Low Back Pain – Causes, Symptoms, Diagnosis, Treatment

Low back pain is a pain, muscle tension, or stiffness localized below the costal margin and above the inferior gluteal folds, with or without leg pain (sciatica), and is defined as chronic when it persists for 12 weeks or more. Non-specific low back pain is a pain not attributed to a recognizable pathology (such as infection, tumor, osteoporosis, rheumatoid arthritis, fracture, or inflammation). This review excludes chronic low back pain with symptoms or signs at the presentation that suggests a specific underlying condition. People solely with sciatica (lumbosacral radicular syndrome) and pain due to herniated discs, or both, are also excluded. People in this review have chronic low back pain (>12 weeks’ duration).

Types of Low Back Pain

Low back pain can be broadly classified into four main categories

• Musculoskeletal – mechanical (including muscle strain, muscle spasm, or osteoarthritis); herniated nucleus pulposus, herniated disk; spinal stenosis; or compression fracture
• Inflammatory – HLA-B27 associated arthritis including ankylosing spondylitis, reactive arthritis, psoriatic arthritis, and inflammatory bowel disease
• Malignancy – bone metastasis from lung, breast, prostate, thyroid, among others
• Infectious – osteomyelitis; abscess

In addition, symptoms of lower back pain are usually described by the type of onset and duration

• Acute low pain – This type of pain typically comes on suddenly and lasts for a few days or weeks, and is considered a normal response of the body to injury or tissue damage. The pain gradually subsides as the body heals.
• Subacute low back pain – Lasting between 6 weeks and 3 months, this type of pain is usually mechanical in nature (such as a muscle strain or joint pain) but is prolonged. At this point, a medical workup may be considered and is advisable if the pain is severe and limits one’s ability to participate in activities of daily living, sleeping, and working.
• Chronic low back pain – Usually defined as lower back pain that lasts over 3 months, this type of pain is usually severe, does not respond to initial treatments, and requires a thorough medical workup to determine the exact source of the pain.

Causes of Low Back Pain

• Fracture

  • Significant trauma (relative to age), Prolonged corticosteroid use, osteoporosis, and age greater than 70 years, Contusions, abrasions, tenderness to palpation over spinous processes

Pediatrics

Diagnosis of Low Back Pain

• Straight leg raise (SLR) – performed by raising the patient’s leg to 30 to 70 degrees. Ipsilateral leg pain at less than 60 degrees is a positive test for lumbar disk herniation. Likelihood ratio (LR) of 2, negative likelihood ratio (NLR) of 0.5. If the pain reproduction occurs contralaterally, it is a positive test for a lumbar disk herniation with LR of 3.5 and NLR of 0.72.[rx]
• One leg hyperextension test/stork test – Have the patient stand on one leg and (while being supported by the provider) have them hyper-extend their back. Repeat this maneuver on both sides. Pain with hyperextension is positive for a pars interarticularis defect.[rx]
• Adam test – Have the patient bend over with feet together and arms extended with palms together. The practitioner should observe from the front. If a thoracic lump is present on one side or the other, it is an indication of scoliosis.[rx] There are numerous other examination techniques; however, they have mixed evidence for inter-practitioner reliability and poor sensitivities or specificities.[rx][rx][rx][rx]

Lab Test

• Blood tests – CBC ,ESR,Hb, RBS,CRP, Serum Creatinine, Serum Electrolyte,
• Bone scan – a bone scan may be used for detecting bone tumors or compression fractures caused by brittle bones (osteoporosis). The patient receives an injection of a tracer (a radioactive substance) into a vein. The tracer collects in the bones and helps the doctor detect bone problems with the aid of a special camera.
• Electromyography (EMG) – assesses the electrical activity in a muscle and can detect if muscle weakness results from a problem with the nerves that control the muscles. Very fine needles are inserted in muscles to measure electrical activity transmitted from the brain or spinal cord to a particular area of the body.
• Evoked potential studies – involve two sets of electrodes—one set to stimulate a sensory nerve, and the other placed on the scalp to record the speed of nerve signal transmissions to the brain.
• Nerve conduction studies (NCS) – also use two sets of electrodes to stimulate the nerve that runs to a particular muscle and record the nerve’s electrical signals to detect any nerve damage.

