Acute back pain is common. 80% of people experience back pain during their lifetime and as many as 50% of the population will have an episode of back pain in any one year.

Key Points

• GOOD PAIN CONTROL
• EARLY RETURN TO ACTIVITY
• IT WILL HURT YOU WON'T HARM IT

Acute low back pain is defined as pain in the back, anywhere between the lower ribs and the buttock crease. The definition of acute is simply an episode that is shorter than 6 weeks in duration.

It can be very painful and very frightening. Fortunately, it most commonly gets better on its own. What most patients seek from doctors is how to get better quicker and how to reduce the chances of it happening again.

Acute back pain can take different forms. Many people have occasional back pain that isn’t too bothersome. That is, they cope well and get on with life, maybe just taking a few painkillers now and then.

A common concern is a severe acute episode. Some people have ‘spasms’ or an acute locking, getting ‘stuck’ in one position. Don’t worry if this happens, the back muscles always ‘unlock’. The question is how to ‘unlock’ and get back to being able to do things quickly. A key to early rapid recovery seems to be good pain control and early movement, returning to activity as soon as possible.

The Back Book

‘The Back Book’ has been shown in a randomized controlled trial to assist in giving the right message at an early stage. Many Health Centers and Hospitals will have it, if not, it can be obtained from The Stationary Office by post.

All the research over the last 10 years suggests that resting up may prolong the time it takes to recover.

An important message is YOUR BACK WILL HURT, YOU WILL NOT HARM IT

Pain control is important. Many ‘over the counter’ preparations can be very effective. The combination of Paracetamol, two tablets, as well an anti-inflammatory is quite safe as they work in different ways. Ibuprofen at a dose of 400mg three times daily is safe and effective for most people. Paracetamol is a pain killer that works both centrally within the brain and at the peripheral pain source. Recent studies have shown it to be particularly effective for back pain. It may be that because it available in supermarkets the public perception is that it is not very strong, this belief has been shown to be a factor in the effectiveness of pain killers. Ibuprofen is an anti-inflammatory, it also a good analgesic or pain killer as well.

Occasionally the pain isn’t relieved and stronger pain killers that contain codeine for instance can be used for a short time. Some of these are available over the counter or from a pharmacist. Stronger painkillers than these need to be prescribed by your doctor. It may be that if the simpler common solutions are not working the reassurance and assessment by a doctor or similar health care professional will help you get better quicker.

Patients will often have a concern they may ‘mask’ the pain with pain killers and damage themselves further. This is simply not true. The body has very powerful protective reflexes, and simple pain killers do not remove them. The analogy would be that you can’t put your hand into boiling water just by taking simple pain killers, so it is that you won’t harm your back by moving when you have taken simple pain control measures.

So remember, Paracetamol One gram and Ibuprofen 400 mg on a pretty regular basis until the pain is significantly improved.

If you have any concerns about taking this type of medication discuss it with a pharmacist.

Most episode of acute back pain get better. Once the pain is starting to improve it is important to get back to normal activity as soon as possible.

Don’t wait to be 100% better before returning to activity or work. Early movement seems to shorten acute episodes and get them better quicker.

Bed rest seems positively HARMFUL so all current recommendations are to avoid bed rest. This is based on scientific controlled trials which compared bed rest of two days to carrying on with normal activity. The link below will take you to a brief abstract and the full scientific paper if you wish.

The Treatment of Low Back Pain

The effect of bed rest or keeping active is small. A comprehensive review is avalable at the link below.

http://content.nejm.org/cgi/content/abstract/332/6/351

The Cochrane Library

Physiotherapy, chiropractic and osteopathic treatments do not seem to have a large effect in the first 4 weeks of an acute back pain episode; this is because it so often gets better on its own.

The role of health care professionals is mainly around giving the ‘right’ message and the reassurance that there is nothing seriously amiss. Avoiding ‘mixed messages’, which can be very confusing is important, so make sure you use reliable information sources that hopefully are not too ‘commercial’.

Doctors have a number of ‘RED FLAGS’ that sometimes mean further investigation or assessment would be wise. The red flags can be indicators of serious disease but not always. Doctors are on the look out for nerve root compression, spinal cord compression, cancer or infection; these are uncommon causes of back pain.

http://mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD001254/frame.html

Red Flags

• A previous history of cancer surgery or a previous diagnosis of cancer
• Unexplained weight loss
• Pain that continues to get worse despite good pain killers
• Risk factors for infection might be the recent use of high dose steroids, or drugs to suppress rejection. Other risk factors would be any factors that reduce resistance to infection such as I.V. drug use or AIDS.
• A first episode of severe back pain over the age of 55 years
• Pain that wakes you from sleep at night and you can’t get back off again.

Cauda Equina Syndrome

This is a condition that we treat as an emergency. The main features are numbness around the bottom area and alteration in the function of bladder or bowel. The back pain is often severe and may go down both legs.
If this happens you should seek emergency medical advice without delay.

Yellow Flags

These are sometimes the obstacles or hurdles to recovery. They can usually be overcome, but some patients need help with them. Early treatment can avoid the disability that will sometimes occur when back pain continues for longer than 4 weeks.

Many of the yellow flags are the fears and beliefs that we all have about pain. Some patients become fearful of the future, worried about ending up in a wheelchair. Some patients will start to practice what we call ‘pain avoidance behavior’ where they stop doing things because they are frightened of making it worse.

These fears and beliefs can sometimes be made worse by helpful ‘friends’ who have frightening negative stories about back pain. The views of many years ago regarding back pain are now known to be wrong. Modern studies have given us many ways to get people back to function and work much quicker than before.

Remember ‘It will hurt, but you won’t harm it’

Some of these links have useful advice, have a look.