A pain in the ass! Managing chronic lower back pain.

Please raise your hand if you’ve experienced pain in your back?

Look to the person on your left and right. They’ve probably also experienced back pain at some point in their lives and if they haven’t, they probably will do at some point. In fact, back pain affects about 80% of adults at some point in their lifetimes. It has affected the author of this blog and is a real pain!

Don’t forget about the young ones; back pain also affects kids! But that is another discussion & blog post.

In this article we will discuss pain that occurs in the lower part of the back in adults.

In the medical field we usually call this ‘low back pain’ but for the purposes of this blog article we’ll call it ‘lower back pain’.

Back pain is the most common cause of disability & sick days from work. It affects men and women. It can affect young or old. It can be mild or debilitating. It can start suddenly or slowly. It can be localised (you feel it in a small area of your back) or diffuse (you feel it over a wide area of your back). It can last for a short time (days) or a long time (years). It can sometimes be hard to treat.

Lower back pain is often acute, or short term, and lasts a few days to a few weeks. It tends to resolve on its own with self-care and there are no long-term effects. The majority of acute lower back pain is mechanical in nature, which means that there is a temporary disturbance in the way the many components of the back fit together and work. Components of your back include the spinal vertebrae or bones, the intervertebral discs between the bones, the spinal cord and multiple nerves and many different muscles, tendons and ligaments. These components of your back all work seamlessly together like the parts and gears in a complex piece of machinery: if one part is faulty, then the whole system can be affected and malfunction.

Lower back pain is called subacute if it lasts longer, that is, between 4 and 12 weeks.

Lower back pain is called chronic if the pain lasts for 12 weeks or longer, even after the initial injury or underlying cause of the lower back pain has been treated. Chronic lower back pain can occur in about 20% of people that get acute lower back pain. This means that in 20% of people your pain can continue for much longer than expected and in some of those cases the chronic lower back pain can be difficult to treat.

What components make up the lower back?

The lower back is where most spinal pain occurs. The lower back includes the five lumbar vertebral bones called L1, L2, L3, L4 and L5 (Figure 1). These bones support most of the weight of your upper body. Between these vertebrae are supportive soft, round, elastic pads called the intervertebral discs (Figure 2). These discs act like shock absorbers throughout your spine to cushion & support the vertebral bones as your body & spine move in all directions. The vertebrae and discs are held in place by bands of tough tissue that run up and down over them. These bands of tissue are called ligaments. Tendons are the tough bits at the ends of your muscles that attached your muscles to your spinal column.

Figure 1. Your lower back. (Drawing by LadyofHats)

 

Figure 2. Some of the structures making up your lower back. (Drawing by Anuskafm under the GNU Free Documentation License.)

From the top of your spine, 31 pairs of big nerves come off the spinal cord and travel around your body. These nerves are very important and they control sensation, body movements and other important body functions. Your lower back has 5 lumbar nerves (1 on each side of the spine). These nerves can get pinched by a buldging (prolapsed) disc (Figure 3). When this happens it causes a shooting pain down your leg and can sometimes feel like an electric shock.

Figure 3. Herniated disc. (Drawing by Edave under Creative Commons Attribution-Share Alike 3.0 Unported)

What causes lower back pain?

The majority of lower back pain is mechanical in nature. This means that there is a temporary disturbance in the way the components of your back fit together and work.

Some examples of problems that cause mechanical lower back pain include:

Sprains and strains

Sprains are caused by overstretching or tearing of the ligaments in your lower back. Strains are tears in your tendons or muscles. Sprains and strains occur from twisting or lifting something improperly or lifting something too heavy, or overstretching. These movements can also trigger spasms or cramps in your back muscles, which can also be very painful.

Spondylosis

Spondylosis means the natural aging and gradual deterioration process that occurs throughout your spine. This ‘wear and tear’ occurs, as we get older and is part of the normal aging process. It can occur in all parts of your spine but commonly affects the joints (called facet joints – see below). Spondylosis can also affect your intervertebral discs, the bones themselves and all of the ligaments, tendons and muscles too.

Facet joint syndrome

Facet joint syndrome is pain that occurs at the joints between any two vertebrae in your spine. Another term for facet joint syndrome is osteoarthritis. The facet joints are the joints in your spine that make your back flexible and enable you to bend and twist. When these joints cause lower back pain it hurts when you extend your back (look upwards) and when someone puts pressure on your facet joints by pushing on them or twisting your spine. Facet joint pain is a pain that is relatively common to treat by using nerve blocks and other interventional treatments like radiofrequency (see below).

