Back pain

Low back pain is extremely common.  More than 80% of people will experience it at some point in their life.  Low back pain is a major cause of worry, disability and time off work.  Even though it can be extremely painful it is rarely associated with serious disease.

There are three broad types.

• Mechanical Low Back Pain
• Nerve related back pain (Sciatica)
• Serious Spinal Pathology.

Mechanical Low back Pain

This is the most common type of back pain (95%).  It is not possible to diagnose the exact cause in the majority of people suffering with back pain.

It is thought that in some cases the cause may be a sprain or strain of a ligament or muscle. In other cases, the cause may be a minor problem with the disc between two vertebrae, or a problem with a small 'facet' joint between two vertebrae. There may be other minor problems in the structures and tissues of the lower back that result in pain.

It is not possible to identify these causes of the pain by tests. Therefore, it is usually impossible for a clinician to say exactly where the pain is coming from, or exactly what is causing the pain. To some people, not knowing the exact cause of the pain is unsettling. However, looked at another way, many people find it reassuring to know that the diagnosis is mechanical back pain which means there is no serious problem or disease of the back or spine.

The vast majority of people will recover from an episode of low back pain in six to eight weeks.  However, it is common to have further bouts of pain (recurrences) from time to time in the future.  In a small number of cases the pain persists and can be a long-lasting condition.

Sciatica (nerve root pain)

A small number of people will develop sciatica (5%).  Sciatica is caused by physical and/or chemical irritation of one of the nerve roots in the lower back.  It can cause leg pain with or without numbness and/or pins and needles in the leg.  Most of the time this improves, and the management of choice is exercise.  Should it persist and/or your symptoms worsen then please speak to your physiotherapist.

Serious Spinal Pathology

In rare circumstances (less than 1%) back pain can cause symptoms that require medical attention.

You should seek immediate medical attention by attending the emergency department if you have developed any of the following symptoms in association with your low back pain.

• Loss of feeling/pins and needles between your inner thighs or genitals
• Numbness in or around your back passage or buttocks
• Altered feeling when using toilet paper to wipe yourself
• Increasing difficulty when you try to urinate
• Increasing difficulty when you try to stop or control your flow of urine
• Loss of sensation when you pass urine
• Leaking urine or recent need to use pads
• Not knowing when your bladder is either full or empty
• Inability to stop a bowel movement or leaking
• Loss of sensation when you pass a bowel motion
• Change in ability to achieve an erection or ejaculate
• Loss of sensation in genitals during sexual intercourse.

Additionally, if you feel your back pain is associated with fever or unexplained weight loss you should also discuss this with a medical professional.

Why have I been referred?

Your health professional has assessed you and feels your symptoms are best managed through exercise. Please be reassured if your healthcare provider thought you had a condition that was serious and warranted further medical intervention you would have been referred to a specialist.  If your symptoms change or you are concerned, then please liaise with the physiotherapists in the class.

Research agrees that exercise is frequently the best treatment for people with low back pain. The evidence shows that exercise can reduce pain and improve overall function.  Other kinds of treatments can help in the short term, but doing exercise seems to make the biggest difference in the long-term.  These exercises are designed for those looking to get back to functional activity or sport.

When might I need further intervention?

Physiotherapy and time are the usual management of most lower back pain with or without sciatica. However, a small amount of people may need extra help with their symptoms. If physiotherapy is not helping over the course of 3 months and your symptoms have not improved, or are worsening then further investigations may be required. Magnetic resonance imaging (MRI) is the usual imaging modality for spinal pain. These are used primarily to look for invasive management targets, such as locations to trial a pain-relieving injection or surgery. If you are not seeking injections or surgery, MRI is usually of little help and would not change the management of your back pain. MRI scans of the spine often have findings in people without pain, known as incidental findings, so having an MRI when it is not needed can cause unnecessary worry and misattribute pain and lead to interventions that are not needed. If you have questions about this, you can discuss them with your physiotherapist or doctor.

 

If you would like this information in another format, for example large print or easy read, or if you need help communicating with us please contact:

First Community (Head Office)

Call: 01737 775450 Email:    fchc.enquiries@nhs.net    Text: 07814 639034

Address: First Community Health and Care, Caterham Dene Hospital, Church Road, Caterham, Surrey, CR3 5RA.

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Posture

We all come in different shapes and sizes.

There is not one particular posture that will prevent back pain. Research shows there is no link between a particular posture and pain.

