When to worry about back pain

Back facts

Let's face it, our backs have a fundamental design fault - they're not made to stand up to the extra stresses and strains placed on them by humans walking upright. The bones in our back need to be fixed together in a way that keeps them stable, but still allows enough flexibility to stop us moving around ramrod straight. This is possible because we have lots of small bones - the vertebrae - separated by 'discs' of tough connective tissue surrounding a squashy centre, as well as muscles and ligaments criss-crossing between them. Being upright means gravity is constantly compressing our spinal bones and discs.

This complicated structure means there are lots of things that can go wrong. Being overweight puts more strain on the structures of your back, but poor posture is a major cause. Long hours hunched over a computer don't help.

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What are the 'red flag' warning symptoms?

Because of the way our spines are designed, your neck and low back (lumbar spine) are most likely to cause symptoms. If you develop pain in your thoracic spine - behind your ribcage - you should have it checked out.

The pain from a prolapsed disc (sometimes called a 'slipped disc') is often very severe, especially if it results in pressure on, or irritation of, one of the nerves coming from the spinal cord. However, cauda equina syndrome - a rare but potentially very serious complication in which the nerves at the very bottom of the spinal cord are pressed on - is a medical emergency.

Symptoms to look out for include:

• Numbness around your bottom.

• Sudden weakness in one or both legs.

• Loss of control of your bladder or bowel or loss of sensation of your bladder.

If you've had cancer, take steroid tablets or have osteoporosis (thinning of the bones), or if you've had major trauma to your back, you shouldn't delay in seeing your doctor. And you should also seek help if the pain isn't relieved by rest and keeps getting worse.

There's a more comprehensive list in our feature on 'How to get back pain under control'.

What treatment options are available?

If you need to see your doctor they'll ask about your symptoms and examine you, but probably won't need to send you for tests including X-rays in the short term. They will certainly advise that you keep moving, even if it hurts - although you should avoid things that make the pain much worse. Painkillers and sometimes muscle relaxants may help in the short term.

On the NHS, your GP may refer you to a physiotherapist. They use a wide variety of techniques which will depend on your symptoms. These include a structured exercise programme, where you do stretching, or muscle strengthening and posture exercises (often in a group), along with massage and spinal manipulation.

You can also access videos of qualified physiotherapists demonstrating exercises, along with an exercise sheet to download.

Until recently, the National Institute for Health and Care Excellence (NICE) also recommended that acupuncture, where tiny needles are placed at set 'trigger points' in your skin, could be considered.

However, new draft guidelines no longer recommend this because of a lack of evidence that they are any more effective than 'sham' treatment (this allows patients in clinical trials to be treated with acupuncture or not, without them knowing whether they're having acupuncture treatment). The new guidance also recommends all sorts of exercise - including yoga, stretching, aerobics or strengthening exercises - as the first step in the management of low back pain. It only recommends massage and spinal manipulation alongside exercise, because of a lack of evidence that they help when used on their own.

Looking to the longer term

If your symptoms don't settle, or suggest an underlying problem, you may be referred for further tests. These include CT or MRI scans, which can look at your discs and nerves as well as the bones of the spine. In severe cases, surgery is sometimes recommended, although there are risks because the surgeon is operating very close to your spinal cord. Epidural (anaesthetic/painkilling) injections are also an option.

Outside the NHS

Chiropractors work mostly by manipulating your spine. They use over 50 'adjustments' which consist of short, controlled thrusts against individual joints. You sometimes hear a popping sound when this is done (don't worry, it's harmless). Osteopaths believe each part of the human body is dependent on other parts, and the musculoskeletal system (bones, joints and muscles) is the framework. If this gets out of alignment, all sorts of problems result. Osteopaths use similar 'adjustments' to chiropractors, but also work on muscles and use gentle manipulation. These treatments are not available on the NHS.

In the longer term, lots of people swear by the Alexander Technique for preventing further low back problems. The theory is that the relationship between the head and neck/back governs the way the rest of the body works. Regular classes, with practising in between, aims to undo all the bad habits we've got into and teach us to stand tall and move again in the natural way children do. People who practise it say it also helps with breathing, relaxation, co-ordination and balance. It's impossible to do a trial where patients get Alexander Technique treatment or not, without knowing which group they're in, so it's not possible to rule out a 'placebo' effect of people thinking it works. Nonetheless, it's a safe technique and there's some evidence it helps.

With thanks to 'My Weekly' magazine where this article was originally published.