Back Pain — Causes, Types, Categories, Risk Factors, Red Flags and Treatments 

Young businessman holding his back with a pained expression

“The spine affects and is affected by every movement your body makes. The way you stand, the way you sit, the way you move, the way you pick up and carry objects — all these things have the potential to help or hurt your back.”

Mary Pullig-Schatz, M.D., Centennial Medical Center in Nashville, TN

Who is at risk for back pain? 

Up to 75 percent of the population experience low back pain lasting more than one week at some point in their lives.  

Back pain in people 18-24

In a one year period, the estimate of people with an episode of back pain is about 17 percent.  Also the estimate of the people 18 to 24 years having back pain in a one year period is 13 percent.  

“The prevalence of back pain in the youngest group studied (18-24 years old) was 13 percent for females and males.”

Back pain in people 25-40

“People between 25 – 40 years old had between 16 – 18 percent incidence of back pain.”

Back pain by age 50

By the age of 50 years old, about 85 – 90 percent of adults will have degenerative changes in their vertebral  discs, and these changes begin to occur in the third decade of life.  Also, by the age of 50 years, about 85-90 percent of adults will be found on autopsy to have degenerative disc disease.

Back pain is one of the most common medical disorders in industrialized societies.  After the common cold, low back pain is the most frequent cause of lost work days in people under 45 years of age.

Epidemic of low back pain in industrialized nations  

“Today major literature from virtually every developed country of the world describes prevalence, incidence, risk factors, and natural history of low back pain and sciatica.”  “An Overview of the Incidences and Costs of Low Back Pain,” Orthopedic Clinics of North America, 1991 

Some studies state that back pain disables 5.4 million Americans each year.  

Of people with new onset back pain 70 percent will recover within one month and 90 percent in three months. 

Symptoms last for greater than six months in only 4 percent of the cases; however, this group represents 85 percent of the money spent on treatment and compensation for back pain.  

Office worker syndrome - man with back pain
Office man Illness from hard work. Office syndrome Infographics.

Countries convened to discuss back pain disability

Only about 50 percent of people with long-standing back pain ever return to work.  The disability situation is so important, numerous countries and organizations have convened to discuss the problem.  

People may need to modify work or play activities once an episode of back pain occurs.  Certain factors may predispose people to injury, such as —

  • Improper lifting techniques, 
  • Poor posture while sitting 
  • Poor posture while standing 
  • Prolonged sitting    

A good regimen to follow to reduce existing back pain or prevent future back pain is a daily routine of stretching.  The more flexible a person is, the less likely they are to experience pain. 

“For a rapid recovery from low back pain, maintain minimal bed rest, make changes in the workplace, and follow simple educational tips to avoid re-injury.” National Health and Nutrition Examination Survey, 1995

CAUSES OF BACK PAIN 

Changes in the Natural Curve of the Spine 

The spine is a structure that connects your upper body, including your chest and arms, to your lower body consisting of your pelvis and legs.  

The spine provides mobility and strength.  The mobility allows you to turn, twist, and bend.  The strength allows you to walk, stand and lift.  Proper functioning of the spine is needed for almost all activities of daily living.

In the upright position, sitting or standing, with normal spinal curve (lordosis), the ligaments of the body maintain the spine with little need for the muscles to help.  However, if the normal curve of the spine is flattened (sitting on a flat seat surface, repetitive forward bending) or accentuated (pregnancy, “beer-belly”) the weight-bearing muscles must contract.  

Changes in the natural curve of the spine make the joints and spine weight-bearing, and these changes in body mechanics cause back pain.  

