Talk About Your Physical Functioning Or Lack Of
Pain is more than a set of unpleasant sensations. It has the power to disrupt daily activities and lifelong dreams. Back pain can impair your ability to fully participate in both work and play, and even to do very basic things such as coughing and sneezing.
That said, your expectations and attitudes may play a determining role as to how much disability you experience when you have back pain. The ICSI, a group that provides guidance to healthcare providers treating back pain, asserts that giving up on yourself or your treatment may perpetuate the pain. In this case. giving up means disengaging from self-care activities. The ICSI says social support and spirituality very much factor into the healing equation.
Another thing that affects your ability to function during the time you deal with back pain is your own perception or appraisal of yourself as able to perform actions and tasks this is called self-efficacy. A study published in the European Journal of Pain found that back patients with strong self-efficacy had less disability.
During your physical exam, the healthcare provider will likely ask questions about your functioning and how it has changed since the pain started. She may also try to determine the level of pain you experience while at rest and during activities.
Straight Leg Raising Test
With the patient in the supine position, each leg is raised separately until pain occurs. The angle between the bed and the leg should be recorded. Pain occurring when the angle is between 30 and 60 degrees is a provocative sign of nerve root irritation . Bending the knee while maintaining hip flexion should relieve the pain, and pressure in the popliteal region should worsen it .11 If placing the knee back in full extension during straight leg raising and dorsiflexing the ankle also increase the pain , nerve root and sciatic nerve irritation is likely.
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FIGURE 1.
The result of straight leg raising is positive in 95 percent of patients with a proven herniated disc at surgery, but it is also positive in 80 to 90 percent of patients without any form of disc protrusion at surgery.12 In contrast, crossed straight leg raising is less sensitive but much more specific for disc herniation. In the crossed straight leg raising test, the contralateral, uninvolved leg is raised . The test result is positive when pain is produced.
When To See A Doctor
Once youve determined whether your pain is coming from your back or your kidneys, consider seeing your doctor for evaluation and treatment.
You should always be seen if you think you have a kidney infection or kidney stone.
You might be able to treat acute back pain thats mild without seeing your doctor, but if it doesnt get better, is more than mild pain, or spreads, you should see your doctor.
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How Will My Doctor Diagnose My Lower Back Pain
After taking a complete medical history, your doctor will perform a thorough physical exam to narrow down the possible causes of your lower back pain. The exam will include palpation along the lower back to locate areas of tenderness or joint abnormalities a sensory exam to check your reaction to touches, pin pricks, or other senses and a range of motion test to look for positions that worsen or recreate your pain.
Part of the diagnostic process usually involves ordering several imaging studies so your doctor can check the condition of your bones, intervertebral discs, nerve roots, and connective tissues. This can help diagnose your lower back pain and help your doctor locate a specific problem area. Your doctor will also analyze how you describe your symptoms to get a general idea of the source of your pain. Common imaging tests include X-rays, CT scans, MRI scans. Other diagnostic tests include injection studies.
Severity Of The Symptoms
The severity of your symptoms is one factor you should consider when determining if your LBP is serious. However, symptom severity can sometimes be misleading. For instance, a strained lower back muscle may produce severe pain for the first few days until the tissue irritation and swelling subsides. On the other hand, LBP from degenerative disc disease can result in dull aches that slowly become more distracting over time.
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Clarify The Timing Of Your Pain
The “when” of back pain, if it comes on suddenly or gradually, if it is present constantly or only sometimes, or if there is a particular time of day when it always shows up, is key information to your healthcare provider as she or he goes through the process of determining a diagnosis. Healthcare providers evaluate changes in pain patterns to monitor your progress and to be on the lookout for new problems.
Understanding your individual patterns of pain may also help your healthcare provider determine the best time for you to take medication.
More specifically, pain may come and go, which is called intermittent pain, or it can always be there, but with fluctuating severity. This second version is called variable pain.
People with variable pain may also experience breakthrough pain and background pain. Breakthrough pain is a temporary condition where pain is extremely severe and may benefit from medication or a specific pain management strategy. Background pain is of lower severity but is fairly constant.
There’s also stable pain, where the pain, which also includes its intensity, is always constant.
Lower Back Pain And Cancer
Cancer involving the lumbar spine is not a common cause of back pain. However, in people who have a prior history of cancer, for example, in the breast or prostate, or who have weight loss or loss of appetite along with back pain cancer needs to be considered.
Night pain can be a clue to cancer in the spine. A benign tumor called osteoid osteoma, which most often affects young people, causes pain that tends to respond well to aspirin. Multiple myeloma is a malignancy that occurs when the plasma cells in the bone marrow begin spreading uncontrollably. It is most common in older people, and can cause pain in many parts of the spine. When tumor or infection are suspected, blood tests may be ordered, including a CBC , sedimentation rate , and protein electrophoresis .
