Back pain and low back pain: causes, therapy & what really helps
At a glance
FrequencyOne of the most common complaints of all and a leading reason for sick leave in Germany
DefinitionLow back pain = pain below the costal margin and above the gluteal folds, with or without radiation
Mostly benignThe large majority of back pain is non-specific — no single structural cause can be demonstrated
Therapy of choiceMovement, pain relief, active coping strategies — imaging and bed rest are generally not necessary with acute non-specific back pain
GuidelineNVL Non-specific low back pain (BÄK/KBV/AWMF, 2nd edition 2017)
ICD-10M54 (back pain)
1. What is back pain?
Back pain is among the most common complaints in Germany — almost every adult is affected by it at some point in the course of life. Low back pain (pain in the lower back, the lumbar spine) is by far the most common form.1
The good news: the large majority of back pain is benign, not dangerous and mostly improves on its own within a few weeks. In most cases, no single structural cause can be demonstrated — this is then referred to as non-specific back pain.1,2
The most important thing: stay active
Bed rest and excessive rest generally worsen back pain — movement is the most effective measure, even if it is difficult at first.
2. Specific vs. non-specific
Non-specific back pain
No single structural cause can be demonstrated. Makes up the large majority of all back pain. The complaints often arise through an interplay of muscle tension, lack of exercise, stress and psychosocial factors.1
Specific back pain
A concrete structural or pathological cause can be demonstrated — e.g. a
herniated disc, spinal stenosis, a vertebral fracture, inflammation (spondylitis), a tumor. Affect a considerably smaller proportion of those with back pain.
3
Important to know
Even with conspicuous findings on imaging (e.g. a disc bulge, arthrosis of the small vertebral joints), these are not always the cause of the pain. Many people have changes on imaging without ever having complaints.
3. Symptoms and red flags
Typical symptoms (non-specific)
- pain in the lower back — dull, pulling or stabbing
- muscle tension and a restriction of movement
- radiation into the buttock or thigh possible (without a true nerve-root irritation)
- stiff in the morning, generally improves with movement
Red flags — warning signs that require a quick work-up
With the following symptoms, have it clarified by a doctor immediately
Numbness or paralysis in the legs, bladder or bowel disturbances (can no longer urinate or cannot control bowel movements — a sign of a cauda equina syndrome, an emergency!), fever and night sweats, unintentional weight loss, a known tumor disease, trauma (a fall, an accident), osteoporosis as well as pain that does not improve when lying down or increases at night.
4. Causes and risk factors
Lack of exercise: The most important risk factor. A sedentary lifestyle, little everyday activity and weak back and core musculature favor back pain.
Psychosocial factors: Stress, dissatisfaction at work, anxiety, depression, catastrophizing (the conviction that the pain is very dangerous) and protective behavior can trigger, intensify and chronify back pain. The guideline expressly emphasizes the role of psychosocial factors.1
Overweight: Obesity increases the load on the spine.
Occupational strain: Heavy physical work, prolonged sitting, whole-body vibrations.
Smoking: Can increase the risk of back pain (among other things through impaired blood flow to the discs).
Specific causes: A herniated disc, spinal stenosis, spondylolisthesis, facet syndrome, a vertebral-body fracture, spondyloarthritis, infection, a tumor.
5. Diagnosis
With acute, non-specific back pain without red flags, imaging is generally not necessary and is expressly not recommended by the guideline — it can even do harm, because incidental findings cause uncertainty and can lead to unnecessary procedures:1
History and physical examination: The most important diagnostic measures. Rule out red flags, capture psychosocial risk factors for chronification (e.g. with the STarT Back tool).
Imaging: Generally only recommended when red flags are present, with suspicion of a specific cause, with a lack of improvement after several weeks or with a planned intervention. MRI is the imaging of choice with suspicion of a herniated disc or spinal stenosis.
Laboratory: With suspicion of an inflammatory cause (CRP, ESR, blood count) or osteoporosis.
More on this: Preparing for a doctor's appointment.
6. Therapy for acute back pain
The NVL Non-specific low back pain is clear: movement is the most important measure. Bed rest is expressly not recommended.1
Core messageStay active
- continue everyday activities as normally as possible
- take up light physical activity (walking, swimming, cycling) as early as possible
- avoid bed rest — it generally worsens the course
- warmth can relieve the complaints (a hot water bottle, a cherry-stone cushion)
Pain medications
Paracetamol (acetaminophen)
Is generally no longer recommended by the guideline as effective with low back pain — the evidence for an effectiveness with back pain is weak.
Muscle relaxants
Can be considered short-term with strong muscle tension. Pay attention to side effects (tiredness).
Opioids
Are generally not recommended with acute non-specific back pain. Only as an exception with very strong pain and the failure of other measures — and then as short as possible.
What is NOT recommended
Bed rest, imaging without red flags, passive measures as the sole therapy (massage, ultrasound, TENS) as well as injections into the spine with acute non-specific low back pain.