Sacroiliac joint syndrome

The sacroiliac joints are the lowest joints in your spine (Figure 4). They are actually joints in the back part of your pelvis, in the area where the pelvis meets the spine. They are the joints where the ‘dimples’ occur at the top of your buttocks. There are two sacroiliac joints; one on each side. Like the lumbar facet joints, your sacroiliac joints can become arthritic or malfunction and cause you pain. Sacroiliac joint pain is a pain that is commonly treat by using joint blocks and other interventional treatments like radiofrequency (see below).

Figure 4. Sacroiliac joint and sciatic nerve. (Drawing by BruceBlaus under Creative Commons Attribution 3.0 Unported)

Disc degeneration

Intervertebral disc degeneration is a common cause of mechanical lower back pain. It occurs when the rubbery discs between your vertebrae lose their strength and sponginess. This occurs, as we get older. In a young or healthy back, the intervertebral discs provide height and allow you to bend, flex, and twist your lower back. When the discs degenerate the outer part can become swollen and inflamed and cause lower back pain. Sometimes this is called degenerative disc disease.

Herniated or ruptured discs

Herniated discs occur when the intervertebral discs become weaken and bulge outward (herniate) causing lower back pain. Sometimes the discs can even rupture. Your intervertebral discs and surrounding bone can also get swollen and inflamed, which also causes lower back pain.

Foraminal stenosis

Radiculopathy occurs when a spinal nerve or nerves are either compressed, or injured in any way. They can then become irritated and inflamed, which can cause lower back pain.

Buldging (herniated) discs and/or bone spurs and/or inflamed joints can all cause a narrowing of the small openings (neural foramen) through which the delicate spinal nerves from your spinal cord leave the spinal column. When these small openings (neural foramen) become narrowed we call it foraminal stenosis (stenosis means ‘tight’) (Figure 5). Foraminal stenosis causes pressure on your spinal nerves and this causes pain, numbness, tingling or electric shocks that travels (radiates) down your leg where the nerve travels.

Spinal stenosis

Buldging (herniated) discs and/or bone spurs and/or inflamed joints can all cause a narrowing around your spinal cord. This is called spinal stenosis. Spinal stenosis is a narrowing of the spinal column that can then puts pressure on your spinal cord and nerves that can then cause pain or numbness when you walk and over time can even lead to leg weakness and numbness (sensory loss) (Figure 5).

Figure 5. Spinal nerve compression (foraminal stenosis) or spinal cord compression (central canal stenosis) (Drawing by BruceBlaus under Creative Commons Attribution-Share Alike 4.0 International)

Sciatica

Sciatica is the name given to any sort of pain that is caused by irritation or compression of the sciatic nerve. The sciatic nerve is the longest nerve in your body (Figure 4). It runs from the back of your pelvis, through your buttocks, and all the way down both legs, ending at your feet. Sciatica is a type of radiculopathy that occurs when the sciatic nerve becomes compressed by herniated discs, spinal stenosis and/or becomes pinched while it travels through the piriformis muscle in your buttocks.

Spondylolisthesis

Spondylolishesis (say it like this “spon-di-low-list-theesis”) is a condition in which a vertebral bone of the lower spine moves out of alignment and either slips forwards or backwards (Figure 6). Sometimes this slippage requires surgery to prevent it from worsening.

Figure 6. Spondylolisthesis of L5 on S1 (Drawing by PumpingRudi under Creative Commons Attribution-Share Alike 3.0 Unported)

Trauma

Any form of trauma or damage to the spine can occur for example when playing sports, or during car or bike accidents, or even during a fall. Sometimes these injuries to your spine can be minor or very serious and dangerous.

Skeletal abnormalities

Skeletal irregularities like scoliosis, an abnormal curve of the spine might cause back pain.

What are the red flags?

Sometimes lower back pain can be caused by serious and dangerous conditions, which we call red flags. If these conditions occur, urgent, specialist medical assessment and treatment is needed. Some of these serious and dangerous red flag conditions include:

Fractures

Sometimes the bones can be broken as a result of trauma or even just break by themselves, which can occur in elderly people or people who have osteoporosis.