Back pain is often associated with staying in one position for an extended period rather than a particular posture, i.e. when sitting at a computer, sitting watching TV or standing in a queue. Rather than thinking about one posture being good or bad, think about your next posture being your best posture. Moving regularly into different postures in combination with strengthening muscles that support your spine works best.

It may be helpful to think about moving positions every 15 minutes. This does not mean you have to start a mini exercise class. Simple postural changes, such as moving from a slouched to a more erect position when driving, a quick stand up when sitting or bending forwards and backwards when in a queue can be helpful.

Basically, regular movement will help you be able to engage in everyday activities and avoid unnecessary flare ups.

Lifting

A lot has been written with regards to lifting and the correct methods one should utilise, such as keeping the weight close to your body and bending your knees etc. and whilst this is sensible there are other considerations.

Most people will look at an object that needs to be moved and will have an innate sense of whether or not they are physically capable of doing it.

Where potential problems with lifting occur are:

• In emergency situations, such as when catching an elderly person who is falling / catching a picture that is falling off a wall.
• One-off lifting / repositioning i.e. garden flowerpots that are a lot heavier than they look or furniture especially when it gets stuck on the staircase
• Repetitive low loads such as digging in the garden, moving compost bags
• Adding a twisting movement into the equation, such as lifting shopping bags out of the shopping trolley and putting them in the car boot.

Important aspects of lifting to consider:

• Take the time to assess how heavy the object is
• How far it needs to be moved and what is the best method to achieve this
• Is this more than a one-person job? If you have to do it on your own, are you able to adjust the job to make it easier?

There is no optimal position for lifting in general. It is important to think about what you are lifting and your current strength/ability to perform the task at the current time.

 

If you would like this information in another format, for example large print or easy read, or if you need help communicating with us please contact:

First Community (Head Office)

Call: 01737 775450 Email:    fchc.enquiries@nhs.net    Text: 07814 639034

Address: First Community Health and Care, Caterham Dene Hospital, Church Road, Caterham, Surrey, CR3 5RA.

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Watch the ESCAPE-pain video on pacing here

 

Do you recognise the patterns below that you may have adopted due to the pain?

Over / under activity 

The longer you have pain, the harder it is to keep regularly active. In this scenario you often 'boom and bust'. On a good day when your pain is better, you may overdo some activities, which could lead to a flare up in your symptoms. Overtime this can lead to you avoiding activities and you may notice that you are becoming less and less active and are less able to cope with activity and smaller amounts of activity produces an increase in pain. 

What is Pacing?

It is a way of breaking this cycle so in the long run you can achieve more without aggravating your symptoms.

• Pacing is an essential technique for mastering chronic pain and often involves taking a break before you need to
• Pacing may reduce the severity and duration of flare ups
• Pacing may reduce feelings of frustration and low mood through repeated pain flare ups
• Pacing may reduce risk of medication overuse and adverse effects from this
• Pacing may reduce the risk of losing physical condition.

As a starting point you need to be able to calculate your baseline.

What is my baseline?

Try to think of a few activities/exercises that cause your symptoms to start, such as walking, standing, driving, gardening etc.  Your baseline is how long you can do that activity without flaring up your symptoms.

These are the questions you need to ask yourself with each activity -

For example, with walking:

How long can I walk before I have a flare up?

'30 minutes'

Can I for instance walk for 20 minutes without flaring up?

'Probably not'

Can I walk for 15 minutes without flaring up?

'Yes'

In this example the baseline is 15 minutes.

Now consider your activities and set some baselines.

How will this help me to progress?

If you continue working at your baseline level, you are unlikely to improve.  You will need to gradually increase the amount through pacing.

Pacing is a way of increasing your level of activity/exercise without flaring up your symptoms.

You can pace by: -

• Increasing the length of time on that activity/exercise
• Increasing the number of repetitions
• Increasing the 'hold' of an exercise
• Increasing the resistance of the exercise
• Reducing the rest time between the activity/exercise.

How to pace your activities

E.g. pacing your walking

Everyone will progress up the steps at a different pace. Some people may need a week to move from one step to the next, others may need two or three - do what is right for you and what your body can tolerate.

It may help to document this on a table.

Important note:

Do not do more than your daily target for that day, even if you feel good.  However, you must try to complete your daily task even if you are not up to it. If you are flaring up regularly then maybe you have increased the amount each day by too much. Go back and re-evaluate.

This has been shown to be extremely successful if you have the patience and the willpower!

