Lower Back Pain: the public enemy no.2

Back pain, lumbar pain, lower back pain: these are all expressions that indicate a common evil. So common infact, as to be the second main cause of medical advice after sore throats, the number 1 public enemy. So widespread that it justifies 40% of absences from work. In this article we will learn more about what is meant by lumbago, how to prevent it and the remedies used to treat it (from physiotherapy to back exercises).

What are we talking about when we talk about lower back pain?

Let's start with the definition of the World Health Organization:

Lower back pain is a constellation of symptoms that are usually described as acute and reversible.

In this description we are struck by several things, in addition to the poetic ambitions of the WHO. First of all, it is interesting to note that lumbago is not defined as a disease but as a set of symptoms. Not an unambiguous symptom, but a constellation. This is the first point that makes us already understand the complexity of the phenomenon. The symptoms are then acute and reversible, typical of the most widespread lumbago, our number two enemy. When the symptoms occur they are acute, initially, that sometimes excruciating pain that radiates from the lumbar belt and that even prevents us from walking. When the pain spreads along the lower limbs to the feet, one speaks of sciatica loin pain. The good news also confirmed by the WHO is that the pain is acute but reversible, that is, it gradually fades and then disappears in about 30 days.
Acute form
We have just described the most common form of lumbago, the acute one. It is characterized by:

  • pain;
  • injury (muscular, ligament, joint and/or discal);
  • inflammatory phenomena.

Let us say a few words about the last item on the list to dispel a negative myth. When we hear talk of inflammation, a warning bell goes off immediately, and it can evoke feelings of stress. Today we want to tell you that the inflammatory processes come in peace, they are our friends, in a certain sense and they are put in place to make our body react by giving way to the healing process.
After the inflammatory phase, acute lumbar pain is expected to recover within approximately 30 days. It goes without saying that healing does not happen by itself, as if by magic, but we must implement a series of measures that involve therapy in the strict sense but also, and above all, our lifestyle. We will see them later.

Chronic Form
When we do nothing to improve the situation or we do not do any of the things mentioned above and the pain lasts a month, two or three, the acute form becomes chronic. When a situation becomes chronic it means that it lasts over time becoming part of us with the establishment of a new balance, albeit negative. Of course today with the various therapies we can recover a physiological situation but something pathological always remains. If, like many, we suffer from back pain our goal will be to avoid the chronicisation of the condition.

Risk Factors

We will now analyse the main risk factors affecting the transformation of acute to chronic lumbago. We can divide these factors into physical and psychological/social factors:

  • previous lower back pain;
  • low level of physical activity;
  • being overweight;
  • smoker

We usually always focus on physical factors, taking it for granted that if we suffer from back pain the cause is a fracture, tissue damage or muscle tear. But this is not always the case. In fact, an important part of risk factors is psychological and social. One factor above all and this is the stress that is often added in the lumbar and cervical areas. Let's think about how many times we "curl" our shoulders, contracting them while we react to tensions, to nervousness. We multiply this situation several times a day, every day and understand the impact of psychological factors on our back.

Only 20% of lower back pain is caused by a problem specific to the spinal column. The remaining 80% is instead originated by non-specific factors such as incorrect postures and movements, stress, poor fitness and excess weight.

Lower back pain: better known symptoms

Pain and stiffness are the common denominators. The pain may be placed differently, more to the right, left, up or down, but always in the lower back. Pain may occur continuously or intermittently and more frequently during the day or night. It can also be felt more after physical exertion or small movements. The consequences of pain are, however, the difficulty of moving and maintaining certain positions: we can no longer climb stairs, sit down to work or drive. The backache becomes disabling and prevents us from living our everyday lives.
The term constellation, which the WHO uses in its definition of lumbago, gives a good idea of the complexity and granularity of the causes. Back pain in the lumbar region is a multifactorial disorder as we have already pointed out. The scientific literature has identified more than 800 different factors causing back pain and, even grouping these factors according to common characteristics, we find ourselves with at least 30 possible causes. This shows that it is difficult for doctors to make the diagnosis and thus to undertake the correct treatment.
In 2001, a study tried to rationalise the scenario by classifying possible diagnoses into three large groups. Let's leave out what concerns visceral problems (kidney disease, aneurysm, endometriosis...) and focus on the other two groups that divide the prognosis according to mechanical and not mechanical problems. The first group is the master because 97% of lumbago can be traced back to it while only 1% is caused by non-mechanical problems (tumors, infections, rheumatic inflammations).
If we then examine the diagnoses focused on mechanical problems we come across another surprising discovery: only 4% of the prognoses are attributable to the herniated disc, a disease that seems to be much more widespread according to popular belief and beyond. The simple swelling at the vertebral level that is observed in some resonances is not disc hernia but protrusion (the fibrous ring of the disc is deformed under the thrust of the pulpy nucleus). A disc herniation is defined as the complete expulsion of the pulpy core contained within the intervertebral disc. Since this is 4% of all cases, it is not such a frequent disease. So what are most of the mechanical diagnoses to be attributed to? 70% of the cases of lumbago are due to skeletal muscle problems such as overloading or stretching of the back.
In the illustration: disk herniation with core ejection. Different from the simple discal protrusion.