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Why Is It Not Helpful
Back pain can be excruciating. So it seems that getting an X-ray, CT scan, or MRI to find the cause would be a good idea. But thats usually not the case. Heres why:
They dont help you get better faster.
Most people with lower back pain feel better in about a month whether they get an imaging test or not. In fact, those tests can lead to additional procedures that complicate recovery. For example, one large study of people with back pain found that those who had imaging tests soon after reporting the problem fared no better and sometimes did worse than people who took simple steps like applying heat, staying active, and taking an over-the-counter pain reliever. Another study found that back pain sufferers who had an MRI in the first month were eight times more likely to have surgery, but didnt recover faster.
Assessment And Management Of Acute Low Back Pain
ROBERT L. BRATTON, M.D., Mayo Clinic Jacksonville, Jacksonville, Florida
Am Fam Physician. 1999 Nov 15 60:2299-2306.
See related patient information handout on low back pain, written by the author of this article.
Acute low back pain is commonly treated by family physicians. In most cases, only conservative therapy is needed. However, the history and physical examination may elicit warning signals that indicate the need for further work-up and treatment. These red flags include a history of trauma, fever, incontinence, unexplained weight loss, a cancer history, long-term steroid use, parenteral drug abuse, and intense localized pain and an inability to get into a comfortable position. Treatment usually consists of non-steroidal anti-inflammatory agents or acetaminophen and a gradual return to usual activities. Surgery is reserved for use in patients with severe neurologic deficits and, possibly, those with severe symptoms that persist despite adequate conservative treatment.
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Other Conditions That Cause Back Pain In Older Adults
We often see a range of less serious but still painful spine conditions in seniors. Most patients with these conditions will not require surgery. Physical therapy, medication, injectable anesthetics, or a combination of treatments usually can control symptoms.
- Degenerative disc disease, which can cause whole spine pain, and lumbar arthritis, which usually causes low-back pain, commonly develop with age and are considered wear-and-tear conditions.
- Sacroiliitis is an inflammation of the joints that connect your spine and pelvis. This condition can cause pain in the low back, glutes, and upper legs.
- Ankylosing spondylitis is an inflammatory arthritis that causes patients spines to become inflexible, resulting in a continual hunched forward position and spine pain.
- We also check for adult degenerative scoliosis and kyphosis, spine-curving conditions that can result in back pain and weakness in the lower extremities.
Be Transparent About Any Psychological Issues
Many times your state of mind and/or emotion plays a role in your pain and disability status. Your healthcare provider will likely ask you if you have depression, anxiety, substance abuse, or other types of problems currently or in your past these topics are great fodder for your pain journal, as well.
Depression may accompany your chronic back pain even if you don’t have any history of psychiatric disorders. A 2018 study published in the Korean Journal of Pain concluded that unrecognized depression in patients with chronic pain is common.
Cognitive behavioral therapy is a short-term therapy focusing on identifying and changing the thinking patterns that bring unwanted results into our lives. For people with back pain, it’s especially useful for learning how to manage pain triggers.
In their 2017 clinical guidelines, the American College of Physicians strongly recommend cognitive behavior therapy as a non-pharmacological pain management treatment for acute, sub-acute and chronic low back pain.
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Fractures And Lower Back Pain
are often very difficult pain problems and indicate the possible presence of . In patients with severe osteoporosis, spinal fractures can occur with no early warning and no significant trauma the patient does not have to fall to fracture a vertebrae.
Patients with spinal compression fractures experience spasms and, often, very high pain levels.
In patients with low back pain where the cause is difficult to determine, especially for elderly patients with osteoporosis, a fracture in the sacrum may be the cause of the pain. A standard X-ray or bone scan may not show a sacral fracture. Imaging techniques such as CT scan or MRI can often reveal these fractures.
It is very important that patients with acute lumbar compression fractures be tested for osteoporosis. A bone density study is needed, unless the patient has no other osteoporosis risk factors and has had a very high impact fracture. Studies have shown that many patients with fractures in the U.S. are discharged from hospitals with no plans for management of their bone density problems, which then are left to worsen.
Although pain can be very intense, it is best for patients with lumbar fracture to resume activity as soon as possible. This is especially true for elderly patients, who can too easily become weakened, and develop other complications, if mobility is reduced for too long. may be needed for pain control, for as brief a period as possible.