Imaging

• X-rays – These are very accessible at most clinics and outpatient offices. This imaging technique can be used to assess for any structural instability. If x-rays show an acute fracture, it needs to be further investigated using a computed tomogram (CT) scan or magnetic resonance imaging (MRI).
• CT Scan – It is the preferred study to visualize bony structures in the spine. It can also show calcified herniated discs. It is less accessible in office settings compared to x-rays. But it is more convenient than MRI. In the patients that have non-MRI comparable implanted devices, CT myelography can be performed to visualize herniated disc.
• CT myelography – is when the patient has either a contraindication to having an MRI such as having a pacemaker device or defibrillator or be used when a standard CT or MRI is negative or equivocal. Myelography is a CT scan or an MRI with intrathecal administration of contrast. CT myelography visualizes a patient’s spinal nerve roots in their passage through the neuroforamina. CT myelography can be used to assess the underlying root sleeve. A unique population to recommend a CT myelogram is for patients with surgical spinal hardware. A CT is a poor test for the visualization of nerve roots, making it challenging to diagnose radicular disease.[rx][rx]
• Electromyography (EMG) – are complete after three weeks of symptoms, not before. Diagnostic tests such as EMG or nerve conduction studies are accurate only after three weeks of persistent symptoms. The primary reason why ordering an EMG or nerve conduction study is delayed three weeks following the development of pain is because fibrillation potentials after an acute injury lead to an axonal motor loss. These do not develop until two to three weeks following injury.[rx][rx]
• Cerebrospinal fluid analysis – is a useful test if there is a suspected neoplasm or infectious cause or radiculopathy symptoms. The recommendation for a lumbar puncture is in the case of a patient with negative or nondiagnostic neuroimaging, without known primary cancer, who has progressive neurological symptoms and has failed to improve promptly.[28]
• MRI – It is the preferred and most sensitive study to visualize herniated disc. MRI findings will help surgeons and other providers plan procedural care if it is indicated.
• Bone scintigraphy – with single-photon emission computed tomography (SPECT) is more sensitive in detecting facet joint lesions and allows more accurate anatomical localization. A recent study suggested that SPECT could help to identify patients with low back pain who would benefit from facet joint injections [rx]. Facet joint block (FJB) is an indispensable diagnostic instrument in order to distinguish painful from painless facet joints, and to plan the intervention strategy.
• Foraminal nerve root entrapment test – is best visualized on T1-weighted MRI where the high contrast between fat tissue and the nerve root sheath is of great help. Usually, a combination of hypertrophic degenerative facets with osteophytes spurs posteriorly, and vertebral osteophytes and/or disc herniation anteriorly diminishes the anteroposterior diameter of the foramen. Foraminal height is lessened by degenerative disc disease and subsequent disc height loss. Whenever the normal rounded (oval) appearance of the nerve root sheath is lost in combination with loss of the surrounding fat tissue, nerve root compression should be considered.

Treatment of Low Back Pain

Not all treatments work for all conditions or for all individuals with the same condition, and many find that they need to try several treatment options to determine what works best for them. The present stage of the condition (acute or chronic) is also a determining factor in the choice of treatment. Only a minority of people with back pain (most estimates are 1% – 10%) require surgery.

Non-medical

Treatment for back pain generally depends on how long your pain lasts

Acute (short-term) back pain – usually gets better on its own. Exercises or surgery are usually not recommended for this type of pain. There are some things you may try while you wait for your pain to get better:

• Acetaminophen, aspirin, or ibuprofen will help ease the pain.
• Get up and move around to ease stiffness, relieve pain, and have you back doing your regular activities sooner.

