Specializing in Spine, Sports & Physical Medicine

The Vagaries of Low Back Pain

Low back pain is still one of the top two reasons why people see doctors. It is responsible for 40% of all missed work days.  Most back pain complaints are “mechanical” in nature and the severity of the pain is not always an indicator of the severity of the problem.  The vast majority of people get better without medical intervention however upwards of 30% have a recurrence of pain within 6 months and 40% within one year.

There is two general categories for back pain issues, the first being “back dominant pain” in which the primary pain is worse in the lower back.  This pain may radiate into the buttocks or the outside of the hips but the majority of the pain is in the lower back.  This kind of pain can get worse with such things as bending backward or forward and usually comes and goes and there can be spasms when you move.  This is usually a good type of pain because there has been no damage to the nerves or spinal cord and surgery is usually not indicated.

The second type of pain is “leg dominant pain” and there are two common presentations, the first is with a disc problem and there is pressure on one or more of the nerves in your lower back and pain will travel down the legs.  This type of pain is often referred to as sciatica.  It is frequently worse with sitting and better with lying down.  The person may have back pain but the pain in the leg is much worse.  Sciatica can get better by itself but being evaluated by a spine specialist may be beneficial as there are treatments that can ease the pain and improve function.  Additionally, diagnostic imaging such as an MRI can be performed if injections or surgery is being considered.

The second type of leg pain is the kind that is typically worse with standing or walking and is better with sitting or leaning forward.  The pain or heaviness as it is often times described can be anywhere in the leg and patients frequently complain of a worsening of the pain the longer they stand or walk.  This is known as “neurogenic claudication”.  This is typically seen in people in their 60s and older and is result of aging changes in the spine with subsequent narrowing of the channels that the nerves pass-through.  The medical term for this is spinal stenosis.

Pain in the lower back that is short lasting is almost always benign, however, there are certain red flags that may point to a much more significant problem that needs immediate medical attention.  The first is a sudden change in your bladder or bowel control or numbness around the groin or rectal area which could be caused by significant compression of the spinal nerves.  The second is a possible infection in the spine.  This might present with a persistent fever, a history of intravenous drug use, or those with an impaired immune system.  The third is a risk of fracture in the back that can occur from a significant fall, motor vehicle accident or in someone who has osteoporosis.  The fourth red flag is if cancer is suspected especially if there is a current or prior history. This is true especially if the cancer was located in the prostate, breast or lung. Possible clues to the spread include constant pain that is worsened by lying down and a history of unexplained weight loss.

Finally, there is back pain related to autoimmune diseases in which there is a lot of inflammation such as with ankylosing spondylitis.  The good thing is that this is very uncommon.  It usually occurs in those from 15-35 years of age with associated night pain and significant stiffness in the lower back in the morning that can take an hour or more to lessen once the person is up and moving around.

How important are X-rays in acute low back pain?

So, you have back pain and it hurts a lot, is an x-ray always necessary?  An x-ray of the lower back is important to perform if one of the above red flags is present but if not, it is rarely helpful and is estimated that it only shows significant findings in 1 out of 2500 individuals.  Furthermore, in studies in which people without back pain had MRIs of their lower back upwards of two thirds of them showed abnormalities.  So what is the harm in doing these tests?  If someone is told that they have pathology in the lower back such as degenerative disc disease they might think that they have to stop exercising or if they feel a twinge they may stop an activity. In the long run this might actually be more detrimental than helpful.

Do your beliefs about back pain influence recovery?

The attitude that one has as it relates to their low back pain actually can have a strong influence on their outcome.

The next type of flag to discuss are the yellow flags. These are signs that could result in an increased risk of developing a chronic and persistent back pain issue.  The first is the belief that back pain is harmful, the second is the fear and avoidance of activity and movement because of back pain.  The third is a tendency toward a low mood and isolation that is frequently seen in chronic diseases and the fourth is a strong expectation that passive rather than active treatments will help. Active treatment simple means that the patient needs to also do the work to get better not just the therapist.

So what DOES work for back pain?

Movement for back pain actually speeds recovery while strict bed rest slows recovery and people do worse.  The prescription of strict bedrest for back pain use to be very common until medical researchers showed that it was better to move then to be in bed.  With that said, for some individuals such as with significant sciatica there will be periods of time during the day that rest will be important. So movement is important.

Treatments such as massage, acupuncture and chiropractic care can be beneficial in the early stages of back pain but if one does not see significant benefit after 6-10 sessions then more treatment is unlikely to help.  For more chronic back problems two types of treatment strategies that have been shown to help include cognitive behavioral treatment and functionally restorative care which is a multidisciplinary treatment program involving physical and occupational therapists, psychologists and physicians all working together as a team.


  1. The prognosis for acute low back pain is excellent and most improve on their own.
  2. Over 90% of individuals with acute low back pain do recover.  An episode can be brief or last several weeks but typically does improve significantly or goes away.
  3. If there are no red flags people usually do well by acknowledging the pain but not focusing on it.
  4. For those with chronic back pain the prognosis is still good but one needs to try to maintain an active exercise program and to seek medical advice for flare ups that are not settling down especially those that lead to a reduction in one’s ability to stay active and to function normally.  It is important to be aware of one’s attitudes and beliefs towards the pain as this can affect one’s long-term prognosis. Don’t forget- “Movement is Medicine”
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