Infections

Infections can involve the vertebrae (bones) and is this called osteomyelitis; infections can involve the intervertebral discs and this is called discitis; or infections can involve the sacroiliac joints connecting the lower spine to the pelvis, and this is called called sacroiliitis.

Tumours

Occasionally, cancers can start in the spinal column, or spread from elsewhere in the body like prostate or breast cancer. If tumours are in the spine they usually have spread from a cancer in another part of the body. These are called metastases.

Cauda equina syndrome

This occurs when a ruptured disc extends into the spinal canal and compresses important spinal nerves, which then causes loss of bladder and bowel control. Permanent neurological damage may also occur if this is not treated urgently.

Abdominal aortic aneurysms

An abdominal aortic aneurysm (AAA – sometimes called a “triple A”) is a swelling of the aorta, which is the main blood vessel that leads away from the heart, down through the abdomen to the rest of the body. Back pain can sometimes be a sign that this aneurysm is becoming larger and might even rupture (burst). This can be life threatening.

Red flags conditions are dangerous. Seek medical help urgently if any of the following occur regarding your lower back pain:

• If you are older then 50 years old
• Your pain is severe and unrelenting
• If your pain is worst at night or if your pain is not relieved by bed rest or lying down
• Your pain doesn’t respond after 1 month of treatment
• You have had a fall on your spine or sustained any other trauma e.g. a car accident
• If you have an unexplained fever
• If you have unexplained weight loss
• If you have had cancer in the past
• If you are having altered sensations in the lower half of your body or troubles moving your legs, or problems with your bladder or bowel function
• If the pain is spreading into your abdomen
• If you also feel unwell in any other way

What are the risk factors for developing lower back pain?

Sometimes people are a bit more prone to developing back pain. Here are a few risk factors that might make the development of back pain more likely:

Age

None of us can escape this one!
Back pain becomes more common when we are older than 30 years. As we get older, we develop spondylosis, our bones can weaken (osteoporosis), discs become dehydrated (loose fluids) and can buldge and muscles can weaken and tighten up. All these things can cause lower back pain.

Fitness level

We could all be better at this!

Back pain is far more likely to occur in people that are not physically fit and active. Weak back and abdominal muscles are not able to support the spine.

Don’t be a weekend warrior because they are more likely to get back pain! Weekend warriors exercise a lot on the weekends after being inactive during the week and this is the wrong way to exercise. Rather do moderate physical activity every day or every few days.

So start moving your body regularly and start doing it now!

Weight gain

Being overweight, obese, or quickly gaining significant amounts of weight can put significant stress on your spine and cause lower back pain.

Genetics

There are some types of back pain that caused by your genes. One example is ankylosing spondylitis, a form of arthritis that involves a natural fusion of the spinal joints leading to stiffness of the spine.

Certain occupations

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. An inactive job or a desk job may also lead to or contribute to pain, especially if you have poor posture or sit all day in a chair with inadequate back support.

Backpacks in children

Don’t overload kids backpacks! Backpacks or schoolbags can strain the back and cause muscle fatigue.

Risk factors for developing lower back pain in kids include:

• A schoolbag that weighs more than 10 per cent of the child’s weight
• Holding the bag in one hand by its straps
• Carrying the bag over one shoulder
• An incorrectly packed backpack
• An incorrectly fitted backpack

For more on back pain in kids click here to check out Victoria’s BetterHealth page on back pain in children 

Pregnancy

Pregnancy can be accompanied by lower back pain, which results from pelvic changes and alterations in weight loading. Back symptoms usually resolve after birth. If they persist, see your doctor.

How is lower back pain diagnosed?

As you can see chronic back pain is a complex problem and hence should be assessed by a medical professional or pain specialist who will take the time to understand the story of your lower back pain, your medical history and perform a physical examination.

In most cases imaging tests are not needed to understand your lower back pain but in some circumstances they may be ordered by your doctor or pain specialist.