Chronic (long-term) back pain – is typically treated with non-surgical options before surgery is recommended.

Nonsurgical Treatments

• Pain relievers – that are taken by mouth or applied to the skin. Examples include acetaminophen and aspirin. Your doctor may suggest steroid or numbing shots lessen your pain. Involves using pulleys and weights to stretch the back, which may allow a bulging disk to slip back into place. Your pain may be relieved while in traction, although pain returns once you aren’t in traction.
• Practice healthy habits – such as exercise, relaxation, regular sleep, proper diet, and quitting smoking.
• Manipulation – Professionals use their hands to adjust or massage the spine or nearby tissues.
• Acupuncture – This Chinese practice uses thin needles to relieve pain and restore health. Acupuncture may be effective when used as a part of a comprehensive treatment plan for low back pain.
• Acupressure – A therapist applies pressure to certain places in the body to relieve pain. Acupressure has not been well studied for back pain. Move your body properly while you do daily activities, especially those involving heavy lifting, pushing, or pulling. Back pain is generally treated with non-pharmacological therapy first, as it typically resolves without the use of medication. Superficial heat and massage, acupuncture, and spinal manipulation therapy may be recommended.
• Heat therapy –  is useful for back spasms or other conditions. A review concluded that heat therapy can reduce symptoms of acute and sub-acute low-back pain.
• Regular activity and gentle stretching exercises – is encouraged in uncomplicated back pain, and is associated with better long-term outcomes. Physical therapy to strengthen the muscles in the abdomen and around the spine may also be recommended.
• These exercises  – are associated with better patient satisfaction, although it has not been shown to provide functional improvement. However, one study found that exercise is effective for chronic back pain, but not for acute pain. If used, they should be performed under the supervision of a licensed health professional.
• Massage therapy – may give short-term pain relief, but not functional improvement, for those with acute lower back pain. It may also give short-term pain relief and functional improvement for those with long-term (chronic) and sub-acute lower pack pain, but this benefit does not appear to be sustained after 6 months of treatment. There does not appear to be any serious adverse effects associated with massage.
• Acupuncture – may provide some relief for back pain. However, further research with stronger evidence needs to be done.
• Spinal manipulation – is a widely-used method of treating back pain, although there is no evidence of long-term benefits.
• Back school – is an intervention that consists of both education and physical exercises. A 2016 Cochrane review found the evidence concerning back school to be very low quality and was not able to make generalizations as to whether back school is effective or not.
• Heat Or Ice Therapy – Applying heat pads, ice packs or using both alternatively can help to relieve stiffness, inflammation, and muscle spasms in the back. Cold compresses can be used to reduce swelling in the back.
• Braces – For patients with chronic back pain or a deformity in the spine, the doctor may recommend wearing a brace to provide support. Back braces can help to maintain proper posture, limit strenuous movement, and realign the spine to provide relief from pain.
• Physical Therapy – The physical therapist may apply heat, ice, electrical stimulation, and other mechanisms to release stiffness from the back muscles. He may also help the patient learn posture correction techniques to prevent the pain from recurring.
• Exercise – Your doctor may advise you to perform light stretching exercises to increase the flexibility of the muscles in the back. He may also recommend certainly or exercises to strengthen the core and improve the overall well-being of the patient.

Medication

If non-pharmacological measures are not effective, medications may be tried.