Back Pain Caused by “Overt Instability”

“There is reasonable evidence that overt instability while sitting and standing causes back pain and elimination of that instability will reduce pain.”  Cholewicki and McGill – 1996

Back Pain Caused by “Postural Dysfunction”

“Most people are completely unaware of all the things they habitually do that contribute to this problem.  What set it up (back pain) to begin with, though, was some sort of postural dysfunction that already existed and actually created a weak spot in the spine.” Bell and Rothman, 1984; Basmajian 1989

Twisting, Bending, and Poor Posture

For example, a person with or without a history of back pain could be picking up boxes, vacuuming, working in front of a computer and twisting the body slightly.  At the time, the person may not notice any change in the way his or her back feels.  However, over time (sometimes long, sometimes short) these types of activities strain the muscles of the back and cause poor posture which can cause and worsen weak spots in the spine causing back pain.

Back Pain due to Leg Length Discrepancy

One of the most common postural problems leading to back pain is a leg length discrepancy which causes a pelvic tilt.  When this situation becomes severe it is usually termed scoliosis.  

Some experts say that anyone that has broken a leg must assume they have a leg length difference, especially if a leg injury occurs during childhood, while the leg growth plates are still growing.

Common Causes of Low Back Pain

Common causes of low back pain are: 

  1. Trauma leading to muscle strains
  2. Degenerative changes
  3. Disc herniation
  4. Vertebral (Spine) Fractures

1. Trauma

Trauma is the most common cause of low back pain.  These events lead to muscle strain, and these injuries will almost always heal with time.

2. Degenerative Low Back Syndrome

The symptoms of Degenerative Low Back Syndrome are often recurrent and chronic in nature.  This type of pain is regularly made worse by bending or lifting, which suggests postural, muscular, or arthritic factors are playing a role.  

Degenerative Low Back Syndrome is the most common syndrome seen in orthopedic clinics.  What was formerly called “sacroiliac strain” is now known to be due to, in many instances, disc disease.

3. Disc Herniation is Common in People – 30’s and 40’s

Herniation of lumbar discs is a major cause of severe and recurrent low back pain and leg pain.  People usually experience this in their 30’s and 40’s.  The cause is usually a flexion (bending) injury.  However, a considerable proportion of patients do not recall any traumatic episode.  

Note:  If sitting makes low back pain worse in a person between the ages of 30 and 50, a herniated disc is a likely diagnosis.  

4.  Vertebral Fractures – Common in the Elderly

Vertebral (spine) fractures are the most common type of fracture in the elderly accounting for height changes related usually to osteoporosis.  These fractures are also the result of bending-injuries that may occur such as a fall, an auto accident, or other violent injury.  They can lead to chronic back pain.

It is noteworthy that low back pain, buttock pain, and sciatica each have large numbers of cases that are unsolvable.

BACK PAIN CATEGORIES

Back pain can be divided into two categories

Back pain can be divided into two basic categories:  acute pain (new onset) and chronic pain (long-standing).  

1.  Acute Back Pain 

Acute pain starts quickly, either immediately or a few hours after the initial injury.  Acute back pain usually starts with a trauma (such as a fall, a motor vehicle accident, an injury lifting heavy objects either once or repetitively).  Acute pain usually lasts less than six weeks and goes away without the need to seek medical attention.  

2.  Chronic Back Pain

Chronic back pain usually comes on slowly and can last from months to years.  Chronic back pain has a tendency to come and go, but many authors and sufferers state the pain is never far from their minds.  Most clinicians diagnose back pain as chronic only if it has been present for more than three months.  

Many chronic pain sufferers state the back pain prevents them from participating in the activities they want to do.  The complaint of chronic back pain is the most common reason for early social security disability in the United States.  

Acute Back Pain and Chronic Back Pain are Interrelated

Acute and chronic back pain can have different ranges of severity, location, and duration, but oftentimes they are interrelated.  

Often acute back pain can occur several times leading to chronic back pain; and, just as often, chronic conditions could set off the symptoms of acute back pain. 