Types of imaging tests are:

• X-rays
  X-rays can show the bony structures and any vertebral misalignment or fractures. X-rays only show the bones so often don’t provide a lot of information for your doctor or pain specialist.
• CT-scan
  Computerized tomography (CT) uses an advanced form of x-rays to show structures other than bones but this form of imaging doesn’t show great detail like pinched nerves.
• MRI scan
  Magnetic resonance imaging (MRI) is considered the ‘gold-standard’ in visualising the structures of the spine. It uses magnetic force and not x-rays. MRI scans produce highly detailed images.
• Myelogram
  Myelograms enhance the diagnostic imaging of x-rays and CT scans. In this procedure, a contrast dye is injected into the spinal canal, allowing spinal cord and nerve compression caused by herniated discs or fractures to be seen on an x-ray or CT scans. Myelograms are quite invasive and also painful, so are not often performed without a good reason to do so. Myelograms are not often needed now that we use MRI scans.
• Bone scan
  Bone scans are used to detect and monitor infection, fracture, or problems in the bones. A small amount of radioactive material is injected into your bloodstream. The dye will then gather in the bones, particularly in areas with some abnormality. Then pictures are taken and the pictures will show the bones and areas where the dye has collected (Figure 7).

 

 

 

 

 

 

 

 

 

 

 

 

 

Figure 7. Bone scan showing prostatic cancer in various parts of the spine. (Drawing by RadsWiki under Creative Commons Attribution-Share Alike 3.0 Unported)

• Ultrasound
  Ultrasound imaging can show tears in ligaments, muscles, tendons, and other soft tissue masses in the back.
• Discography
  Discography involves the injection of a contrast dye into a spinal disc thought to be causing lower back pain. The fluid’s pressure in the disc will cause the person’s lower back pain if the disc is the cause. The dye also helps to show the damaged areas on a CT scan taken following the injection. Discography may provide useful information in cases where people are considering lumbar surgery. Discography is not generally needed and used nowadays and comes with risks.

Other tests may include:

• Electrodiagnostics are mainly used to confirm whether a person has a problem with one or more nerves e.g. a pinched nerve (radiculopathy). The procedures include nerve conduction studies (NCS) to assess nerve function or electromyography (EMG) to assess muscle strength. Neurologists do these tests: they insert fine needles into muscles to measure electrical activity in the nerves and muscles.
• Blood tests are not routinely used to diagnose the cause of back pain; however in some cases they may be ordered to look for signs of inflammation, infection, and/or the presence of some forms of arthritis.

How is back pain treated?

Treatment for lower back pain generally depends on whether the pain is acute or chronic lower back pain.

Here are some types of treatments for lower back pain:

Simple treatments

Hot or cold packs
Heat packs have never been proven to quickly resolve low back injury; however, they have very little risk and may help ease pain, reduce inflammation and allow greater mobility in some people.

Physical activity
Bed rest should be limited to a few days at the most. People should start stretching exercises and resume normal daily activities as soon as possible, while avoiding movements that aggravate pain. Research shows that people who continue their activities without bed rest after they develop lower back pain have better back flexibility compared to people who rested in bed for a week. Bed rest alone may make lower back pain worse and can lead to other complications such as depression, weakened muscles and even blood clots in the legs.

Exercises
Strengthening exercises, beyond general daily activities, are not recommended for acute lower back pain, but exercises can be an effective way to speed recovery from more longstanding lower back pain (chronic or subacute lower back pain).

Maintaining and building muscle strength is important. Your health care providers or pain specialists can provide a list of beneficial exercises that will help improve coordination, balance and posture.
Have you tried yoga to ease chronic low back pain?

Physical therapy
Physical therapy programs can strengthen core muscles that support your lower back. They can improve mobility and flexibility, and work well in combinations with other treatments.

Transcutaneous electrical nerve stimulation (TENS)
TENS involves wearing a battery-powered device consisting of electrodes placed on the skin over the painful area that generate electrical impulses designed to block incoming pain signals from the peripheral nerves. The research suggests that TENS is not that useful in managing lower back pain but it is a very low risk treatment.

Acupuncture
Acupuncture was thought to be moderately effective for chronic low back pain. When the needles are inserted and then stimulated (by twisting or passing a low-voltage electrical current through them) they cause the release of naturally occurring painreducing chemicals such as endorphins (your natural morphine) and serotonin. Current and updated recommendations by NICE advise that acupuncture is not useful for back pain and should not be used.