• Analgesics – with or without paracetamol may improve pain and function compared with placebo. However, long-term use of NSAIDs or opioids may be associated with well-recognized adverse effects.
• Non-steroidal anti-inflammatory drugs – (NSAIDs) may be more effective than placebo at improving pain intensity in people with chronic low back pain. Pain medicines and anti-inflammatory drugs help to relieve pain and stiffness, allowing for increased mobility and exercise. There are many common over-the-counter medicines called non-steroidal anti-inflammatory drugs (NSAIDs). They include mainly or first choice etodolac, then aceclofenac, etoricoxib, ibuprofen, and naproxen. Nonsteroidal anti-inflammatory drugs were again the first-line pharmacologic agents recommended followed by tramadol and duloxetine as the second-line treatments.
• Antidepressants  – decrease chronic low back pain or improve function compared with placebo in people with or without depression. Antidepressants such as tricyclic antidepressants and SNRI’s, topical analgesics, muscle relaxers, N-methyl-d-aspartate (NMDA) receptor antagonists, and alpha 2 adrenergic agonists are also the most effective pharmacological therapies.
• Muscle Relaxant – Benzodiazepines may improve pain, but studies of non-benzodiazepine muscle relaxants have given conflicting results. Muscle relaxants, such as baclofen, tolperisone, eperisone, methocarbamol, carisoprodol, and cyclobenzaprine, may be prescribed to control muscle spasms.
• Gabapentin –The initial treatment of neuropathic pain and chronic back pain is often with gabapentin or pregabalin.  It is Considere’s most effective treatments are in general recommended in chronic low back pain. They are indicated for postherpetic neuralgia, diabetic neuropathy, and mixed neuropathy.[rx]
• Tricyclic antidepressant (TCA) – A type of drug that can be used to treat back pain this use is different from its action in treating depression, which usually requires a much higher dose. Examples include amitriptyline and imipramine
• Epidural corticosteroid injections – or local injections with corticosteroids and local anesthetic improve chronic low back pain treatment in people without sciatica. Facet-joint corticosteroid injections may be more effective than placebo at reducing pain.
• Epidural glucocorticoid injections – are beneficial for up to three months in duration in patients with acute lumbar radiculopathy. This benefit is modest yet clinically significant in the short-term.[rx][rx][rx] If a patient has not improved after six weeks of conservative management, they would be eligible for an epidural glucocorticoid injection.
• Oral systemic steroids tablet – are often prescribed for acute low back pain, and chronic low back pain although there is limited evidence to support their use. It is basically used to remove nerve-related inflammation, edema, hematoma. There is evidence that a single dose of steroids, such as dexamethasone, may provide pain relief.
• The serotonin-norepinephrine reuptake inhibitor (SNRI) – duloxetine is useful in treating chronic pain, osteoarthritis, and the treatment of fibromyalgia.[rx] Furthermore, the efficacy of duloxetine in the treatment of comorbid depression is comparable to other antidepressants.[rx][rx] Venlafaxine is an effective treatment for neuropathic pain, as well.[rx] A TCA can also be utilized, such as nortriptyline. TCA medications may require six to eight weeks to achieve their desired effect.[rx]
• Topical lidocaine and ointment – is a useful treatment for neuropathic pain and allodynia as in postherpetic neuralgia.[rx][rx] [rx][rx] Separately, topical capsaicin cream is an option for chronic neuropathic or musculoskeletal pain unresponsive to other treatments.[rx]
• Opioids – are considered a second-line option; however, they may be warranted for pain management for patients with severe persistent pain or neuropathic pain secondary to malignancy.[rx] [rx] Opioid therapy should only start with extreme caution for patients with chronic back pain and musculoskeletal pain.[rx] Side effects of opioids are significant and frequent and may include opioid-induced hyperalgesia, constipation, dependence, and sedation.[rx][rx]
• Epidural corticosteroid injection – (ESI) is a procedure in which steroid medications are injected into the epidural space. The steroid medications reduce inflammation and thus decrease pain and improve function. ESI has long been used to both diagnose and treat back pain, although recent studies have shown a lack of efficacy in treating low back pain.
• Carisoprodol – This muscle relaxant was investigated in two high-quality studies on acute low back pain. The first study compared carisoprodol with diazepam [rx]. Carisoprodol was superior in performance on all the outcome parameters measured. A comparison of carisoprodol with cyclobenzaprine‐hydrochloride in the second study revealed no statistically significant differences between the two treatments [rx].
• Chlorzoxazone – This muscle relaxant was compared with tizanidine in one high-quality study in a very small sample of patients with degenerative lumbar disc disease [rx]. No differences were found between the treatments.
• Cyclobenzaprine‐hydrochloride – Cyclobenzaprine was compared with diazepam in a low-quality trial on chronic low back pain, but no significant differences between the treatments were identified [rx]. There was also no significant difference between cyclobenzaprine and carisoprodol in one high-quality study on acute low back pain [rx].
• Diazepam – In comparison with carisoprodol, diazepam was found to be inferior in performance on muscle spasm, global efficacy, and functional status in a high-quality trial on acute low back pain [rx]. In a very small high-quality trial (30 people) comparing diazepam with tizanidine, there were no differences in pain, functional status, and muscle spasm after seven days [rx].
• Tizanidine – This muscle relaxant was compared with chlorzoxazone and diazepam in two very small high quality [rx]. Both trials did not find any differences in pain, functional status, and muscle spasm after 7 days.
• Pridinol mesylate – One low-quality trial showed no differences between this muscle relaxant and thiocolchicoside on pain relief and global efficacy.

