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Back Pain

July 30, 2013

Roughly 80% of back pain has a mechanical nature.It is mechanical in the sense that it originates from structures in the back and responds to position and movement. Any of the structural components in your back can be at fault, namely, muscles, tendons, ligaments, vertebrae, and the spinal cord.

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The good news is that the overwhelming majority of back pain does not indicate serious damage. More often than not, it goes away by itself. Only 10% of cases need a referral to a spine surgeon, and fewer than 5% are good candidates for surgery. A mere 10-20% may benefit from imaging technology such as MRI. The problem with MRI is a tendency to show inevitable wear and tear, which bears little correlation with the severity of symptoms. Up to 90% of people have an abnormal MRI, unrelated to the extent of their back pain. In most cases, imaging does not help to manage your recovery.

An important step in managing your pain is to exclude the presence of red flags. Red flags indicate potentially serious problems. The common red flags that I screen for are a history of previous cancer, age over 50 years, unexplained weight loss, nighttime pain, problems with bladder or bowel control, ‘saddle area’ numbness, leg numbness or weakness, fever, and chills.

In the absence of red flags, it is helpful to think of low back pain, not as a disease, but as a condition best managed by reducing pain in order to increase function. Treatment of mechanical back pain involves a strategy of escape positions and exercises. Escape positions are positions that provide relief, i.e., positions of rest that provide the greatest amount of pain control. With a few simple strategies, care need not be expensive and can be self-directed. The ultimate goal is pain control.

In order to prescribe a strategy, we would first need to identify your pattern of pain. There are four patterns of back pain. Each pattern represents a constellation of symptoms and signs that appear together in a predictable fashion and therefore respond predictably to certain treatments.

It is best to not self-diagnose. You must see a physician who will perform certain physical maneuvers to rule out serious problems. The positions and exercises suggested in these links serve as an auxiliary tool for patients, who have consulted with a physician and have formally been diagnosed with a particular pain pattern.

If you were diagnosed with Pattern 1: Mechanical Back Pain

Find your exercise and escape position prescription here: Pattern1

Back pain that is worse bending forward, but better bending backward, benefits from these positions:  ”Z” lie, Lumbar support when sitting. Also, you may find it helpful to place one foot on a stool when standing.

If your pain is worse bending in all directions, make liberal use of positions like ”Z” lie, Minimal lumbar support, Lumbar night roll, and Prone Lie. For constant pain, try these positions: Knees to Chest, Lie prone: pillow under pelvis.

Back pain aggravated by bending forward can be exercised with sloppy push-ups (5-10 every hour or two).

If you were diagnosed with Pattern 2: Mechanical Back Pain

Find your exercise and escape position prescription here: Pattern2

Pain increased by bending backward but never worse when bending forwards, can be targeted with these positions: Z lie, Supine Knees to Chest.

Certain movements are also recommended: repeated Knees to Chest, and repeated seated flexion. Try to push up on your thighs when moving from sitting to standing.

If you were diagnosed with Pattern 3: Constant Leg Dominant Pain

You have constant leg pain that is unlikely to benefit from specific exercises. The basis of your treatment is scheduled rest in your preferred escape positions (Pattern3) for 20-40 minutes every hour. The most effective position is the ”Z” lie.

Scheduled rest, medication and time will be your greatest allies. If you fail to improve, you may undergo nerve root or epidural steroid injections. Surgery is another option. Over 80% of cases resolve with time but full recovery can take a year or longer. The acute phase usually resolves in 4-6 weeks.

If you were diagnosed with Pattern 4: Intermittent Leg Dominant Pain

You need a long-term regular exercise program, focused on increasing strength in your core muscles. See the patient handout (Pattern4). Of the four patterns, this pattern is best treated with surgery.

There are several additional treatment options for back pain.


Nondrug therapy is preferred for low back pain.

For an acute backache (lasting less than 4 weeks), treatment starts with heat, massage, acupuncture, or spinal manipulation. Drugs that may prove useful are nonsteroidal anti-inflammatories or skeletal muscle relaxants.

For chronic low back pain (lasting more than 12 weeks), drug therapy is not effective. Any nondrug treatment that appeals to the patient can be used (e.g. exercise therapy; massage; acupuncture; mindfulness-based stress reduction; tai chi; yoga; motor control exercise; progressive relaxation; electromyography biofeedback; low-level laser therapy; operant therapy; cognitive behavioral therapy; or spinal manipulation). These treatments all appear to be equally effective.

If medications are used, a nonsteroidal anti-inflammatory drug is a first-line treatment and tramadol (Ultram) or duloxetine (Cymbalta) is second-line. I do not prescribe opioid (narcotic) medications for chronic back pain because the benefits of treatment do not outweigh the risks. ( (

There are no sure-fire ways to prevent back pain. However, maintaining a healthy back is part and parcel of adopting a healthy lifestyle. Here is how to take good care of your back: healthy-back-patient-info. Even good drivers have accidents, but they tend to have fewer of them. Think “prehabilitation”.



The doctor’s secrets …

Latest guideline:

Movement is medicine, motion is lotion. (

Mostly, back pain goes away by itself. (

Doing unnecessary tests “just to be sure” fails to reassure. ( (

A psychologist can help for chronic pain. (

Tylenol is unlikely to provide benefit. (

Epidural corticosteroid injections work as well for leg pain as placebo injections. Interestingly, placebo injections will help ( Gabapentin is sometimes a treatment option (

Is acute low back pain likely to last longer that 3 months?


Roland Morris Disability Questionnaire: english-canadian

Throwing your back out is a figure of speech. I really dislike this term as it promotes medical illiteracy and misinformation. ‘Putting it back in’ is the chiropractor’s blue lie ( (

Predictably, placebo can decrease pain and disability in patients with chronic low back pain ( 


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