the most common problems seen in a clinical setting today.  However, sometimes the treatment of back pain might not be as straight-forward as it seems. 


It is essential to exclude the presence of any serious underlying pathology.  There’s nothing wrong with taking professional opinion so please don’t be afraid to do so..

 
Correct examination and diagnosis is vital in the management of lower back pain

It is dangerous to assume that every incidence of lower back pain is simply that; since there are so many other medical conditions that can masquerade as simple lower back pain. 

Consequently, there are several conditions that MUST be excluded when dealing with lower back pain.  These are commonly referred to as ‘red flags’ and include:

  • A history of cancer   - either in yourself or in your immediate family
  • Sudden and unexpected weight loss
  • Night pain; and / or unexplained pain at rest -particularly at night


In any examination, therefore, these have to be excluded by simply asking the appropriate questions to establish whether or not any or all of three are present.

If any of the answers are unclear, then further investigation should immediately be instigated by the examining physician or treating therapist.

Sudden and unexplained weight loss is where this occurs rapidly as opposed to through dietary or exercising leading to weight-loss for example, and can be a sign of underlying pathologies that may require further investigation.

A history of cancer is self-explanatory.  Night pain refers to when the symptoms are unexplained; as opposed to simply turning over in bed and aggravating an injury. 

Night pain tends to occur when the body is at rest; and an important differentiation to make is whether the pain actually wakes you up and forces you to change position; or whether it is the actual movement that leads to the pain.

It cannot be over-emphasised that the above are all conditions that MUST be excluded by the examining or treating medical professional where lower back pain is concerned. 

The examiner should also establish whether numbness, tingling or pins and needles are present; whether there are any problems with bladder or bowels, and whether the legs appear to ‘give way’.

Additionally, a neurological examination assessing reflexes, skin sensation and power should also be conducted on the initial assessment; together with establishing whether pain is localised to one specific region or is being referred from an intervertebral disc into the buttocks and leg.

One important question that should be asked relates to the feeling of numbness or altered sensation in the groin; similar to that experienced when you have been sitting on bike for a long while for example.

This is referred to as ‘saddle anaesthesia’ and can point to the presence of underlying conditions requiring further investigation.

Cauda equina syndrome is one of these.  This is a serious condition requiring immediate and urgent medical attention arising from compression of the nerves at the base of the spinal cord and is a medical emergency. 

Symptoms of cauda equina include bladder / bowel dysfunction, severe pain in the lower back, numbness, tingling and weakness, and / or the saddle anaesthesia referred to above.

Again, if there are any doubts over the presence of any of the symptoms referred to above, further medical opinion should be sought without delay.

Additional underlying conditions accompanying (or presenting as) lower back pain include cancer of the spine, spinal infection, fractures, visceral disease, haemorrhaging, cauda equina compression and spinal tuberculosis.

Again, the presence of any of these need to be excluded without delay.  Glibly stating that having a bad back is only to be expected because ‘you are no longer a teenager’ is dangerous and is totally irresponsible.  It happens, though, and this is something that needs to change.

Similarly, it is dangerous to assume that the presence of lower back pain is easily explained by a client being overweight; since often an increased body mass (BMI) is the result of not being able to exercise due to the presence of lower back pain in the first place!

So having a ‘bad back’ might well be more than just a simple case of lower back pain; hence the need to be thorough in all aspects of examination and assessment.  Initiating deeper and further investigation if deemed appropriate remains preferable to the alternatives.



Basic anatomy of the Spine:

The spine is formed of 24 moveable interlinking vertebral bones connected by strong ligaments together with deep and superficial muscles. 

Of the different sections of the spine, there are seven vertebrae in the cervical region, twelve in the thoracic region, and five in the lumbar spine.  Cervical vertebrae are numbered from C1 to C7, thoracic from T1 to T12, and lumbar from L1 to L5. 

The lowest lumbar vertebrae, L5, then articulates with the immovable uppermost part of the sacral bone to form the L5 – S1 joint; which is an area of the lumbar spine that is particularly susceptible to injury.

Each vertebrae interlinks with the vertebrae above and below via the facet joints and are connected by strong muscles and ligaments.  Nerves pass adjacent to the facet joints and can easily become irritated resulting in pain and stiffness.

The vertebrae are separated at each level by the intervertebral discs, which are essentially fluid-filled shock absorbers which can swell and ‘bulge’ if injured or damaged. 

In the older population, the inter-vertebral discs begin to lose their fluid content as part of the natural ageing process, thus leading to a susceptibility to injury.  Since dehydration of the discs is associated with the ageing process, this results in a reduced cushioning effect and adapted movements through altered biomechanics.

Since the inter-vertebral discs are basically water-filled shock absorbers which take the impact translated through the spine from the lower limbs, these can swell or bulge as described above; either independently or as result of associated muscle spasm.  ​   

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On the next page we look at some common injuries and conditions affecting the lower back..​.

              
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