Chronic Back Pain: a patient's guide
About this advice
This advice has been compiled as a source of information for individuals with chronic back pain. It has been compiled by the Cambridge Arthritis Research Endeavour (CARE) at Addenbrooke's Hospital, Cambridge, UK for patients living within East Anglia.
The advice contained is produced using the latest medical evidence following the most recent UK and European guidelines.
This advice aims to:
- Supplement the advice given to you by your doctor;
- Explain chronic back pain as a condition, including its causes and diagnosis;
- Give advice on what you should and should not do;
- Explain techniques that you should use to manage the condition;
- Explain the medical treatments and interventions available and indicate their likely effectiveness;
- Provide links to outpatient services and support groups locally and nationally;
- Answer your questions and help to alleviate your concerns;
- Provide references for further reading about your condition.
Please note: It is recognised that the advice provided will be of interest to many people with chronic back pain. It should not be used as a substitute for seeking professional medical advice from your own doctor.
Contents
- Chronic Back Pain: the basics
- What is chronic back pain?
- How common is chronic back pain?
- Have I done serious damage to my back?
- Doesn't pain indicate that I am doing damage to my back?
- Should I take plenty of bed rest?
- Can I still work?
- What are the longer term effects of chronic back pain?
- What is chronic back pain?
- What causes chronic back pain? Has something more serious been missed?
- Causes.
- The chronic pain cycle.
- Causes.
- How is it diagnosed?
- Diagnosis.
- Diagnosis.
- What can I do to manage my condition?
- What medical interventions are available and will they benefit me?
- Medication.
- Therapy-based treatments.
- Pain clinics.
- Surgery.
- Other treatment regimes.
- Medication.
- Answers to commonly asked questions.
- What services are available locally?
- Exercise referral schemes.
- Back to work programmes.
- Physiotherapy programmes.
- Exercise referral schemes.
- The take home message: what you must do to help yourself
- Further information
- .pdf version
Chronic Back Pain: the basics
- What is chronic back pain?
Chronic back pain is back pain that has persisted for more than 3 months.
The word 'chronic' is a medical term used to mean 'long-lasting' rather than indicating the severity of the pain. The level of pain experienced may be anywhere on the scale from mild to severe.
Back pain caused through activities such as heavy lifting or poor posture
is different. It is self-resolving, lasts for less than 6 weeks and is called
Acute Back Pain. (N.B. 'acute' is a medical term meaning 'of short duration').
Further information on the causes and treatment of Acute Back Pain can be
found here.
Only around 5-7% of people with acute back pain do not get better within 6 weeks. They progress to develop chronic back pain. The level of discomfort experienced in chronic back pain is generally disproportionate to the actual injury to your back. The continuing pain often causes distress, unnecessary suffering and inability to perform everyday tasks.
- How common is chronic back pain?
Over 70% of individuals in Western society experience back pain during their life and between 2-7% go on to develop chronic back pain. Most people are able to return to a normal lifestyle. This advice aims to help you learn to manage your condition and avoid or minimise the potentially disabling effects of the pain.
- Have I done serious damage to my back?
The vast majority of patients with chronic back pain have no serious problem in their back and screening methods used by doctors are designed to spot these. The cause of chronic back pain is often multi-factorial, difficult to diagnose and influenced by a large number of other factors which unfortunately contribute to the problem. Your understanding of this answer will develop as you read the later sections of this advice on causes, diagnosis and management of your back.
- Doesn't pain indicate that I am doing damage to my back?
The pain in chronic back pain does not indicate that you are causing damage to your back and with appropriate management should not prevent you from working and living an active lifestyle.
Occasionally, you may experience more severe pain (acute back pain) on top of your chronic back pain through doing too much, e.g. heavy lifting. This extra pain is a warning sign that you are doing too much. You should decrease the activity which is triggering this increase.
- Should I take plenty of bed rest?
No! Recent medical evidence supports the view that bed rest is no longer considered the correct treatment for back pain. Bed rest leads to weakening of the muscles, ligaments and joints in your back which ultimately leads to stiffness and more pain. Your back is one of the strongest parts of your body and is designed to be kept active; only by staying active will you help manage the pain.
- Can I still work?
Yes! Studies have shown that patients who manage their own back (through techniques such as those covered in later sections of this advice) are able to return to work without a limitation in their day-to-day activities. You do need to consider whether your work is right for you, e.g. if your job involves lots of heavy lifting it may be worth requesting a move into a different position. Services exist that provide advice and financial support for those wishing to return to work. See here for local schemes and more advice on how to return to work.
- What are the longer term effects of chronic back pain?
This is a difficult question to answer as no two patients are the same. Don't forget that this is a common problem and there are many others around you with the same condition to whom you can turn for help and support. Whatever happens, techniques exist for you to learn to manage your pain and improve your mobility. These are covered in the remainder of this advice.
