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Low Back
Pain : The Disease Burden

Low back pain is the commonest symptom reported in an
orthopedic out patient department. With 80%-90% of the general population
facing the problem at some point in their lives, it significantly affects DALY
i.e disablility adjusted life year of the population as a whole. Low back ache
also accounts for the commonest cause of disability in population below 45
years of age , thus affecting the major workforce group. Apart from the
disability burden Low Back Pain significantly contributes to the financial
burden , accounting for almost 20-40 billion USD per year.  

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Types of Back

Common types of back pain include:


• Acute back pain

An episode of sudden onset pain usually associated with
bending the back with a jerk or lifting heavy objects. Most common cause of
acute back pain is a strain or sprain of the muscles or the ligaments
supporting the lower back. The pain, although is predominantly experienced in
lower back region  but spreading to the
buttocks or front and back of thighs is not uncommon and many sufferers also
experience spasms. This kind of pain generally responds to rest and muscle
relaxants which should be followed by gradual muscle stretching and strengthening
exercises of the back.


 • Chronic persistent back pain

This type of back pain follows an indolent course gradually
increasing in intensity. When back pain persists beyond four to six weeks
despite rest, physical therapy and analgesics, further medical evaluation may
be required. This pain is often originating from the joints between the
vertebrae, discs or supporting muscles of the back. In a few cases, cancer or
an infection may be found.


Causes of
Low Back Pain

The spine is made up
of a number of special type of bones also called the vertebrae. These vertebrae
have a cushion between each vertebrae called the intervertebral disc and are
connected to each other by very strong ligaments and joints also called facet

Lumbar spine or the lower back is the most commonly affected
part of the spine as it bears the maximum part of the body weight. One of the
most common causes of low back pain is overstreching i.e strain or sprain of
the muscles or ligaments supporting the lower back. Muscles and ligaments can
be injured by incorrect posture while lifting weights or even sitting and
standing in a particular posture for a long duration. Muscles in the back or
abdominal muscles can also become weak from lack of exercise. Engaging in
sports that involve actions such as push and pull without adequate muscle
training and warming up eg. Weightlifting, boxing, gymnastics may increase the
risk of a injury to the lower back.




Other causes of low
back pain include:


•     Obesity

“Slipped” disc, caused when a disc between
vertebrae bulges past the bones and presses against  a nerve

•     Osteoporosis (deterioration
of the quality of bone leading to thinning of the bone)

Canal stenosis i.e compression of the spinal
cord due to overgrowth of supporting ligaments and   joints

•     Osteoarthritis,
a breakdown of the tissues or bones of the joint between the two vertebrae

•     Fibromyalgia, with
painful tender or trigger points, among other symptoms

•     Trauma from
injury due to an accident or fall that causes a fracture or soft tissue injury

•    Other serious
causes such as cancer or infection



Low Back Pain : Management

Prevention of low back pain by careful modification of
activities of daily living and adequate strengthening of lower back and abdominal
musculature is of utmost importance for the management of low back pain. The
common old notion of advising rest in every cause of back pain is not advisable
any more as it may even worsen the pain. Staying highly active and continuing
your day to day activities while avoiding overexertion is the best way to deal
with the common causes of low back pain.


How to keep your back healthy ?

Spine health is not just a few do’s and dont’s at the work
place but a round the clock process. We have tried to elaborate a few healthy practices
to be kept in mind while performing the activities of daily living aimed to
maintain the spine healthy.







correct sitting and standing posture during day to day life is of utmost
importance to prevent early degeneration of spine , thus leading to low back



Support your back

One of the most common causes of sitting
related back pain is lack of adequate support to your lower back. Make sure
that your lower back is well supported specially for students and in jobs
involving long sitting hours. Addition of a lumbar support is advisable. A
correctly adjusted chair will reduce the strain on your back. Adjustable chairs
which allow adjusting the height, back position and tilt are very useful. Your
knees should be bent lesser than 90 degrees and feet resting flat on the
ground. Use a footrest, if it feels necessary.



Take regular breaks

Avoid sitting in the same position for long hours.
Practice the rule of 10 mins of walking after every 50 minutes of sitting
wherever and whenever practicable. Sitting in the same position for long
periods puts excessive stress on a certain set of muscles of the back without
allowing adequate rest. Make sure you change your posture as often as is
practicable so that the fatigued muscles get adequate time to recover while
other muscles take over. Frequent short breaks are better than fewer long ones.



Ensure the seat is firm

Sitting on a soft couch or a sagging chair exerts high
levels of stress to the back  although it
may feel comfortable. A firm seat giving support to the lower back will not
just reduce the stress levels on the lower back but also help maintain the spinal
curvature thus, improving the sitting posture.



Posture tips for
laptop users

Although laptops
being portable and light provide a ton of benefits but the very same qualities
of a laptop promotes poor posture and harmful practices eg. using a laptop
while lying down on a bed or a sofa. Wherever possible use a detachable
keyboard and mouse so the laptop can be put on a height and the screen kept at
eye level. Using your keyboard on a stable base where there is support for your
forearms and elbows is advisable rather than keeping your elbows in your lap. Adopt good sitting posture with lower back support, and ensure
other desk equipment like stationary, telephone etc.  is within reach to avoid excessive bending of
your back to reach them.