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Surgery of Low Back Pain

Surgery for back pain is typically used as a last resort when the serious neurological deficit is evident. A 2009 systematic review of back surgery studies found that, for certain diagnoses, surgery is moderately better than other common treatments, but the benefits of surgery often decline in the long term.

Surgery may sometimes be appropriate for people with severe myelopathy or cauda equina syndrome. Causes of neurological deficits can include spinal disc herniation, spinal stenosis, degenerative disc disease, tumor, infection, and spinal hematomas, all of which can impinge on the nerve roots around the spinal cord. There are multiple surgical options to treat back pain, and these options vary depending on the cause of the pain and your doc may refer to a surgeon for following a surgical procedure.

NIH’s National Institute of Neurological Disorders and Stroke (NINDS) lists the following as some of the surgical options for low back pain. But NINDS also cautions that “there is little evidence to show which procedures work best for their particular indications.”

• Vertebroplasty and kyphoplasty – These procedures are used to repair compression fractures of the vertebrae caused by osteoporosis. Both procedures include the injection of glue-like bone cement that hardens and strengthens the bone.
• Spinal laminectomy/spinal decompression – This is performed when spinal stenosis causes a narrowing of the spinal canal that results in pain, numbness, or weakness. The surgeon removes the bony walls of the vertebrae and any bone spurs, aiming to open up the spinal column to remove pressure on the nerves.
• Discectomy – This procedure is used to remove a disk when it has herniated and presses on a nerve root or the spinal cord. Laminectomy and discectomy are frequently performed together.
• Foraminotomy – In this procedure, the surgeon enlarges the bony hole where a nerve root exits the spinal canal to prevent bulging discs or joints thickened with age from pressing on the nerve.
• Nucleoplasty also called plasma disk decompression – This laser surgery uses radiofrequency energy to treat people with low back pain associated with a mildly herniated disk. The surgeon inserts a needle into the disk. A plasma laser device is then inserted into the needle and the tip is heated, creating a field that vaporizes the tissue in the disk, reducing its size and relieving pressure on the nerves.
• Spinal fusion – The surgeon removes the spinal disk between two or more vertebrae, then fuses the adjacent vertebrae using bone grafts or metal devices secured by screws. Spinal fusion may result in some loss of flexibility in the spine and requires a long recovery period to allow the bone grafts to grow and fuse the vertebrae together.
• Artificial disk replacement – This is considered an alternative to spinal fusion for the treatment of people with severely damaged disks. The procedure involves the removal of the disk and its replacement by a synthetic disk that helps restore height and movement between the vertebrae.