What causes chronic back pain? Has something more serious been missed?
Causes
Your back is made up from many bones (vertebrae) and very strong ligaments and muscles. Only 10% of all cases of chronic back pain are caused by a specific problem with some part of your back. Most chronic back pain (90%) is non-specific and no definitive diagnosis is made.
Many back pain patients feel somewhat disheartened by the lack of a specific diagnosis, however, you should not: the treatment and management of your condition is the same regardless of the specific cause. You should feel assured that if no specific cause has been found then this is the norm. It is very unlikely that anything serious has been missed and you should follow the advice of your doctors and that of this document to aim towards managing your condition.
The chronic pain cycle
All types of chronic pain are a vicious circle. The pain prevents you from partaking in daily activities causing loss of strength and fitness. It may affect your sleep and your work. It can lead to unnecessary anxiety, stress and depression which all contribute towards the pain you are feeling. There is medical evidence which demonstrate that this cycle can contribute more to the perception of pain that the actual problem causing the pain in the first place.
Your brain also 'learns' the pain. By this, we mean that the "pain circuit" in your brain is constantly "on". This circuit then misbehaves: non-painful stimuli such as movement and stretching can be felt as pain and small amounts of pain may be amplified and perceived as much more severe.
This isn't to say that the pain is all in your mind. The pain you are feeling is real and the pain was most likely the triggering cause for this cycle of events. Much of the advice in this document concentrates on breaking this cycle at many different points and there is medical evidence that this is effective in helping those like yourself to manage and cope with the condition.
How is it diagnosed?
Diagnosis
Diagnosis of chronic back pain is a diagnosis of exclusion during which your doctor will try to rule out any possible serious cause. Fortunately most of these causes can be ruled out with great confidence just by your doctor asking about your symptoms and associated problems.
Diagnostic imaging such as X-rays, CT scans and MRI scans are unhelpful in diagnosing chronic back pain. These scans are only useful in confirming the cause if your doctor suspects you may have a specific cause for your pain. Many of the changes seen on such scans are indicative of wear and tear in your spine that is part of the normal aging process, and don't provide any definitive answer to the cause of pain.
What can I do to manage my condition?
Patients who succeed in improving mobility and are able to reduce or cope with their pain do so by actively managing their own condition. This section gives advice and techniques you should use routinely to manage your condition, to improve your mobility and reduce the chance of a flare-up.
- Do not take bed rest unless you have disabling pain during a flare-up. Even then you should rest for no more than 2 days before returning to activity. Bed rest is bad for your back.
- Stay active. Your back is designed to be strong and fully utilised. If you do not stay active you risk your back becoming stiff and more painful. Of course, you may need to do a little less when the pain is bad and you may have to take things easier at first. The technique of pacing which is covered later will help.
- Take plenty of exercise A healthy body leads to a happier back. Exercising strengthens your muscles and bones, keeps you supple, makes you feel better and releases natural chemicals into your body which reduce pain. Walking, exercise bikes and swimming are suitable activities that don't put too much stress on your back. They get your joints moving and help improve your heart and lung fitness. It also helps you to loose weight, in turn putting less strain on your back.
Exercising at first will not be easy. Techniques of goal setting and pacing covered later in this advice will help. When anyone exercises they find that their muscles start to ache and you should expect your back to do the same. You may find that you need to take painkillers at first to overcome this. Of course, if the pain is too severe then you should stop and seek expert advice from a physiotherapist.
There are specific stretching, strengthening and stability exercises that you can perform. The safest way to learn these is from a physiotherapist who can assess which exercises are safe and beneficial for you.
Some of these exercises can be found in the Back Booklet produced by the Arthritis Research Campaign (ARC). The same advice applies as above: some aching is to be expected at first although you must stop any exercises that cause pain.
- Adequate and restful sleep is extremely important for those experiencing any type of chronic pain. Sleeping well is probably the most important factor involved in breaking the chronic pain cycle. Mattresses should be comfortable, maintain the natural arches in your back and not be too hard or too soft. Some websites such as the IKEA Website provide easy to follow advice on choosing a correct mattress for you. Before purchasing a new mattress here are a couple of top tips to try: (i) if your mattress is too soft then place a hard piece of wood under your mattress to support it; (ii) if your mattress is too hard then lay a spare duvet or quilt over the mattress under the mattress cover to soften.
People with chronic pain often find it difficult to drop off to sleep or stay asleep because of the pain. All of the self-help techniques presented here, particularly the relaxation techniques in the next few sections, will help with your sleep. As a general rule: caffeine, tea, alcohol and smoking should be avoided for 4 hours before bed. You should avoid napping in the day, try to go to bed at the same time each night and do not go to bed until you feel tired. Sleeping tablets should be avoided when possible as many of these medications lead to dependance.
