Most episodes of LBP are self-limited, however, episodes do tend to become more frequent with age.
LBP is most commonly due to repeated stress on the lumbar spine over many years (“degeneration”), although an acute injury may cause the initiation of pain.
Mechanical back pain may also result from trauma, posture, occupation, or overuse. As a rule morning pain would suggest some type of inflammatory process. If the pain gets worse during activity or as the day goes on, this might indicate a muscular issue.
There is also a large body of research linking low back pain to emotional or psychological states (such as depression) and also to lifestyle issues such as lack of exercise, poor core stability and smoking.
Most acute mechanical episodes last less than six weeks - so if the pain hasn’t remitted after six weeks you should consider another underlying issue. The most likely issues are a disc injury, facet issue, other underlying pathology (se below) or most commonly, “trigger points”.
Simple Lower Back Pain (85%)
There are two main types of LBP, "Simple" and "Radiculopathic".With Simple LBP which is by far the most common, the patient is typically aged between 20-55. Pain is felt in the lumbosacral, buttock area or front/back of the thighs; it is a “mechanical” type of pain.
Mechanical pain tends to change with physical activity and/or throughout the day. General well-being is typically normal and the patient is otherwise healthy. Simple LBP is highly associated with trigger points. In fact Dr. Bob Gerwin from the John Hopkins School of Medicine asserts that “up to 95% of mechanical LBP may trigger point related.”
Radiculopathic LBP (5%-10%)
The vast majority of radiculopathic pain is from an injured or diseased disc (discopathic). Other structures such as osteophytes (extra bone growth) or spinal anomalies may also produce radiculopathic pain.
The pain is usually unilateral (one sided) and radiates into the leg. Characteristically, the leg pain is worse than the back pain. There may be numbness and or “pins and needles.”
On examination, there may be signs of nerve irritation such as positive sciatic or femoral nerve stretch signs (SLRT, etc.). If severe or chronic, there may also be motor, sensory or autonomic skin (trophic) changes. Pain is usually limited to one nerve root.
Trigger Points and Low back Pain
Trigger points may develop in (spinal) muscles for a number of reasons including overload, under-load (poor conditioning), trauma, or even as part of the body’s protect and defense mechanism.
If untreated, trigger points may lead to a vicious cycle of lowered pain threshold (sensitization) and prolonged mechanical pain. Trigger points can often be “left-over” from previous untreated or poorly managed episodes of back pain.
They can also build up over time to form larger clusters. This is why it’s so important to understand what trigger points are, and how to address them.
When we are making a diagnosis we are making a “best guess” or a working hypothesis as to what is causing LBP. We can improve our guesswork with a thorough examination, good case history and appropriate investigations.
The Good News
The good news is that 86% of LBP is non-specifc which means it probably involves the discs, joints, ligaments and almost certainly, the muscles. The chart above shows the breakdown of the percentages for back pain as it presents to healthcare practitioners (Gordon Waddell, 2004).
Most healthcare systems are reluctant to spend money on investigations for non-specific LBP. Thankfully, this group of patients can be most improved by trigger point and other manual therapy techniques. To get a more complete picture however, we need to peer a little bit into that remaining 14%.
Long Term Symptoms
If the pain persists for more than six weeks, is constantly intense, or is getting worse, it is important to seek further investigation. Of the 14%, 10% is nerve impingement pain, which may be from discopathy, piriformis syndrome, post surgical scarring and/or radiculopathy.
A further 2% is from collagen disorders, spondylarthropathy (joint pathologies) or haematological (blood related) disorders.
The final 2% is from secondary (metastasis) or primary cancers, osteomyelitis and or vertebral fractures. As the numbers show, these cases make up a tiny proportion of LBP cases, and LBP is so common that you should not panic at the onset of pain. Start by finding yourself a good manual therapist!
This trigger point therapy blog is intended to be used for information purposes only and is not intended to be used for medical diagnosis or treatment or to substitute for a medical diagnosis and/or treatment rendered or prescribed by a physician or competent healthcare professional. This information is designed as educational material, but should not be taken as a recommendation for treatment of any particular person or patient. Always consult your physician if you think you need treatment or if you feel unwell.
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