Pain is the Most Important Symptom of Spinal Disease

There are several symptoms of spinal disease:  

  • Stiffness
  • Limitation of movement 
  • Deformity
  • Pain, which is considered by most to be the most important symptom of spinal disease  

FOUR TYPES OF BACK PAIN

There are four types of pain, which are described below: 

  1. Local
  2. Referred 
  3. Radicular 
  4. Muscular spasm

1.  Local Back Pain

Most often local pain is described as steady and aching, but it may be intermittent and sharp.  It is always felt in or near the affected part of the spine.  Usually there are involuntary, protective contractions or spasms of the muscles surrounding the spine.  

Certain movements and postures tend to aggravate back pain.  Also, the superficial (closer to the skin) parts of the body in the injured area are tender, and direct pressure evokes pain.  Muscles that are continually in reflex spasm may also become tender and sensitive to deep pressure.  

2.  Referred Back Pain

Referred back pain is pain projected from other parts of the spine or even other organs in the body to the spine.  

Pain from the lumbar spine can be referred or radiated to the buttocks and the back of the thighs.  This is due to irritation of the lower spinal nerves.  

Pain of this type is usually diffuse (wide-spread) and has a deep aching quality, as well as a more superficial projection of pain.

3.  Radicular / Root Back Pain

Radicular / Root Back Pain has some of the characteristics of referred pain, but it differs in its greater intensity, further radiation, and the factors that cause it.  

Coughing, sneezing, and straining characteristically evoke this type of pain.  The pain is sharp, often intense, and usually superimposed on the dull ache of referred pain.  Radicular back pain nearly always radiates from a central position close to the spine to some part of the legs.

 4.  Muscular Spasm Back Pain

Pain resulting from muscular spasm usually occurs in relation to local pain.  The spasm may be thought of as a protective reflex for the injured body part against harmful motion of the spine.  Muscle spasm is associated with many disorders of the low back, and it can distort normal posture.

Of note, long periods of time standing or sitting can give rise to dull, cramping aches from muscular spasm.

RISK FACTORS FOR BACK PAIN

Risk factors for back pain are:

  1. Prolonged sitting
  2. Prolonged standing
  3. Static posture
  4. Tasks that require heavy and/or repetitive lifting  
  5. Exposure to vibration produced by vehicles and industrial machinery, especially prolonged driving
  6. Smoking, which can weaken the bones

Diseases Which Increase Risk for Back Pain

There are also certain diseases which place people at a high risk for back pain such as:

  • Spinal osteoarthritis 
  • Spondylitis
  • Compression fractures

These conditions are more prevalent in the elderly, and consequently older people have a higher risk of developing back pain.

Red Flags Warrant Further Evaluation

Red flags that may indicate a serious problem that warrants further evaluation are:  

  • Pain at rest
  • No positional relief 
  • Pain that wakes you from sleep 
  • Progressive weakness in the legs 
  • Bowel and/or bladder incontinence 
  • Fevers
  • Weight loss
  • History of cancer 
  • Morning stiffness that lasts more than 30 minutes  

Tell Your Doctor About Your Back Pain

The most important pieces of information concerning back pain to tell a health care provider are:  

  • The onset
  • Duration 
  • Quality (sharp or dull pain) 
  • Severity
  • Location 
  • Radiation (movement of the pain from one place to another)
  • Any loss of function

TREATMENT OF BACK PAIN

“For a rapid recovery from low back pain, maintain minimal bed rest, make changes in the workplace, and follow simple educational tips to avoid re-injury.” National Health and Nutrition Examination Survey, 1995

Conservative Therapy for Back Pain

Conservative therapy for low back pain is as follows:  rest for three or four days; alternate applying heat and ice; use NSAIDs (aspirin, ibuprofen. . .), or use acetaminophen (Tylenol).  After a few days, try to get back to your daily routine.  

Believe it or not, the more time you spend off your feet, the longer it will take your back to heal.  Physical therapy and specific exercises are of good use.  

If the pain is not improved in a week or two, you may want to see a care-giver.  

Physical Therapy for Back Pain

The key decision point in treatment of low back pain is six weeks after an injury.  Back pain should spontaneously improve in this time.  If not, the person with back pain should be reassessed.  Referral to physical therapy programs are helpful.