Some surgical treatments are not recommended by NINDS, which cautions, for example, that intradiscal electrothermal therapy is “of questionable benefit.” NINDS notes that radiofrequency denervation provides only temporary pain relief and that “evidence supporting this technique is limited.”

Lower back pain exercises

A series of exercise routines you can do to help reduce any lower back pain (occasionally referred to as low back pain), including tension, stiffness, and soreness. These exercises from physiotherapists and BackCare expert Nick Sinfield help to stretch, strengthen and mobilize the lower back. When starting out, go gently to get used to the movements and work out how far you can go into each position without feeling pain.

Aim to do this routine at least once a day if the pain allows. You can complement this routine with walking, cycling and water-based activities. You are advised to seek medical advice before starting these back pain exercises and to stop immediately if you feel any pain.

Bottom to heels stretch

Stretches and mobilizes the spine

Start position: Kneel on all fours, with your knees under hips and hands under shoulders. Don’t over-arch your lower back. Keep your neck long, your shoulders back and don’t lock your elbows.

Action: Slowly take your bottom backward, maintaining the natural curve in the spine. Hold the stretch for one deep breath and return to the starting position.

Repeat 8 to 10 times.

Tips:

• Avoid sitting back on your heels if you have a knee problem.
• Ensure correct positioning with the help of a mirror.
• Only stretch as far as feels comfortable.

Knee rolls

Stretches and mobilizes the spine

Start position: Lie on your back. Place a small flat cushion or book under your head. Keep your knees bent and together. Keep your upper body relaxed and your chin gently tucked in.

Action: Roll your knees to one side, followed by your pelvis, keeping both shoulders on the floor. Hold the stretch for one deep breath and return to the starting position.

Repeat 8 to 10 times, alternating sides.

Tips:

• Only move as far as feels comfortable.
• Place a pillow between your knees for comfort.

Back extensions

Stretches and mobilizes the spine backward

Start position: Lie on your stomach, and prop yourself on your elbows, lengthening your spine. Keep your shoulders back and neck long.

Action: Keeping your neck long, arch your back up by pushing down on your hands. You should feel a gentle stretch in the stomach muscles as you arch backward. Breathe and hold for 5 to 10 seconds. Return to the starting position.

Repeat 8 to 10 times.

Tips:

• Don’t bend your neck backward.
• Keep your hips grounded.

Deep abdominal strengthening

Strengthens the deep supporting muscles around the spine

Start position: Lie on your back. Place a small, flat cushion or book under your head. Bend your knees and keep your feet straight and hip-width apart. Keep your upper body relaxed and your chin gently tucked in.

Action: As you breathe out, draw up the muscles of your pelvis and lower abdominals, as though you were doing up an imaginary zip along your stomach. Hold this gentle contraction while breathing from your abdomen for 5 to 10 breaths, and relax.

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Repeat 5 times.

Tips:

• This is a slow, gentle tightening of the lower abdominal region. Don’t pull these muscles in using more than 25% of your maximum strength.
• Make sure you don’t tense up through the neck, shoulders or legs.

Pelvic tilts

Stretches and strengthens the lower back

Start position: Lie on your back. Place a small, flat cushion or book under your head. Bend your knees and keep your feet straight and hip-width apart. Keep your upper body relaxed and your chin gently tucked in.

Action: Gently flatten your low back into the floor and contract your stomach muscles. Now tilt your pelvis towards your heels until you feel a gentle arch in your lower back, feeling your back muscles contracting and return to the starting position.

Repeat 10 to 15 times, tilting your pelvis back and forth in a slow rocking motion.

Tips:

• Keep your deep abdominals working throughout.
• Don’t press down through the neck, shoulders or feet.

Modification

• Place one hand on your stomach and the other under your lower back to feel the correct muscles working

What are the risk factors for developing low back pain?

