Introduction

Low back pain is the most common musculoskeletal condition seen and it is the number one cause of disability globally. It can occur in all age groups from children to the elderly population. Around 40% of people in their teenage years and most adults have back pain. Overall about 80% of people will experience low back pain at some point in their lifetime. Furthermore, the incidence of low back pain is predicted to increase over the next two decades (Hartvigsen et al. 2018).

Types of back pain

There are three different types of back pain:

Specific (Serious pathology, such as vertebral fractures)
Radicular (Pain caused due to irritation of a nerve root)
Non-specific (Specific structure causing the symptoms cannot be identified)

The most common type of back pain is non-specific, which accounts for 90-95% of all low back pain. Only about 1% of low back pain is caused by something medically serious, such as vertebral fractures, cancer, cauda equina syndrome or infection. And about 5-10% of the cases low back pain is caused due to nerve root irritation (Bardin et al. 2017).

Unfortunately, no matter how many clinical tests or different scans are available, a specific structure that is causing the symptoms cannot be identified in cases of non-specific back pain. Pain can be caused by several different tissues, such as muscles, joints, tendons, ligaments, discs to name a few and all of them can present very similarly.

Acute non-specific low back pain has a favourable prognosis. About 90% of people with acute episode recover between 2-6 weeks (Tulder et al. 2006). However, it is likely to recur. This study followed people after they recovered from an episode of low back pain and found that 70% of people will experience another episode within 1 year (Silva et al. 2019). Therefore, looking for a short-term fix might not be the best approach, but rather making changes in lifestyle and improving overall health should be the main focus.

Non-specific low back pain can cause discomfort in the lower back and sometimes it can refer to other areas in the body. The image below shows how irritation of the facet joints in low back can refer symptoms in legs - in some cases pain and discomfort can even be referred to the lower leg and foot!

Who is more likely to get back pain?

(smoking, alcohol, obesity. Prognosis about expectations, length of symptoms, pain self efficacy etc)

Even though back pain is very common some people are more likely to experience it than others. This study by Guan et al. published in 2024 reviewed the relationship between low back pain and several lifestyle factors, such as obesity, smoking, alcohol consumption, sleep and activity levels.

Obesity

There is a growing body of evidence that identifies increased body mass index (BMI) as a predictor of back pain. This study also found a direct causal effect of BMI on back pain, which could be due to heightened load on weight-bearing joints and inflammation.

Sleep

There is a bidirectional relationship between poor sleep and chronic pain, with poor sleep being a trigger for chronic pain, and chronic pain exacerbating poor sleep. It has also been found that individuals with insomnia are twice as likely to experience chronic low back pain compared to those without insomnia.

Smoking and alcohol consumption

It has been reported that current and former smokers have increased risk of experiencing low back pain than those who do not smoke. Smoking can lead to constriction of blood vessels and reduced blood supply. The chemicals can also cause chronic inflammation that could harm the tissues. It may also lead do reduced bone mineral density leading to increased risk of vertebral fractures.

Alcohol consumption, similarly as smoking, can also lead to decreased bone mineral density. Additionally, it affects the nervous system, which can lead to low back muscle fatigue and pain.

Activity levels

And lastly, activity levels! The study found that more sedentary lifestyle either at work or free time can lead to increased risk of back pain.

Treatment options

Exercise

Exercise is recommended as a first-line treatment for low back pain and is consistently recommended in clinical practice guidelines. When compared to individuals who do not engage in physical activities, exercise can reduce pain and disability. It has also been shown to reduce work absence in people with low back pain and is associated with general cardiorespiratory, metabolic, mental, bone and muscle health benefits (Cashin et al. 2021).

It is not clear what type of exercise is best to improve pain and function in people with chronic low back pain. However, there are a range of different exercise options that have been shown to be beneficial, such as yoga, pilates, aerobic and resistance exercise.

This research done by Tataryn et al. (2021) compared posterior chain resistance training with more general exercise and walking programmes in people with chronic low back pain. They found that people in both exercise groups improved, but resistance training had significantly better outcomes in pain, disability and strength than any type of general exercise, especially if it was done for longer durations. Following resistance training exercise programme for 12-16 weeks lead to better outcomes than 6-8 weeks.

Also, exercise does not need to be complicated with fancy rehab programmes and endless amount of different exercises. A study done by Holmberg et al. (2012) looked at how effective is deadlift training for chronic low back pain. The participants of this study trained twice a week for 8-10 weeks and performed only one exercise - deadlift. They found that all participants lifting capacity increased and pain levels reduced or did not change.

And this study by Aasa et al. (2015) compared deadlift training with motor-control exercises in people with low back pain. The researchers found that at 12 month follow-up both groups significantly improved in pain, strength and endurance, but there were no significant differences between the groups.

This shows that resistance training including doing deadlifts can be a safe and just as effective strategy in the management of chronic low back pain.

Furthermore, exercise can also prevent development of first-time low back pain and prevent future episodes of back pain too. It can also reduce future low back pain intensity and disability (Shiri et al. 2018; Campos et al. 2021).

Manual therapy

Treatment methods such as spinal manipulation or mobilisation, acupuncture and massage are optional and can be used as a second-line treatment. They can provide improvements in pain and function, mostly in short-term, and a short course of these therapies might be suggested to some who do not do well with other treatment (Foster et al. 2018).

Other types of electrical and physical modalities such as traction, ultrasound, orthotics are generally ineffective, as recommended on NICE’s guidelines for low back pain management.

Injections and surgery

Epidural, facet joint injections or prolotherapy are not recommended for low back pain (Chou et al. 2009). And for pain thought to originate from degenerated discs in lower back a fusion surgery might be considered, however, the benefits are similar to those of intensive rehabilitation. Furthermore, surgery carries greater risk of adverse events and is more costly (Foster et al. 2018)

Myths and misconceptions

A popular belief is that back pain is caused by poor posture, misalignments of hips or spine or weak core. However, pain is much more complex than that. This paper by Cholewicki and colleagues in 2019 looked at several different biomechanical factors that could be the cause of back pain. They came to a conclusion that focusing on biomechanical factors only will not provide a solution for low back pain. The authors agreed that low back pain is multifactorial, caused by biomechanical, psychological and social factors.

A systematic review written by Christensen and Hartvigsen (2008) assessed 54 studies that looked at different spinal shapes and back pain. They concluded that there is no evidence between sagittal spinal curves and back pain. Another study looked at lumbar lordosis between people with and without back pain and found no difference in the degree of lumbar lordosis between the groups (Murrie et al. 2003).

And this study by Reyes-Ferrada et al. (2021) looked at trunk strength between people with and without low back pain and found no difference between the two groups.

It is illustrated in this image how many different possible factors there are that could contribute to back pain, disability and quality of life. The answer is not as straight forward as poor posture or weak core.

In summary, low back pain is the most common musculoskeletal condition with non-specific back pain accounting for 90-95% of cases. Acute low back pain has good prognosis, but it is likely to recur, therefore, focus should be on making changes in our lifestyle for long-term benefits and goals. And it might not be as straight forward as blaming posture or core strength as a cause of low back pain, instead it seems to be a multifactorial problem and can be affected by biomechanical, psychological and social factors.

The Back Pain Breakdown