Surgery for Back Pain

Surgery should be considered a last resort for most people.  Surgery may be beneficial for people who have not responded to a good, active, functional restoration program or for someone who shows signs of progressive injury. 

Prevent Future Back Pain 

Fortunately, most people with low back pain have a complete recovery in 3 – 4 weeks.   It is important to discuss ways to prevent recurrent attacks. 

Areas of discussion include: 

  • Posture 
  • Weight control
  • Exercise
  • Work activities  

References with Quotes – more info about back pain:

1.  Am. J. Ind. Med. 28:602, 1995

“Back pain is the most frequently filed worker’s compensation claim in the United States.”  

“The total lost on back pain was $50 – $100 billion in 1990.”

“National estimates. . .representing 22.4 million cases and a prevalence rate of 17.6 percent during the one year period {studied}.” 

“We estimate that a total of 149.1 million workdays were lost {due to back pain} in the one year period.”

“Our report indicated that about 50 percent of those who had experienced a back pain episode did not seek medical attention.  Therefore, compensated cases are a relatively small part of all back pain patients and are not likely to be representative of all workers with back pain.”

“We conclude that back pain is not a health problem limited to the older worker.”

“Back pain is a self reported condition often without any objective findings and  no medical test can really refute the existence of back pain.

2.  Bureau of the Census 1993

“Our analysis shows that the health and economic impact of back pain have been previously underestimated.  Nearly one fifth (1/5) of U.S. workers may suffer an episode of back pain for a week or more during a one year period, and workdays lost by cases alone may cost more than $13.3 billion.”  

3.  National Ambulatory Medical Care Survey, 1995

“Mechanical low back pain is the fifth (5th) most common reason for all physician office visits.  Nonspecific low back pain was the most common diagnosis (56.8 percent) of these cases.

4.  “An Overview of the Incidences and Costs of Low Back Pain,” Orthopedic Clinics of North America, 1991

5.  National Health and Nutrition Examination Survey, 1995

6.  Chapter 11:  Pain in the back, neck, and extremities

“Up to three quarters (3/4) of the population have low back pain at some time in their lives; by the age of 50 years, about 85-90 percent of adults will be found on autopsy to have degenerative disc disease.”

“Changes in the intervertebral discs and ligaments as a consequence of aging and perhaps a succession of minor traumas begin to occur as early as the third decade of life.”

“[Elements] combine to decrease the water content of the discs.  The dehydrated discs thin out and become more fragile.”

“Similar changes occur in the annulus (a ring of connective tissue around the discs), which frays with the passage of time, permitting the disc to bulge and sometimes with injury, they extrude.”

7.  Chapter 171:  Approach to the patient with back pain,  G. O’Sullivan

“Low back pain is becoming a growing problem in industrialized countries, accounting for up to $50 billion spent per year in the U.S. alone.  90 percent of the budget is spent on 10 percent of those patients who have persistent pain lasting longer than three months.”

“In 85 percent of cases, an underlying cause for low back pain is not established.”  

“It is easy to become confused by conflicting diagnoses and different terms used by various care-givers, such as medical doctors,  chiropractors, osteopaths, and physiotherapists.”  

* * * 

Author: Melanie Loomos

I was a court reporter for 10 years then became an inventor. I invented The Buttpillow™ and was granted a patent called the "Pillow with Cantilever Supports." At the same time, I also submitted a patent for "The Carpal Tunnel Chair," which I was advised I did not get. After R&D on The Buttpillow™, the patent for the "Ergonomic Seating Cushion" was filed and later amended to include an embodiment for women during pregnancy. The USPTO granted the "Ergonomic Seating Cushion" patent in late 2002. Subsequently, in 2003, I also invented Ergosoft™ break reminder software to remind people to take breaks with an Ergo-Tip™ so people can identify and minimize ergonomic risk factors around them.

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