Anyone can have back pain. Factors that can increase the risk for low back pain include:

• Age – The first attack of low back pain typically occurs between the ages of 30 and 50, and back pain becomes more common with advancing age. Loss of bone strength from osteoporosis can lead to fractures, and at the same time, muscle elasticity and tone decrease. The intervertebral discs begin to lose fluid and flexibility with age, which decreases their ability to cushion the vertebrae. The risk of spinal stenosis also increases with age.
• Fitness level – Back pain is more common among people who are not physically fit. Weak back and abdominal muscles may not properly support the spine. “Weekend warriors”—people who go out and exercise a lot after being inactive all week—are more likely to suffer painful back injuries than people who make moderate physical activity a daily habit. Studies show that low-impact aerobic exercise can help maintain the integrity of intervertebral discs.
• Weight gain – Being overweight, obese, or quickly gaining significant amounts of weight can put stress on the back and lead to low back pain.
• Genetics – Some causes of back pain, such as ankylosing spondylitis (a form of arthritis that involves fusion of the spinal joints leading to some immobility of the spine), have a genetic component.
• Job-related factors – Having a job that requires heavy lifting, pushing, or pulling, particularly when it involves twisting or vibrating the spine, can lead to injury and back pain. Working at a desk all day can contribute to pain, especially from poor posture or sitting in a chair with not enough back support.
• Mental health – Anxiety and depression can influence how closely one focuses on their pain as well as their perception of its severity. Pain that becomes chronic also can contribute to the development of such psychological factors. Stress can affect the body in numerous ways, including causing muscle tension.
• Smoking – It can restrict blood flow and oxygen to the discs, causing them to degenerate faster.
• Backpack overload in children – A backpack overloaded with schoolbooks and supplies can strain the back and cause muscle fatigue.
• Psychological factors – Mood and depression, stress, and psychological well-being also can influence the likelihood of experiencing back pain.

Can low back pain be prevented?

Recurring back pain resulting from improper body mechanics may be prevented by avoiding movements that jolt or strain the back, maintaining correct posture, and lifting objects properly. Many work-related injuries are caused or aggravated by stressors such as heavy lifting, contact stress (repeated or constant contact between soft body tissue and a hard or sharp object), vibration, repetitive motion, and awkward posture.
Recommendations for keeping one’s back healthy

• Exercise regularly to keep muscles strong and flexible. Consult a physician for a list of low-impact, age-appropriate exercises that are specifically targeted to strengthening lower back and abdominal muscles.
• Maintain a healthy weight and eat a nutritious diet with a sufficient daily intake of calcium, phosphorus, and vitamin D to promote new bone growth.
• Use ergonomically designed furniture and equipment at home and at work. Make sure work surfaces are at a comfortable height.
• Switch sitting positions often and periodically walk around the office or gently stretch muscles to relieve tension. A pillow or rolled-up towel placed behind the small of the back can provide some lumbar support. Put your feet on a low stool or a stack of books when sitting for a long time.
• Wear comfortable, low-heeled shoes.
• Sleeping on one’s side with the knees drawn up in a fetal position can help open up the joints in the spine and relieve pressure by reducing the curvature of the spine. Always sleep on a firm surface.
• Don’t try to lift objects that are too heavy. Lift from the knees, pull the stomach muscles in, and keep the head down and in line with a straight back. When lifting, keep objects close to the body. Do not twist when lifting.
• Quit smoking. Smoking reduces blood flow to the lower spine, which can contribute to spinal disc degeneration. Smoking also increases the risk of osteoporosis and impedes healing. Coughing due to heavy smoking also may cause back pain.

