Nick Worth is our Lead Clinician at Ascenti and an established expert in his field.
He has been a physiotherapist for more than 25 years, is a qualified Extended Scope Practitioner (ESP) and has completed an MSc in Orthopaedic Medicine, alongside various other specialist programmes.
Nick also acts as a professional advisor, trainer and speaker at Universities and physiotherapy events across the UK.
I have seen more patients with back pain than any other complaint.
It is by far the most common reason that people come for physiotherapy and is often misunderstood.
Back pain accounts for 40% of working days that are missed and around one-third of the UK population will experience it every year.
Lower back pain, or what we call pain in the lumbar spine, is the most common.
The majority of back pain is not caused by anything serious and it is important to remember that it is not a ‘disease’.
Back pain will usually go away on its own or with the right management within six weeks.
It’s important to understand back pain to improve recovery and prevent future reoccurrence.
What is my back?
The back isn’t a single bone, muscle or structure.
You have 24 separate bones called vertebrae that make up your spine. Around each of these you have a small disc that acts as a shock absorber when you twist or bend the vertebrae.
The disc is made up of cartilage and contains fluid to help with movement. As you get older, the fluid in the disc tends to reduce which makes your back less flexible.
Right at the bottom of your spine (the area you sit on) you have your sacrum and coccyx, which are smaller bones that tuck inwards slightly.
You have a long cord that runs through your spine and transports nerve signals between your whole body and your brain.
Around your spine you then have a range of connective muscles, ligaments, tendons, tissues and nerves.
When you put all of these components together you have a sophisticated and complex structure.
Your back is strong and perfectly designed to keep you upright and to support the millions of small tasks and movements that you complete every day.
Most of the components in your back are pain sensitive, which is why you experience back pain if they are under abnormal stress or overloaded.
What is classed as back pain?
Back pain can affect different people in different ways.
It is usually either pain or stiffness, but can also be a combination of both.
It may be a sharp pain that starts suddenly or a small discomfort that gradually increases over time.
The pain may feel focused to a particular area for some, but for others it may feel like it moves around and transfers to other areas.
The below are common symptoms of back pain:
- Sharp pain
- Dull aching pain
- Pain that travels to your buttocks, hips or legs
- Stiffness or difficulty moving without pain
- Discomfort when sitting or staying in the same position for long periods
- Pain that feels better when you change positions
- Difficulty sleeping and pain when you wake-up
Are there different types of back pain?
There are many different types of back pain and clinical diagnosis, but for the purposes of this article let’s look at the two main areas that we see.
The first is what we call ‘back dominant pain’. This is typically felt around the spine and possibly radiating into the buttocks.
People with back dominant pain can experience spasms and usually find that certain positions or movements aggravate the pain.
The second type of back pain that we commonly see is ‘leg dominant pain’. This is where the pain is felt more down the legs than in the back.
One form of leg dominant pain is sciatica. Sciatica tends to be felt down the back of the leg and often in the hamstrings.
Another presentation of leg dominant pain is when patients only feel the pain when walking or standing and often describe a heaviness that gets worse in the legs.
Why does back pain happen?
The sophisticated nature of this area and the demand that we put on our backs day to day means that at times we may experience back pain.
Sometimes there is an obvious problem such as an injury from an accident, but often it is not possible to identify or diagnose one single cause or reason for back pain.
The causes are often multifactorial and there can also be physical triggers as well as stress-related causes.
This is a clinical way of saying that back pain is often due to a combination of different things, including emotional factors as well as the physical condition of your back and any mechanical causes.
Just some of these factors may include:
- Spine or muscle imbalance
- Lack of strength or weakness in a certain area
- Natural degeneration and changes that come with old age
- Poor posture
- Preconceived ideas about back pain and managing it
- Conditions that affect inflammation, such as arthritis
- Pregnancy-related changes
- Stress and anxiety
- Repetitive strain, for example, sitting for long periods or lifting with one arm
- Being overweight
- Trauma or injury to the area, such as a trapped nerve or muscle tear
- Your outlook and how you feel about your back pain
- Biomechanics, which is how your body functions as a whole and distributes weight
How is back pain diagnosed?
Most people with back pain will seek out physiotherapy themselves or speak to a GP who will refer them for physiotherapy.