Avoid wrong sitting

sitting habits are generally adopted to compensate for inappropriate chair
size, shape, support or tilt. Habits such as sitting with a foot kept under the
buttock, sitting on the edge of the seat in order to allow your feet touch the
floor or sitting with your feet dangling to be able to reach the back rest for
support should be avoided.


Standing posture

posture is as important as sitting posture. Humans being bipedal are more prone
to spinal degeneration as lower back bears the major weight of the body. While
standing excessive stooping as commonly seen in tall individuals or excessive
arching of the back should be avoided as shown in the figure below.




Lifting and handling weights

Lifting of heavy weights with an incorrect posture is one of
the commonest causes of low back pain. Learning and applying the
correct method for lifting loads can help prevent injury to the back and thus,
avoid back pain. The important points have been discussed here.



Think before you

Planning the
lift especially when the load is heavy is advisable. Your physical limits
should be kept in mind while making a lift. Divide heavy loads into multiple
smaller loads if possible. Remove distractions, such as plastic wrappers or
discarded papers from around the load. For long lifts, such as from floor to
above shoulder height, resting the load mid-way on a table or bench to change to
a more suitable grip over the load.

Correct position while lifting

Bend your
knees to go down, not your back. While making the lift make sure you raise the
load and straighten your legs simultaneously. If you straighten your legs before
starting to raise the load you will bend the back further which may lead
to injury to the lower back.

Also, make
sure your feet are wide apart with one foot slightly forward as shown in the figure to
maintain balance. Avoid wearing heels while lifting load off the ground.




Keep the load close to the waist

The farther the load is from the body, more
is the force on the lower back. Hold the weight as close to the waist for as
long as possible while lifting to minimize the strain applied on the back.
Also, try keeping the heaviest side of the weight closer to the body. Avoid
twisting, turning or leaning sideways while lifting heavy weights. If you want
to turn, move your feet.



Avoid jerks

Jerky movements are always difficult to control. Avoid jerking
or snatching the load as this increases the risk of injury.




Back care in bedroom

third of our average lives are spent in bed. A healthy bed is an absolute
necessity for a healthy back.



Know when to change the mattress

You should always keep in mind the quality of
the mattress you sleep on and know when to change it. Although a soft and saggy
mattress may feel comfortable to sleep on but one should be ready to change the

if it is more than 6-8 years old

the mattress has become saggy, too soft or  uneven           

if springs are felt protruding out          

you wake up with pain or stiffness in your back or



Mattress should be adequately firm

The firmness of the mattress should always be
kept in mind while buying a new mattress. To find the right
degree of firmness, lie down on the mattress with your back straight and ask
your friend to insinuate his hand under the curve in your lower back.  If the hand can not be insinuated , the bed
is too soft; if its very easy to insinuate, the bed is too hard. It should also
be kept in mind NOT to put a new mattress on an old one. It is bound to adopt
the shape of the old mattress and will be no better for your back.




to keep your back healthy

A series of exercise routines can be followed to keep
your back muscles strong and healthy, thus preventing the occurrence of low
back pain. Also, these exercises help reduce any lower back pain including
tension, stiffness and soreness. Start the routine gently without putting any
excessive amount of stress or pressure on your back. Gradually stretch your
limits and see how far you can go in each position without feeling pain.








Bottom to heels stretch

Stretches and mobilises the spine


Start position: Begin from kneel down position such that knees and hands are right
below your hips and shoulders respectively. Look straight ahead and avoid
locking of the elbows.


Action: Gradually bend your knees further in order to
take your bottoms backwards till they reach your ankles. Hold the stretch for one deep breath and return to the starting


Repeat: 8 to 10 times.



Ensure proper breathing in and out along with the stretch.
Do NOT overstretch.
Stop the routine if you experience pain while doing the same.





Knee rolls

Stretches and mobilises the spine

Start position: Begin by lying down
flat on your back with knees kept together, bent to 90 degrees and both feet
flat on the ground. Keep your upper body relaxed and both arms spread wide


Action: Keeping the upper body stable, roll both your
knees to one side followed by your pelvis. Hold the stretch
for one deep breath, return to the starting position followed by repeating the
stretch to the opposite side..


Repeat: 8 to 10 times,
alternating sides.



Do NOT overstretch.
Keep a firm cushion or a book under your head.



Back extensions

Stretches and mobilises the spine backwards

Start position: Begin by lying on a firm surface on your stomach, with elbows bent
and palms flat on the ground as shown in the image. Keep your shoulders,
back and neck stretched and straight.


Action: keeping  Keeping your
shoulders,back and neck straight, push your hands down, straighten the elbows
to 90 degrees and arch your back up. Breathe in, feel the stretch in your
abdominal muscles and hold for one deep breath and return to start position


Repeat: 8 to 10 times.



Don’t bend your neck backwards.
Keep your hips and lower abdomen fixed to the ground.




