Low Back Pain

Around 80% of people experience back pain in their lifetime, but it is rarely life threatening. For 10-30%, of people back pain can be very distressing, interfering with daily activities, the ability to remain active and negatively affecting their quality of life. This can also impact those caring for the sufferer – usually family and friends.

There are many common and unhelpful myths about back pain:

In fact, for these myths, the opposite is true:

Check out our downloadable fact sheets 15 things you didn’t know about back pain and Managing Back Pain.

Yes: ‘specific’ and ‘non-specific’.

‘Specific’ back pain is rare.

Less than 1% of people have back pain related to cancer, infection, fracture or an inflammatory process, such as ankylosing spondylitis (AS). Internal organs can also sometimes refer pain to the lower back.

Only about 5% of people have nerve compression resulting in a loss of power and sensation in the leg. In rare cases, this may also affect the function of the  bowel or bladder. This means that the majority of people with back pain DO NOT have ‘specific’ pathology.

The good news is that for most people (90-95%) back pain is NOT related to ‘specific’ pathology.

Some back pain is caused by a simple strain of the back, usually at a time when we are more vulnerable (i.e. run down, tired, stressed, tense, sad, inactive or over-active). At other times, back pain (like a headache) can occur without any mechanical trigger: at a time of stress, sadness, tiredness or inactivity.

While this kind of back pain can be really intense and scary, where even small movements hurt and the muscles in the back “seize up”, the majority of people with this kind of back pain recover in a week or two.

Your health professional can screen you for specific pathology. You can also use our pain self-checks to see if you should seek help.

Scans are NOT recommended for the majority of back pain unless ‘specific’ pathology is suspected. The problem with scans is that most people without back pain have age-related changes to discs such as degeneration (up to 80%) and disc bulges (50-60%). These changes are like ‘wrinkles on the inside’ and they do not predict back pain¹. Sometimes getting a scan can make things worse, especially if we start to worry about our backs in an unhelpful way and over-protect our movements and activities.

Your health care professional will direct your management. Ask your health care professional what the best evidence for treatment is for your back pain (benefits and risks, costs and what happens if you do nothing).

If you have nerve compression due to a disc prolapse (which is really painful), the good news is that the majority of these disorders resolve in 3-6 months and the prolapse disappears without the need for surgery.

Surgery is rarely needed unless you progressively or suddenly lose muscle power and/or bladder/bowel function. If you have a fracture (break), the good news is that bones heal within 6-8 weeks and your back pain should resolve.

Ask your health care professional what the best evidence for treatment is for your back pain (benefits and risks, costs and what happens if you do nothing).

The scientific recommendations for the management of ‘non-specific’ back pain are:

• For most people, back pain gets better – so don’t panic.
• Don’t take it easy for more than a day or two and gradually increase your mobility and activity levels in the first day or two.
• Avoid staying in bed.
• Remaining at work is safe (even if you have to modify what you do) and can help to keep your mind off the pain. Returning to work early predicts better outcomes.
• If you feel distressed and can’t cope with the pain, seek medical advice early.

In a small group of people (20-30%), back pain can persist beyond 8-12 weeks. Surprisingly, this is usually NOT because there is something damaged in the back.

The things that predict back pain persisting, are related to:

• Our thoughts (such as worrying, thinking negatively, becoming fearful and not trusting our backs)
• Our emotions (such as high levels of stress, anxiety, low mood, sadness, frustration, anger)
• Things we do (such as not sleeping, tensing up, overdoing it, getting run down, smoking and drinking to excess, as well as avoiding movement/exercise and work).

These things can make our nervous system more sensitive and over-protective of our backs: we can get stuck in a vicious cycle of pain and disability.

While the ‘mix’ of factors linked to back pain is different for everyone, there are some things that are helpful for all people with back pain².

It’s also smart not to rely too much on people doing things ‘to you’. It is much better to find things that you can do yourself to control your pain and get your life back.

This is often really hard to do when you are in pain and may require some health professional support.

If your pain is distressing and your movement and activity is limited, seeking care from a registered health care practitioner may be necessary. They can provide you with a diagnosis and assist you with ways to manage your pain and regain mobility and function. This should involve exercises to enhance mobility and activity (work and exercise/movement) advice.

Some of these important aspects are covered in this website under the pain management modules. Your GP or health professional may be able to guide you in your selection of the modules if you are unsure which ones to do.

Medicines have a very limited role in the management of acute and chronic low back pain. Clinical trials show they are not effective^5,6. They also have significant side effects.

Here is a summary of current recommendations for the use of medicines in low back pain care:

• Paracetamol, one of the most common medicines available (and very safe in usual doses of below 4 gms a day [ie 2 x 500 mg tabs every 6 hours]), has been shown to be ineffective for management of acute low back pain⁵.
• Anti-inflammatory medicines (NSAIDs) may give a small reduction in pain for some people, but have many serious side effects⁶.
• If medications such as ibuprofen are used, taking the lowest effective dose for the shortest duration, is recommended.