Medications

A wide range of medications can be used to treat acute and chronic lower back pain. Some are available over the counter but others require a doctor’s prescription. Certain drugs, even those available over the counter, carry risk and can be unsafe in some circumstances. Always discuss medications with your doctor or pain specialist before using them. The following are the main types of medications used for lower back pain:

Analgesic medications are those specifically designed to relieve pain. They include paracetamol and opioids like codeine, oxycodone, hydrocodone, and morphine. Opioids should only be used for a very short period of time and strictly under a doctor’s supervision. Opioids carry many risks, which include:

• People can develop a tolerance to opioids and require increasingly higher dosages to achieve the same effect.
• Dependence (addiction). ?
• Risk of overdosing, which can be very dangerous?and even fatal. ?
• Hormonal changes. ?
• Chronic dry mouth (which can cause tooth decay). ?
• Bone weakness and fractures from minor falls. ?
• Chronic constipation. ?
• Problems with sleep. ?
• Other problems with opioids include drowsiness, constipation, decreased reaction time, and impaired judgment. Long-term use of opioids can even aggravate mood problems like depression and anxiety.

Nonsteroidal anti-inflammatory drugs (NSAIDS)
Nonsteroidal anti-inflammatory drugs (NSAIDS) include ibuprofen, naproxen and diclofenac, relieve pain and inflammation. NSAIDS also carry significant risks like stomach irritation, gastritis, bleeding ulcers, heartburn, diarrhoea, fluid retention, and in rare cases, kidney failure and cardiovascular disease and even death. The longer a person uses NSAIDs the more likely they are to develop side effects. Many other drugs cannot be taken at the same time a person is treated with NSAIDs because they alter the way the body processes or eliminates medications.

Anticonvulsants
Anticonvulsants are medications primarily used to treat epilepsy but are very good pain medications and are commonly used for other chronic pain problems. These medications calm down overactive nerves. Sometimes these medications may be useful in treating people with certain types of back pain. Some of these medications include, gabapentin and pregabalin (Lyrica).

Antidepressants
Antidepressants medications like tricyclics and serotonin and norepinephrine reuptake inhibitors (SNRIs) are commonly prescribed for chronic low back pain, but their benefit for nonspecific low back pain is unproven. Some of these medications include amitriptyline (Endep), nortriptyline (Allegron) and duloxetine (Cymbalta)

Interventional therapies - injections and more advanced therapies

Nerve blocks
Chemical blocks use needles to inject and block nerves with local anaesthetics (usually for diagnostic purposes), steroids and other medications (like clonidine) can also be applied directly to nerves. An example would be using medial branch nerve blocks to assess whether your back pain may be coming from the small facet joints of your spine. If you pain is reduced by the test injections, then you may progress to a treatment called radiofrequency neurotomy.

Radiofrequency
Radiofrequency treatments use current that applied directly to nerve(s), through needles, that generate high temperatures (90°C) at the tips of the needles which then breaks down the nerves. This can then result in prolonged pain relief lasting anything from 4 months to 2 years. This is called radiofrequency neurotomy. The current can also be used to apply lower temperatures (42°C) directly to different nerves, which causes pain reduction without actually breaking down the nerves. This is called pulsed radiofrequency.

Neurostimulation
Neurostimulation (spinal cord stimulation)
Neurostimulation is when we can activate parts of the nervous system using microelectrodes connected to a small implantable battery. This uses the same principle as pacemakers that are used to control an abnormal heartbeat, except now we can use these specialised pacemakers to control abnormal nerve function that causes chronic pain. We can pace the nerves, which scrambles the pain signals of the nerves and reduces pain. Neurostimulators can be applied to any part of the nervous system, including the spinal cord or smaller nerves. When applied to the spinal cord, we call this spinal cord stimulation. Sometimes this therapy is called neuromodulation.

There is some growing and strong research that spinal cord stimulation can be used in some forms of chronic back pain that has become refractory to therapy. Refractory means that nothing is helping to reduce the pain.

Epidural steroid injections
Epidural steroid injections are a commonly used short-term option for treating low back pain and sciatica associated with inflammation. Pain relief associated with the injections, however, tends to be temporary and the injections are not advised for long-term use. The use of epidural steroid injections are limitied in the therapy of lower back pain.

Surgery

Surgery is generally only recommended if there is worsening nerve damage and when tests show structural changes, which need corrective surgery.

When other therapies fail, surgery may be considered an option to relieve pain caused by serious musculoskeletal injuries or nerve compression. It may be months following surgery before healed is complete. Some risks may include permanent loss of flexibility or any of the other potential risks involved with surgery. Surgical procedures are not always successful, and there is little evidence to show which procedures work best for their particular indications. Patients considering surgical approaches should be fully informed of all related risks & your surgeon will do this. If you are not sure which surgeon to assess you, you could ask your GP or pain specialist. We work with many highly regarded spinal surgeons.