 

If you would like this information in another format, for example large print or easy read, or if you need help communicating with us please contact:

First Community (Head Office)

Call: 01737 775450 Email:    fchc.enquiries@nhs.net    Text: 07814 639034

Address: First Community Health and Care, Caterham Dene Hospital, Church Road, Caterham, Surrey, CR3 5RA.

For office use only: Version 1 PFD_TS091(1)  Publication date: April 2025

(Persistent pain - also known as Chronic Pain)

What is pain?

Pain is our body's response to a perceived threat. It is a protective mechanism to help protect the body and optimise healing.

For example, if you were to roll your ankle and sprain a ligament, your brain would receive the sensory information that there is damage to the ligament and a protective mechanism is required to prevent further injury and optimise healing. That protective mechanism is to give you pain.

What is the difference between acute and chronic pain?

Acute pain comes on suddenly and is caused by something specific.  Acute pain usually doesn't last longer than 6 months.  It goes away when there is no longer an underlying cause for the pain, for example, when the ligament has healed.

Persistent pain is ongoing and usually lasts longer than 3-6 months.  This type of pain can continue despite the underlying cause having healed or gone away.  Persistent pain may be a symptom or consequence of a long-term condition such as Fibromyalgia or Rheumatoid Arthritis. Or it may develop following an injury or after an operation.  Some people experience chronic pain when there is no past injury or body damage. Therefore, pain does not always equal damage.

Living with persistent pain is associated with other symptoms, which can also include:

• Feeling very tired or wiped out
• Not feeling hungry
• Trouble sleeping
• Mood changes
• Weakness
• A lack of energy.

These symptoms can affect your life in more ways than just dealing with pain. It can affect your work, relationships, finances, mental health and social wellbeing. It is difficult to know whether these symptoms are due to the pain, but they are also known to make pain worse. Addressing the other impacts on your life can often help with pain. See section: 'Strategies to help persistent pain'.

Why do we get persistent pain?

Changes to the nervous system

There is evidence which shows that people living with persistent pain will have changes to their nervous system. This is because after prolonged periods of pain, the nervous system becomes more sensitive, and the brain sends pain signals without there being any physical damage. The signals are sent as a response to things which should not be painful, such as movement and pressure. 

Memory

Our own memories can influence pain.  Our brain remembers pain and can cause us to feel pain when we reproduce a previously painful movement based on stored memory of past pain.

Someone who strained their back muscles whilst lifting something may experience that pain when lifting again, a few months later. The muscles are healed from the initial injury, but their brain will want to protect them from another injury and will use the pain as a warning signal.

Increased attention

The brain decides what you will experience in response to information from the nervous system, the more attention certain information is given, the louder it is heard.

If you think about a ticking clock in room, when you busy and are not thinking about the clock you do not notice the ticking. However, if your attention is drawn to the clock for some reason such as, waiting for an important appointment, you will be more aware of the ticking noise.

So, are we saying the noise of the clock is louder? No, the sounds travelling from the ear to the brain is the same, but the brain decides how loud you hear it. This is very much like pain and how much we can experience it.

Mood and emotional state

A person's beliefs and attitude towards their pain can also contribute to persistent pain. Someone with negative thoughts, beliefs and attitudes towards their pain is more likely to have poorer outcomes compared to someone who is well informed and has a positive attitude.

It is widely accepted that mood and emotional state can affect pre-existing pain. Emotional distress can make pain seem worse. For instance, it is not uncommon for someone's pain levels to increase when they are going through a stressful time such as, experiencing a bereavement, going through a divorce, financial difficulties etc.

Deconditioning

People who are in pain tend to avoid movement, this can lead to muscle weakness and joint stiffness (deconditioning). These effects can contribute to our pain experience. Deconditioning can be effectively improved with physiotherapy.

Injury / condition

After an injury the scar tissue can have more sensory receptors, so it can feel more sensitive to movement and touch.

If you have a long-term condition, such as Rheumatoid arthritis, this pathology itself can contribute to ongoing symptoms.

Strategies to help persistent pain

Even though research suggests that persistent pain may never go away completely, there are several strategies and treatment options which have been proven to help make persistent pain less impactful on your life. These strategies need to be seen as a long-term management option, as they will not provide a quick fix for the pain.

Education: It is vital that you inform yourself about your condition so you are able to make the right lifestyle choices which may improve your symptoms over time. You may find that there are dedicated services and charities which are able to provide more specialist support. 