Homeopathy Treatment for Low Back Pain

• Aesculus – Pain in the very low back (the sacral or sacroiliac areas) that feels worse when standing up from a sitting position, and worse from stooping, may be eased with this remedy. Aesculus is especially indicated for people with low back pain who also have a tendency toward venous congestion and hemorrhoids.
• Arnica montana – This remedy relieves lower back aches and stiffness from overexertion or minor trauma.
• Bryonia – This remedy is indicated when back pain is worse from even the slightest motion. Changing position, coughing, turning, or walking may bring on sharp, excruciating pain. This remedy can be helpful for back pain after injury and backaches during illness.
• Calcarea carbonica – This is often useful for low back pain and muscle weakness, especially in a person who is chilly, flabby or overweight, and easily tired by exertion. Chronic low back pain and muscle weakness may lead to inflammation and soreness that are aggravated by dampness and cold.
• Calcarea phosphorica – Stiffness and soreness of the spinal muscles and joints, especially in the neck and upper back, may be relieved by this remedy. The person feels worse from drafts and cold, as well as from exertion. Aching in the bones and feelings of weariness and dissatisfaction are often seen in people who need this remedy.
• Natrum muriaticum – Back pain that improves from lying on something hard or pressing a hard object (such as a block or book) against the painful area suggests a need for this remedy. The person often seems reserved or formal but has strong emotions that are kept from others. Back pain from suppressed emotions, especially hurt or anger may respond to Natrum muriaticum.
• Nux vomica – This remedy is indicated for muscle cramps or constricting pains in the back. Discomfort is made worse by cold and relieved by warmth. The pain usually is worse at night, and the person may have to sit up in bed to turn over. Backache is also worse during constipation, and the pain is aggravated when the person feels the urge to move the bowels.
• Rhus Toxicodendron – This remedy can be useful for pain in the neck and shoulders as well as the lower back, when the pain is worse on initial movement and improves with continued motion. Even though in pain, the person finds it hard to lie down or stay still for very long, and often restlessly paces about. Aching and stiffness are aggravated in cold damp weather and relieved by warm applications, baths or showers, and massage.
• Sulfur – This remedy is often indicated when a person with back pain has a slouching posture. The back is weak and the person feels much worse from standing up for any length of time. Pain is also worse from stooping. Warmth may aggravate the pain and inflammation.

Other Remedies

• Cimicifuga (also called Actaea racemosa) – Severe aching and stiffness in the upper back and neck, as well as the lower back—with pains that extend down the thighs or across the hips — may be eased with this remedy. It isoften helpful for back pain during menstrual periods, with cramping, heaviness, and soreness. A person who needs this remedy typically is talkative and energetic, becoming agitated or depressed when ill.
• Dulcamara – If back pain sets in during cold damp weather, along with catching a cold, or after getting wet and chilled, this remedy may be indicated. Stiffness and chills can be felt in the back, and pain is usually worse from stooping.
• Ignatia – Back pains related to emotional upsets—especially grief—will often respond to this remedy. The muscles of the lower back may spasm, and twitches, drawing pains, and cramps often occur in other areas.
• Kali carbonicum – Kali Carbonicum is a homeopathic medicine for lower back pain with the feeling that the knees are going to “give in.”
• Hypericum perforatum – This homeopathic remedy relieves lower back pain with sharp throbbing pain.
• Ruta graveolens – This is used to relieve lower back pain caused or worsened by staying immobile.

References

• https://www.ncbi.nlm.nih.gov/pubmed/11844532
• https://www.ncbi.nlm.nih.gov/pubmed/28447605
• https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4303793/
• https://www.ncbi.nlm.nih.gov/books/NBK538173/
• https://en.wikipedia.org/wiki/Spinal_cord_injury
• https://www.spinalcord.com/thoracic-spinal-cord-injury
• https://www.ncbi.nlm.nih.gov/pubmed/23462880
• https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3584795/
• https://www.ncbi.nlm.nih.gov/pubmed/11586110
• https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4303786/
• https://www.ncbi.nlm.nih.gov/books/NBK538173/
• https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3217809/
• https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5573861/
• https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4857557/
• https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3410134/
• https://www.spinalcord.com/thoracic-spinal-cord-injury
• https://en.wikipedia.org/wiki/Brown-S%C3%A9quard_syndrome
• https://www.hopkinsmedicine.org/healthlibrary

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