This sleep leaflet provides excellent sleep advice.
The key message with sleep: find a strategy that works for you. Once you have a strategy you must stick with it to see the benefits.
- Driving is a task that many people can't avoid and involves sitting in the same position for extended periods. It is very important that your seat is adjusted correctly to maintain the lumbar curvature (the hollow) of your back. As a general rule of thumb you should be able to sit in your car seat for 30 minutes without experiencing further pain. If you can't then the seat is incorrectly adjusted for you. For further advice on this you are referred to the Posture Right leaflet or your should consult a physiotherapist.
- Posture and sitting are both important for care of your back. Sitting for long periods of time should be avoided whenever possible and when sitting you should always maintain a good posture. This also applies when sat at a desk or when operating a computer. For further information on correct posture in these situations please refer to the Posture Right leaflet
- Lifting and other manual handling when undertaken incorrectly will put undue strain upon your back. Whenever possible you should avoid all heavy and awkward lifting or handling, and when the need arises you must ensure that you follow proper advice. Always keep the weight close to your body and bend your knees, not your back, when lifting. For further guidance see the European Manual Handling Guidelines Leaflet.
- Avoid stress and anxiety, and relax. This is often much easier said than done! However, stress and the associated muscle tension do increase your pain and fuel the chronic pain cycle. Avoiding stress and relaxing has been shown to help. Special relaxation techniques such as abdominal (diaphragmatic) breathing and breathing squares are recommended. The leaflet Control pain, live life has an excellent section that teaches relaxation techniques.
- Pacing and Goal setting are techniques that allow you to restore the activities that pain or loss of movement have prevented you from undertaking. They involve identifying the goals you wish to achieve, e.g. a particular activity, and building up your level of that activity in a slow, safe and systematic way. The leaflet Control pain, live life has excellent chapters on these techniques and you should refer to this for further guidance.
- Coping with flare-ups. Occasionally your back problem will flare-up and be worse than normal. This should be expected from time to time and how you manage these flare-ups will determine their severity and length. The key is to stay calm, relax, and try not to worry about the flare-up. Take your medications regularly, use your usual relaxation and breathing exercises to reduce stress, and continue with all of the advice given here on staying active, exercising and sleep. Avoid bed rest! If the flare-up continues for more than a few days you should contact your doctor.
What medical interventions are available and will they benefit me?
Medication
Many different medications are used by people with chronic back pain. There is a suggestion that pain-killers are not as effective at treating chronic back pain as they are at treating other types of pain. This could possibly be due to the proportion of pain derived from the chronic pain cycle involving stress, anxiety, tension and poor sleep. Where painkillers are found to be effective they should be taken regularly to prevent pain rather than taken when pain worsens. They are far more effective as a preventative measure.
Advice on pain relief should be sought from your doctor who may recommend using the following approaches:
- Simple paracetamol if taken regularly can provide good symptomatic relief from pain.
- Non-steroidal anti-inflammatory drugs (such as aspirin, ibuprofren and diclofenac) when taken regularly can be of benefit and some medical trials have found these can be more effective than simple pain killers such as paracetamol. (Caution: you should avoid these drugs if you suffer from asthma or stomach ulcers. Consult your doctor for advice.)
- Opiate-based drugs (such as codeine and morphine-based products) are used in chronic pain and have been shown to have some benefit. It is considered best practice to avoid these medications if you can due to their addictive nature.
- Muscle relaxant drugs (such as diazepam) have been shown to help improve mobility in your back and some are believed to help reduce pain too.
- Anti-depressant drugs can help to reduce pain. They act by helping the repair of chemical imbalances in your brain brought about by the chronic pain cycle.
- Epidurals and facet joint injections are occasionally used to help reduce back pain and increase mobility. These provide symptomatic relief in some patients.
Therapy-based treatment
Many patients find some form of physical or manipulative therapy beneficial. There are several different types of therapy around and many of theirs skills overlap. It is recommended that you try these therapies to find which help your pain:
- Physiotherapy, osteopathy and chiropractic therapy are all branches of medicine that diagnose and treat disorders of bones, joints and muscle through manipulation techniques. You doctor will be able to refer you to a physiotherapist who may also give advice on specific exercises, lifting, posture, driving and sleep. Some physiotherapists allow you to book appointments directly yourself (some are included in the local services section of this advice). A local Chiropractor can be found by visiting the BCA website. and an osteopath by visiting the GOC website.
- Acupuncture is a complementary medicine therapy that involves inserting small needles into your skin to help relieve pain. Some pain patients find the technique useful, however, there is no medical evidence that proves its effectiveness.
- The Alexander Technique is taught by qualified teachers (found throughout the UK) and teaches bodily awareness and reduction of muscle tension. Some back pain patients find this technique useful in improving posture which in turn may improve pain and stiffness. For further information or to find a local teacher please visit their website.