Pacing: If done properly, pacing can reduce the number of flare-ups you experience, and will enable you to become more active in the long term, as you will not need to spend so much time resting and recovering from a flare-up.

Pain medication: This could be over the counter medication or prescribed medication. Some people are reluctant to take medication for various reasons; nevertheless, pain medication may be necessary at times to ensure day to day tasks are able to be completed and you are able to stay active.

Pain relief: There are several options, other than medication, which can be used such as TENS, Acupuncture, cold treatment and heat treatment. Find what works best for you.

Regular exercise: This will prevent deconditioning of our muscles, joints and cardiovascular system and in turn reduce pain that was due to muscles being tight and weak. Regular exercise will also help to improve our fitness levels and reduce fatigue. 

Cognitive behavioural therapies: This can be useful to help challenge negative thoughts and beliefs about your pain, which may be leading to anxiety and stress.

Relaxation: This is another way to help manage emotional stress and can be done as little or as often as needed. There are several forms of relaxation which have some evidence to support their use in persistent pain: for example meditation and progressive muscle relaxation. Find a form of relaxation that suits your lifestyle.

To conclude

Pain is multifactorial and not always associated with tissue damage. When pain persists, it may be worthwhile thinking of strategies to keep active and minimise the impact of your pain on other aspects of your life using some of the strategies discussed.

Useful resources

• Turning down the volume on pain booklet. Body logic
• Headspace app: Meditation and sleep made simple. 
• Managing pain at home.    CSP guidance
• 12 tools to help with self-management. Pain Toolkit 
• Understanding Pain in less than 5 minutes, and what to do about it video by Live Active Chiropractic (Live Active Clinic) 
• Making decisions to help you live well with chronic primary pain - NHS

 

If you would like this information in another format, for example large print or easy read, or if you need help communicating with us please contact:

First Community (Head Office)

Call: 01737 775450 Email:    fchc.enquiries@nhs.net    Text: 07814 639034

Address: First Community Health and Care, Caterham Dene Hospital, Church Road, Caterham, Surrey, CR3 5RA.

For office use only: Version 1 PFD_TS091(2)  Publication date: April 2025

There is strong evidence to support exercise in the management of back pain.  Exercise has been shown to successfully reduce pain and improve function.  Being in good physical condition enables you to cope better with everyday tasks.  It will also help you to feel good about yourself as 'feel good' hormones (endorphins) are released.

Exercise incorporates:

• Cardiovascular training - this is any activity that increases your heart rate and gets you out of breath - it does not matter what you do.  You should aim to feel slightly out of breath and be sweating but you should still be able to hold a conversation
• Strength training - targeting specific muscles using free- weights/bodyweight or resistance equipment
• Stretching - Usually done at the end of an exercise session to warm down.  This is most effective if done regularly through the week.

What type of exercise is best for my back pain?

It is best to do a combination of the above so you work your muscles in different ways. All exercise is good and the fitter you are the better.

A few pointers -

• Warm up gently at the beginning of an exercise session and cool down at the end with some stretches
• Ensure your back feels comfortable whilst exercising
• Remember to pace your exercise and progress them gradually over time
• It is normal to feel some muscle soreness at the start of a new exercise programme.This should ease as you get stronger
• It usually takes 6 weeks to start noticing any change in strength, endurance or flexibility.  Do not lose heart if you do not get immediate results.  Be patient as the results are worth waiting for!

Should I exercise outside of the class?

• To get the best results from the programme you should do exercise at home on a regular basis as well.  You can continue with the exercises shown in the class
• The government guidelines for healthy adults is 150 minutes of moderate intensity activity or 75 minutes of vigorous activity a week
• Moderate intensity exercise is defined as increasing your heart rate, sweating but able to hold a conversation
• Vigorous exercise would elevate your heart rate further and you would find yourself out of breath, with difficulty forming full sentences whilst exercising
• Both moderate and vigorous intensity exercise will help your back pain and general health; there is no benefit to choosing one level of intensity over another. The best option is the one you will stick to and enjoy!

 

If you would like this information in another format, for example large print or easy read, or if you need help communicating with us please contact:

First Community (Head Office)

Call: 01737 775450 Email:    fchc.enquiries@nhs.net    Text: 07814 639034

Address: First Community Health and Care, Caterham Dene Hospital, Church Road, Caterham, Surrey, CR3 5RA.

For office use only: Version 1 PFD_TS091(8)  Publication date: April 2025