At your first appointment, your physiotherapist will ask you to tell them as much as you can about your back pain. For example, when it started, where it hurts and how it is affecting your day to day life.
They will look at the area and asses how your body functions, so you should be prepared to remove a few pieces of clothing to expose your back if necessary.
At the end of your first appointment your physiotherapist will be able to discuss possible causes with you and a proposed treatment plan.
Do I need a scan?
Usually, the clinical examination provides a better diagnosis than scans can.
Sometimes scans such as MRIs and X-rays may be required to rule out other serious conditions or illness, but they are not a routine part of diagnosing or treating back pain.
Only 1 in every 2,500 scans will identify an important finding, so scans will not necessarily give you ‘answers’ or improve treatment outcomes.
When will my back pain get better?
Most back pain improves or goes away on its own within a few weeks.
Around 30% of people will experience another period of back pain within 12 months and we call this recurrent pain.
For these people, it’s important to view back pain as a problem that can be managed, as opposed to an illness, disease or event.
Sometimes back pain can turn into what we call chronic or persistent pain.
When should I seek help?
No one should have to suffer with pain, discomfort or worry alone.
I would recommend that you speak to a chartered physiotherapist if:
- The pain doesn’t improve at all within two weeks
- The pain becomes more severe or gets worse
- You are unable to work or complete everyday activities
- You are feeling very low or worried about your back pain
When is back pain serious?
Back pain is rarely caused by a serious underlying problem or condition.
Sometimes the pain can feel very extreme, but this does not mean that it’s reflecting the severity of an underlying cause or problem.
Many patients come in and say ‘I think I’ve slipped a disc?’ or ‘I’m worried that I’ve broken my back?’
These are misleading phrases that have unfortunately become common and part of our casual language.
Our Common myths about back pain article dispels some of these beliefs and also explains how the discs actually work and are likely to become injured.
If you are experiencing back pain and suffering with changes to your bladder or bowel function, this could be a sign of a rare but more serious problem called Cauda Equine.
If you have these symptoms then we recommend that you seek urgent medical attention by calling the NHS helpline on 111 or attending A&E.
What treatment is available?
At your first appointment your physiotherapist will talk to you about possible treatments and the ways that you can work together to address your back pain.
Often because the causes of back pain are multifactorial, it can require patience and a combination of different treatment approaches before things improve.
If you are seeing an Ascenti physiotherapist then your treatment plan may include:
- Soft-tissue massage to reduce tension and improve function
- Exercise therapy to improve strength, stability and balance
- Joint mobilisation to loosen stiffness and improve function
- Using heat and ice at home to relieve pain and swelling
- Moving regularly and avoiding long periods of inactivity or ‘bed rest’
- Stretching exercises to relieve tension and improve function
- Looking at your biomechanics and advice about shoe orthotics
- Lifestyle advice and psychological support
In some cases your physiotherapist may refer you on to other healthcare specialists or professionals.
For example, pain specialists, psychologists, physiotherapists that specialise in certain conditions, nurses or pharmacists.
How can I manage the pain myself?
You are an important part of successfully managing your back pain.
Here are some guiding principles for treating your back pain and links to other articles on our website that can help you:
1. Follow any personalised exercise guidance or lifestyle advice that you have been given by your physiotherapist or doctor.
2. There are ways that you can treat and relieve your pain at home. Read our 10 ways to manage pain article.
3. Try to stay positive and make sure that you know the facts about back pain and have the right outlook – read common myths about back pain.
4. Avoid ‘bed rest’ and keep moving as much as you are able to within your comfort zone.
This is a really important one, as completely immobilising your back can lead to longer-term weakness and problems.
5. Make sure that you are getting the right quality of sleep and rest – read our six tips for a restorative night’s sleep.
6. Eating well and being a healthy weight can make a big difference to back pain. It’s important that you fuel your body with a balanced diet.
7. Back pain can leave people feeling very low, so make sure that you look after your mental health as well as your physical health - read our tips on how to stress less and recover faster.
8. Exercise and be active. Many people perceive their back pain to be disabling or are concerned that exercising will bring it back or cause further pain.
This is not the case and remaining active and moving as much as you can is in fact an important part of long term management.
9. Be proactive about preventing back pain in the future – read how to stop back pain before it starts.