While strong pain medicines have been used for people with low back pain current evidence⁷ shows:

Strong medicines for back pain are not recommended. If you have severe pain, you should discuss the benefits and risks of harm when using stronger medicines⁷.

• For low back pain that does not respond to a combination of active, non-pharmacological treatments and simple analgesics described above, very short term (< 1 week) use of Tramadol (up to a maximum dose of 400mg a day given in divided doses), or Tapentadol (up to 300mg a day given in divided doses) may be recommended. You should discuss this with your doctor.
• Musculoskeletal muscle relaxants while recommended by some authorities⁷, show low benefit and a large risk of side effects, such as making you drowsy. In this category in Australia, Orphenadrine is available (https://www.tga.gov.au/book-page/18-orphenadrine). A combination of orphenadrine and paracetamol is also available.
• Diazepam is not recommended because of the risk of sedation and dependency.

You should always discuss this first with your doctor or pharmacist to see if there are any reasons why you cannot use these medicines. You can read more in the medicine and procedures module.

In some cases, your doctor may suggest that an injection or surgical procedure is indicated as part of your pain management. To see the current evidence for these treatments, refer to our medicine and procedures module.

It is important to choose treatment options that are high value care: this means most likely to give you the most benefit with the least risk and cost.

When talking to your doctor or healthcare provider about possible tests or treatments for your back pain care, there are 5 key questions to ask:

1. What is the evidence for this treatment?
2. What are the costs, benefits and risks?
3. How much of this treatment will I need?
4. What can I do to help myself?
5. Please can you write down this information?

These 5 questions can help to make sure you end up with the right amount of care — not too much and not too little. Click here to find out more about the Choosing Wisely initiative.

The following approach guides you to some of the simple steps you can take to help improve your function and reduce your back pain. The approach is informed by current best evidence practice^2,3. Some of the most effective options are simple, low risk and non-medicine based⁴.

People’s experience of pain is varied and it can be hard to stay positive. Experiencing low mood, anxiety, fear and many other emotions is very common when you have back pain. Remember that back pain is rarely life threatening, it usually gets better and you are not alone – there is help! You might also find the approaching pain module useful.

Whether your back pain is recent or you have had back pain for a long time, moving in a paced way (that is taking the middle road and doing little bits often), and building up gradually over time, can help you recover. Over-protecting the back can delay recovery.

Remember, it is normal to experience some back pain as you begin to move and exercise. It is important not to be afraid of the pain or fear of re-injury. Fear of pain and movement usually causes us to tense up, worry and over protect ourselves, which can make back pain worse and slow recovery.

One of the best ways to manage these fears is for you to gradually build up your movement, exercise and activities over time. Gentle relaxed movement, breathing exercises and physical activity help to “desensitize” your system and prevent the persistence or worsening of your pain. As you keep moving, maintaining your usual activities and adopting a paced approach to activity, exercise and work, the pain will usually settle.

Avoid prolonged bed rest (longer than 24 hours) as this usually leads to poorer outcomes and slower recovery. Stay at work if possible even if you require short-term changes in your work habits; staying at work leads to better health outcomes for you. Your health professional can guide you regarding any work modifications that are needed.

Daily exercise helps to boost your own inbuilt pain modifier medicines (your endogenous pain control systems). This can be a very effective way of improving your function and reducing your pain. The trick here is to use a paced approach – finding the middle road, rather than overdoing or underdoing.

Sleep is ‘medicine’. Engaging in healthy sleep habits such as regular sleep times, reducing screen time and avoiding alcohol /caffeine before bed can improve sleep quality. Getting more than 6-7 hours sleep a night is important and helps reduce the risk of many health conditions.

If you are having trouble sleeping, read more in the sleep and pain module. Relaxation techniques and regular exercise may be helpful for improving your sleep: check out the mindfulness and pain module.

If this fails to help, then specific medicines that help stabilise your mood may be useful in the short term to help you get restorative sleep. Read more in the medicines and procedures pain management module.

A healthy diet is also important as there is growing evidence that abdominal obesity (fat around your belly) is associated with back pain and sciatica (nerve pain) and can cause inflammation. Sometimes losing weight is really difficult and this requires assistance from a health professional with expertise in this area.

Smoking is another predictor for persistent back pain, so getting assistance to quit is a great idea.

Drinking too much alcohol can increase back pain in the long run. Alcohol disrupts sleep, lowers mood and can be dangerous (even fatal) in combination with some medicines. Reducing your alcohol intake is helpful!

For more information visit Cochrane Plain Language Summaries and download the consumer’s guide to managing back pain.

You can use the Orebro Musculoskeletal Pain Questionnaire Screening Tool to help rate the risk of your low back pain persisting.

Lastly, if you would like to talk to a health professional about your lower back pain, please seek further assistance.