Chronic Lower Back Pain
When back pain continues for more than three months, it is considered chronic. Although for most people an episode of back pain is over by that time, in some cases it progresses and can have a major impact on ones ability to function. For some patients, physical therapy with local heat or ice application , combined with a home exercise program and education in proper positions for lifting and other movement techniques can make a major difference. Patients must learn to tolerate a certain degree of pain, or they may allow themselves to become more disabled than necessary. Patients at the Hospital for Special Surgery have had success with graded exercise to work through the pain, gradually increasing the exercise quota at each session so they can learn to tolerate more exercise in spite of the pain, and get back to work and activities. Read more detail on this topic in .
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Note The Intensity Of Your Pain
How bad does it hurt? Knowing this is one of the first steps to working collaboratively with your healthcare provider. Intensity is a measure of the strength of felt pain signals.
As the patient, this is probably the most important part of the ordeal for you. Many healthcare providers will ask you to fill out a visual chart of some sort. You may be asked to rate the intensity of your pain with a number, or by picking a “face” that represents how the pain makes you feel this is called the “oucher” or “faces” chart. The “faces” in the oucher chart go from happy and smiling to crying.
How Doctors Get To Root Of Your Pain
If you have pain in your lower body and arent sure whether your back or hip is to blame, a good first course of action is to visit your personal doctor. He or she will review your medical history and may perform a series of physical exam tests to get to the root of your pain. Alternatively, your personal doctor may refer you to a doctor who specializes in the hip or spine to make an accurate diagnosis.
Your doctor will ask you to describe your pain, including its location, when it worsens/is relieved, and what the pain feels like .
After listening to your description of your pain, your doctor may have you perform several maneuvers or movements as part of a physical exam. The goal of these maneuvers is to determine what movements recreate your pain. One such maneuver is called the Flexion Abduction External Rotation test, which helps determine if the disorder is sourced in your hip and may illuminate sacroiliac joint problems. During this test, you lie down your back while flexing and rotating your hips. Your doctor may also palpate the area of pain.
Next, your doctor may also order imaging scans, such an x-ray to view your bones or an MRI to view soft tissues , which may help reveal the true nature of the spinal or hip problem. It is important for your doctor to then determine if your complaints and exam findings can be explained by what is seen on the images.
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What Are The Symptoms Of Lower Back Pain
Symptoms of lower back pain can come on suddenly or appear gradually. Sometimes, pain occurs after a specific event, such as bending to pick something up. Other times, you may not know what caused the pain.
Pain may be sharp or dull and achy, and it may radiate to your bottom or down the back of your legs . If you strain your back during an activity, you may hear a pop when it happened. Pain is often worse in certain positions and gets better when you lie down.
Other symptoms of lower back pain include:
- Stiffness: It may be tough to move or straighten your back. Getting up from a seated position may take a while, and you might feel like you need to walk or stretch to loosen up. You may notice decreased range of motion.
- Posture problems: Many people with back pain find it hard to stand up straight. You may stand crooked or bent, with your torso off to the side rather than aligned with your spine. Your lower back may look flat instead of curved.
- Muscle spasms: After a strain, muscles in the lower back can spasm or contract uncontrollably. Muscle spasms can cause extreme pain and make it difficult or impossible to stand, walk or move.
Age And Gender Issues
Age and gender are important factors to consider when diagnosing low back pain. In a young patient, a benign tumor of the spine called an osteoid osteoma may be the culprit. Inflammatory bowel disease in young people can be connected with spondylitis and sacroiliitis . Low back pain from disc disease or spinal degeneration is more likely to occur as people get older. Conditions such as abdominal aneurysm or multiple myeloma are also considered in older individuals.
Osteoporosis and fibromyalgia are much more common triggers of back pain in women than in men. Osteoporosis is a progressive decrease in bone density that leaves the bones brittle, porous and prone to fracture. Fibromyalgia is a chronic disorder that causes widespread musculoskeletal pain, fatigue, and multiple tender points in the neck, spine, shoulders, and hips.
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How Is Low Back Pain Treated
Treatment may include:
- Physical rehabilitation, therapy, or both
- Osteopathic manipulation
- A prevention program
- Surgery
- Assistive devices
Rehabilitation is often a part of treatment for low back pain. Generally, there are 3 phases of low back pain rehab.
- Acute phase. During this initial phase, the physiatrist and treatment team develop a plan to reduce the initial low back pain and source of inflammation. This may include using ultrasound, electrical stimulation, or specialized injections.
- Recovery phase. Once the initial pain and inflammation are better managed, the rehab team focuses on helping you return to normal daily activities while starting a specialized exercise program to regain flexibility and strength.
- Maintenance phase. In this phase, you will learn ways to prevent further injury and strain to the back. You will also learn how to start a fitness program to help further increase strength and endurance.