Surgical options include:

• Spinal laminectomy (also known as spinal decompression) is performed when spinal stensis causes a narrowing of the spinal canal that causes pain, numbness, or weakness. During the procedure, the lamina or bony walls of the vertebrae, along with any bone spurs, are removed. The aim of the procedure is to open up the spinal column to remove pressure on the nerves.
• Discectomy or microdiscectomy may be recommended to remove a disc, in cases where it has herniated and presses on a nerve root or the spinal cord, which may cause intense and enduring pain.
• Microdiscectomy is similar to a conventional discectomy; however, this procedure involves removing the herniated disc through a much smaller incision in the back and a more rapid recovery. Laminectomy and discectomy are frequently performed together and the combination is one of the more common ways to remove pressure on a nerve root from a herniated disc or bone spur.
• Foraminotomy is an operation that cleans out or enlarges the bony hole (foramen) where a nerve exits the spinal column. Bulging discs or joints thickened with age can cause narrowing of the space through which the spinal nerve exits and can press on the nerve, resulting in pain, numbness, and weakness in an arm or leg. Small pieces of bone over the nerve are removed through a small slit, allowing the surgeon to cut away the blockage and relieve pressure on the nerve.
• Spinal fusion is used to strengthen the spine and prevent painful movements in people with degenerative disc disease or spondylolisthesis (following laminectomy). The spinal disc between two or more vertebrae is removed and the adjacent vertebrae are “fused” by bone grafts and/or metal devices secured by screws. The fusion can be performed through the abdomen, a procedure known as an anterior lumbar interbody fusion, or through the back, called posterior fusion. 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. Spinal fusion has been associated with an acceleration of disc degeneration at adjacent levels of the spine.
• Artificial disc replacement is considered an alternative to spinal fusion for the treatment of people with severely damaged discs. The procedure is a new therapy and currently undergoing research.

Can lower back pain be prevented?

Recurring back pain resulting from improper body mechanics is often preventable 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 heavy lifting, contact stress (repeated or constant contact between soft body tissue and a hard or sharp object), vibration, repetitive motion, and awkward posture. If these tings can be changed or modified then the risks of developing back pain may be reduced.

Using ergonomically designed furniture and equipment to protect the body from injury at home and in the workplace may reduce the risk of back injury.

Standing desks may useful.

Recommendations for keeping your back healthy

• Following any phase of prolonged inactivity, a program of low-impact exercises is advised. Speed walking, swimming, or stationary bike riding 30 minutes daily can increase muscle strength and flexibility. Yoga also can help stretch and strengthen muscles and improve posture. Consult a pain specialist physiotherapist for a list of low-impact, age-appropriate exercises that are specifically targeted to strengthening your lower back and abdominal muscles.
• Always stretch before exercise and strenuous physical activity.
• Stand straight up. Don’t slouch when standing or sitting. The lower back can support a person’s weight most easily when the curvature is reduced. When standing, keep your weight balanced between both your feet.
• At home or work, make sure all work surfaces are at a comfortable height.
• Sit in a chair with good lumbar support and proper position and height for the task you are doing. Keep you shoulders back. Switch sitting positions often and periodically walk around the office or gently stretch muscles to relieve tension. Use a lumbar support like a pillow or rolled-up towel placed behind the small of the back. During prolonged periods of sitting, elevate feet on a low stool or a stack of books.
• Wear comfortable, low-heeled shoes.
• Sleeping on your side with the knees drawn up in a foetal position can help open up the small joints in the spine (facet joints) 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 your knees, pull the stomach muscles in, and keep your head down and in line with a straight back. When lifting, keep objects close to your body. Do not twist when lifting.
• Keep good nutrition and a balanced diet, which will reduce and prevent excessive weight gain, especially weight around your waistline that may stress your lower back muscles. A diet with sufficient daily intake of calcium, phosphorus, and vitamin D helps to keep bones strong and promote new bone growth.
• Quit smoking right now! Smoking reduces blood flow to your 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. Smoking increases the risk of infections after implantations of neurostimulator devices and spinal fusion surgery.

 

Remember, living well with chronic pain is possible and even probable with the right team and experts around you. Click on the picture below to download our eBook "Coping tips for people living with chronic pain"