Pain Clinics
Many hospitals run pain clinics that your doctor may refer you to. Some chronic pain patients find these beneficial as the doctors are experts in pain medication and will try different approaches to see what works best for you.
Back Management Programmes
Recent medical evidence has shown that intensive back management programmes involving experts from many different fields including joint doctors (rheumatologists), pain doctors (anaethetists), occupational therapists and physiotherapists are suitable for those patients for which other management methods have not helped. Some hospitals including Addenbrooke's offer such programmes and you can be referred to these by your GP. The Addenbrooke's programme is intensive, full-time and lasts for 3 weeks. The programme concentrates on education and teaches techniques to manage and cope with pain, similar to those in this advice. Shorter, less intensive programmes don't work as well and provide no advantage over other therapies.
Surgery
Many patients believe that surgery is the key to resolving back trouble. Unfortunately this is a myth and not normally true! Surgery is occasionally useful in repairing problems when there is a clearly identifiable cause such as a bulging intravertebral disc but for the majority of back pain patients this is simply not the case and surgery is not an appropriate treatment.
Other treatment regimes
- Behaviour Therapy (such as Cognitive Behavioural Therapy). Some evidence exists that these reduce pain and increase behavioural tendencies if more than one technique is used.
- Use of lumbar spine supports (corsets). Current medical belief is that these devices may do more harm by reducing movements and decreasing strength in your back, working against the rest of the advice in this document! They should be avoided.
- Massage therapy. No medical evidence exists for this treatment and thus it is not known whether it is beneficial or harmful.
- Transcutaneous Electrical Nerve Stimulation (TENS) is administered by a machine that passes small electrical currents through your back. Some patients find it beneficial but there is no medical evidence to support this at present. TENS has been shown to be safe and can be tried without causing any harm.
Answers to commonly asked questions
Question: Am I imagining the pain?
No. In many cases of chronic pain it is unclear why the pain has lasted so long and it can be difficult to find what is causing the pain. The section on causes of chronic back pain explained that many aspects of your life can affect the pain and addressing these help you to manage it.
Question: If pain increases after exercise am I doing harm?
A little ache or pain after exercise is expected and is experienced even by healthy individuals. If you have not exercised for some time then your pain may be worse than expected during exercise but should get better with time as you become stronger and more supple. You must always stay within your tolerance level and not do too much of any exercise or activity. Use PACING to build up your tolerance level in a safe and structured way.
Question: Can I still have sex?
Yes, but you will need to find a position that is comfortable for you and your partner. The best way to do this is to experiment and find what works for you. The booklet Sexuality and Arthritis has been written for people with arthritis rather than back pain but the advice is still applicable and may be of some use.
What services are available locally?
Exercise Referral Schemes are exercise schemes run by fully-qualified professionals that are tailor-made to improve your health in a safe and effective way. Your GP can refer you onto such schemes.
- "Startup" is an exercise referral scheme run jointly by Cambridge City Council, South Cambridgeshire District Council and the Cambridge City and South Cambridgeshire Primary Care Trust. For further information phone (01223) 415151 or visit their website.
Back to work programmes are programmes that are part of a national initiative to get those with any form of disabling condition back into work. Most schemes are charity run and can provide advice on procedures at work, specialist equipment (including suitable office desks and chairs), and funding for your employer to purchase necessary aids.
- The Papworth Rehabilitation Programme is the local Cambridge scheme run by the Papworth Trust. For further information phone (01480) 830341 or visit their website.
Physiotherapy programmes that can be accessed directly without a referral from your doctor:
- A Physiotherapy Direct Service is run at the Buchan Street Neighbourhood Centre on Wednesday afternoons and is provided by the Chesterton NHS Physiotherapy Service. You do not need to be referred by your doctor. For further details, call 01223 885404.
The take home message: what you must do to help yourself
A few golden rules to remember:
- Chronic back pain can be a disabling condition if you don't learn to manage it yourself. Self-management and a disciplined routine is vital.
- Severe pain is rarely an indication that you are doing harm and it is not normally an indicator that something is seriously wrong.
- Restful and appropriate amounts of sleep are essential. Find a routine or technique that works for you.
- Avoid bed rest - it does much more harm than good.
- Avoid stress and routinely use relaxation techniques.
- Stay active, take exercise and keep your back supple.
- Don't overdo it. Learn to recognise when to stop.
- If you need to take medication use it regularly every day. Try to stick to the simple painkillers (e.g. paracetamol) and non-steroidal anti-inflammatory drugs (e.g. ibuprofen).
- Aim to lead a normal, active lifestyle and return to work.
Further information
Prepared by Steve Bishop in conjunction with the Department of Rheumatology, Addenbrookes Hospital
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