When should diagnostic tests be carried out?

Identifying lumbago is therefore complex because the structure of the back is articulated, the perception of pain changes from subject to subject and the causes of back pain are highly subjective. What, then, should we do? At this point we need to dispel another myth: for clarity we do not necessarily have to rely on a diagnostic test (X-ray, CT, MRI). First of all we have to understand together with the doctor if there is actually this need, that is if we are in presence of what we could define as red flags, precise signals indicating other pathologies as the cause of lumbago. If these signs do not appear in the first four weeks, there is no need for diagnostic investigations.
The red flags
Below we list those symptoms that act as flags of signaling for our body, indicating the possible presence of other significant pathologies:

  • sudden intestinal changes or difficulty of bladder control with associated numbness of the inguinal area;
  • infection: prolonged fever, weak immune system;
  • fractures associated with severe pain immediately after a road accident or fall, or in the presence of osteoporosis;
  • sudden weight loss: diagnosis of prostate, breast and lung cancer with constant pain for weeks even in a relaxed position or significant weight loss in a short time;
  • rheumatic inflammation and ankylosing spondylitis: morning pain and stiffness already at a young age (15-35 years) which improves with movement.

If these signs do not appear, it is not necessary to carry out further diagnostic examinations in the first four weeks. Also because we remember that in the vast majority of cases the lumbago is given by skeletal muscle problems and therefore should be treated at the level of symptoms.

Therefore, it’s better to avoid exposing ourselves unnecessarily to radiation if possible. Perhaps we do not dwell on this aspect because radiological examinations have now become part of our routine.   But over the course of a lifetime, the radiation is there and is accumlated – examination after examination.

How to Prevent and Treat Lower back pain

So you’ve taken your daily dose of anti-inflammatory drugs, put yourself in bed surrounded by pillows and with a good book for company and the pain eventually passes. It’s convincing that this has been a winning strategy, but it is not.

Antiinflammatory and rest are not the cure.

Of course, during the acute phase, we need to take some action and alleviate the pain that would otherwise prevent us from moving: it is movement that we need to aim for and not absolute rest. We were born to move and therefore we must return to doing so as soon as possible. We can stay in bed if we really cannot do anything else, but the advice is to get up as soon as we get better.
We know that lumbago can be very debilitating and therefore it is advisable to take anti-inflammatories but only in the acute phase, we should not abuse these drugs which, among other things, are particularly harmful to our stomach. In addition, eliminating pain is not so healthy, we’ll explain this better: we emphasized above how the painful sensations are our first alarm bells along with inflammatory phenomena, we need to understand that something is wrong. If we eliminate these warnings altogether, we risk causing further damage to the lumbar area because we resume all our activities without taking the necessary precautions. So you can take anti-inflammatory drugs but do so with caution and do not consider them the cure. Rather as a means to return to exercise.
Physical activity' refers to any form of movement, while 'exercise' refers to a more structured way of moving, performed for specific purposes.
In most cases (97%...) the real cure for lumbago is physical activity. It is the only remedy recognised in medical literature and the only scientifically proven cure. There are countless other types of treatment, from manual treatments such as muscle relaxing massages, to instrumental therapies (lasers, teak), from postural gymnastics to acupuncture. But none of these therapeutic pathways has been scientifically validated. To the question "What is the effective cure against lumbago? The answer is one and is universally recognised: physical activity.
We need to take a softer approach, gradually starting physical activity again. A good rule of thumb is to start with stretching and relaxing exercises for the lumbar region. Among the recommended activities: yoga, tai-chi and pilates, suitable for regaining mobility. In the summer we can opt for outdoor walking or cycling. In a second phase we can work alongside exercises aimed at what was our sporting activity: the aim is to return to practice it but we can not delude ourselves to start physical activity again starting from that. The important thing, even before you start to move, is not to give up but persevere keeping in mind that in 90% of cases back pain regresses within 30 days of appearing.
This is the good news, this is the bad news, that if we do not eliminate the risk factors that predispose us to lumbago, it will reappear in a few months and the cyclical reappear will then lead to a chronic situation. So we can never give up the grip!
Prevention in this case is essential to keep low back pain out for as long as possible. Sometimes it takes very little to prevent back pain. In most cases, 10 minutes of exercise per day is enough to significantly improve the health of your spine. Other times the simple elimination of risk factors (obesity, stress, smoking, incorrect posture) allows to solve the problem at the root or at least to slow down its reappearance. Prevention therefore involves taking on a healthy, wellness lifestyle. It is much more difficult to change one's lifestyle than to take an anti-inflammatory, but the long-term benefits will prove us right.

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