Pelvic tilts

Stretches and strengthens the lower back

Start position: Begin by lying down flat on your back. Place a firm cushion or
book under your head. Bend your knees to 90 degrees and keep your feet flat on
the floor and hip-width apart. Upper body should be relaxed.


Action: Gently contract your lower back muscles ,tilting your pelvis
towards your heels. Feel the arching of your lower back. Hold the same for one
deep breath and return to the starting position.


Repeat: 10
to 15 times.



Don’t press down through the neck, shoulders or feet.
Don’t lift the hips above the ground



Partial Crunches

Stretches and strengthens the lower back and
abdominal muscles


Start position: Begin by lying down flat on
your back with knees kept together, bent to 90 degrees and both feet flat on
the ground. Cross arms over your chest or
put hands behind your neck.

Action: Use the abdominal muscles to raise upper half body off
the floor while lower back is still resting on the floor.  Breathe out as
you raise your shoulders. Hold for 3 seconds, then slowly lower back down to
the starting position.

Repeat 8 to 12 times.


Don’t pull your
body up by the strength of your arms.

Your feet and
lower back should remain in contact with the floor at all times


Bird Dog

Stretches and strengthens the lower back and
abdominal muscles. This exercise is a great
way to learn stabilization of lower back during synchronous mobilization of
arms and legs


Start position:  Begin from kneel down position such that knees and hands are
right below your hips and shoulders respectively. Look straight ahead and
maintain the arch of the back.


Action:  Tighten your stomach muscles. Lift and extend one
leg behind you and stretch the opposite side arm forwards. Keep hips level.
Hold for 3-4 secs, and then switch to the other leg.

8 to 12 times for each leg try to lengthen the time you hold each lift.


While doing this stretch, keep the lower back muscles taut and prevent
sagging of the arch.

Raise the limbs only to a height where the lower back position can be




to be avoided in low back pain


Although exercises are good for low back pain but it should always be remembered
that some exercises may do more harm than good, more so in a setting of low
back pain. Mild discomfort that you feel in the beginning should disappear in
3-4 days as the muscles gain strength and flexibility. If the pain in your
lower back increases while doing a particular type of stretching exercise with
time, or in a particular session of exercise you feel pain persisting beyond 15
mins you should stop immediately and contact a doctor. Some exercises may cause
excessive stretching of the muscles and ligaments of the spine and in turn
aggravate the pain. A few of the exercises to be avoided in low back pain







Standing toe
















Sit ups




Leg lifts













Low Back Pain : The ‘RED FLAG’ signs

Most of the patients with low back pain respond to gentle
back stretching and strengthening 
exercises and over the counter analgesics (NSAIDS) spontaneously in 2-4
weeks. The ‘red flag’ signs are ominous signs which may suggest a serious
underlying pathology and thus, should be reported to a specialist as soon as
possible. A list of ‘Red Flag’ signs has been given here under.


Progressive weakness of lower
limb ( feeling of heaviness, frequent falls , paralysis)
Recent bowel or bladder
Loss of sensation over buttocks
and surrounding region
or numbness over any part of lower limb
Traumatic onset
Age > 50
Male with diffuse osteoporosis
or compression fracture
Cancer history
Insidious onset and persisting
for more than 4-6 weeks
No relief at bedtime or worsens
when supine
Fever, weight loss, loss of
appetite, night sweats
Hx UTI/other infection, IV drug
use, TB exposure
Immune suppression, Steroid use
Previous surgery












Treatment with the specialist

Once you consult a specialist you may be advised to run a
series of diagnostic tests including blood investigations, X-rays and MRI
studies. Further treatment is carried out after a diagnosis is established. The
spectrum of treatment ranges over conservative management with analgesics,
interventional treatments for pain management or surgery in a few patients.

Conservative Care:

For the management of moderate to severe strains and
sprains, the treatment strategy may be divided in two phases. The first phase
is aimed at reducing pain and spasm and may involve rest, locally applied
analgesic creams, rubs and sprays, oral muscle relaxants or some physical
therapy in the form of diathermy or interferential therapy. Once the patient is
pain free, the second phase comes into play to tackle the residual stiffness in
order to achieve pre injury range of motion. It also aims at strengthening the
lower back musculature. Most people experience a full recovery within a period
of 2 weeks. If symptoms continue for more than 2 weeks, further investigation
is warranted.

Even in degenerative spine disorders or a slipped disc
disease the first preference in most cases is to give a trial of physical
therapy and specific set of exercises with a physiotherapist for 4-6 weeks.
Most exercise programs can be carried out at home without special equipment. Patients
who do not respond to physical therapy and drugs require additional treatment.

Treatments :

For a small percentage of patients, back pain remains
chronic, persistent and disabling. For people, with no response to physical
therapy and analgesics more intensive treatment may be needed. A few of the
common interventional treatments that you may be advised depending on your
disease include:

Nerve root blocks and injections

Radiofrequency ablation

Facetal blocks – injection into the joints between
your vertebrae

Epidural injections

Surgery :

For patients who do not respond to the above methods and
patients with crippling pain or ‘red flag’ signs surgery may be the only




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