Lower Back Pain: Causes, Treatment, and Singapore

by Bogota

1. Introduction

Lower back pain can come from a variety of disorders and injuries. The most common cause of lower back pain is strain of the muscles and soft tissues. Roughly 75% of adults have had lower back pain at some point. The sources of the pain can vary widely. It can be localized pain in the muscle or it can be generalized pain throughout the back. It can emanate into the buttocks and hips as movement restriction in the lower back can refer into the muscles of the hips and legs. Pain can range from a simple ache to a sharp pain. It can also accompany other neurological pain such as pins and needles, numbness, and motor weakness.

Lower back pain can originate from many disorders and ailments. The severity of lower back pain can vary greatly. In simple terms, it can be mild discomfort or it can be severe pain that is disabling. It can affect people of all ages, in any walks of life, and at any time. It is a highly prevalent ailment and is a very costly condition in our society.

1.1.          Overview of lower back pain

Lower back pain affects an individual’s back part of the body and it is annoying pain for the person who is suffering it. It has different levels of pain; it can be mild, acute or chronic. Most of the adults suffer from lower back pain in their life. It can occur at any time. Even though it is a spine-related issue, sometimes even simple muscle or ligament may cause this pain. Usually, lower back pain is higher among specific age groups. It begins to appear between ages 30 and 50, and it has been said that pain is the most reason for people being absent from work and for seeking medical consultation. Usually, these people are attributed as a cause of the pain is due to the nature of their work. But it can occur at any age, in almost all people severe pain resulting in more damage happens to middle age or sometimes even earlier. Sometimes acute pain occurs when the person lifts heavy or even simple things in the wrong way. Such occurrences may lead to the damage of intervertebral disc. The intervertebral disc is said to be the shock absorber which is between the vertebrae bones. When the disc is damaged, it will lead to pain due to nerve damage. The sciatic nerves might have been affected and causing pain anywhere from the buttocks to the leg. Although it causes severe pain, it can be treated well if the person diagnosed the problem earlier. But in the worst case, slip-disk condition occurs with severe pain to the patient. Sometimes surgery is needed to remove the problematic disc.

1.2. Prevalence of lower back pain after standing too long

Low-back pain is a common medical problem and it can be quite uncomfortable for the patient, especially if it lasts for more than a couple of days. One of the most common causes is too much sitting or standing in one position. It can be quite frustrating for the patient as usually medical practitioners will not be able to identify the cause of the lower back pain. The patient will then have to go through tests and may end up still not knowing the cause of lower back pain. Often, patients with non-specific lower back pain will think that it is caused by a previous injury, this often is not true. It is thought to be related to factors such as stress, depressive mood, anxiety, job dissatisfaction, and mental and physical load at work. A rapid increase in pain and disability will be noted in some patients if they straight away return to normal work and daily activities. Taking things easy and gradually progressing to normal activities is usually the best approach in trying to reduce the symptoms. Often patients are too eager to get a scan to find the cause of the lower back pain. It has been shown in various research trials that there is usually no significant difference between the prognosis of patients that get early imaging for the pain in comparison to patients who do not get imaging done.

2. Causes of Lower Back Pain

Poor posture when sitting, standing and lifting at work has been identified as a cause of low back pain which can result in injury. This may be sustained over a long period of time as it is the position the person is in regularly which causes the problem. Slouching and sitting in a chair for several hours without a break can cause muscle imbalances. The muscles are the postural and stabilizing muscles and the imbalance is the weakening of these muscles. The position of the pelvis when the lower back is flattened or pressed into the chair defines the shape of the spine and if it is held in this position for an extended period of time it can cause damage to the lumbar discs or put pressure on the nerve which can cause pain. A common disc problem in this position is a postolateral disc prolapse of the L4/L5 disc. The position of the pelvis can also cause a strained muscle injury or a ligamentous sprain. When lifting heavy objects it is often bending and twisting which is the cause of the injury.

Muscular strain is the most common cause of low back pain as it is the force which is applied to the muscles that make the back do the work. Too much force put through it is a direct cause and the ‘final straw’ is a relatively small force applied which the muscles are not strong enough to deal with, where the muscles can only stretch to 20% of their length before they are damaged. The damage of a muscle is a tear and it is the inflammation of the muscle tear which causes the pain. An example of muscular strain is lifting something that is too heavy using your back muscles, the force is excessive and it is too much for the muscles to handle or when using the correct technique it is the sudden unexpected movement which is the force.

2.1. Muscular strain and overuse

The breakdown of muscle occurs much quicker and takes longer to repair than muscle buildup. Thus, taking a short break from intensive manual labour will allow the muscles to recuperate, but they will not be back to the same strength as before. Over time, as the muscle imbalances become more severe, the formation of tense muscle fibres or muscle knots will occur. This is the back’s way of providing a warning sign that it is now at risk of a potential injury. The combination of muscle knots and weakened muscles serve to tighten the back muscles to protect the spine, but in the process, cause back tightness and discomfort. If the warnings are not heeded and there is continued overloading of the back muscles, a back strain or other back problems are likely to occur.

When under stress, the tendency is to use inappropriate body mechanics, such as hunching the shoulders when seated, or standing/walking with an excessive forward lean. Using poor body mechanics for an extended period of time, over weeks or years, can put the hip and back muscles at a disadvantage. While doing simple tasks, such as the ones mentioned above, would not cause any immediate pain, repeated use of poor body mechanics inevitably leads to muscle imbalances. As the muscles are now at a disadvantage, using them for the same tasks as before will now require more effort and force. It is at this point where the back muscles begin to be overloaded.

2.2. Poor posture and body mechanics

Maintenance of proper body mechanics, or the way in which one moves throughout daily life, is essential for maintaining a healthy spine. Proper body mechanics is required not only during lifting, but also in simple activities like sitting, standing, or walking. In fact, poor mechanics in these simple activities can be more detrimental to the back than the act of lifting a heavy object. Unfortunately, many people are unaware that their method of lifting or performing a task is causing their back more harm than good. This, combined with poor posture, is one reason why people will often injure their backs repeatedly. Usually, the injury is minor, but the cumulative effect over time can be quite damaging. An example of improper body mechanics is seen in individuals who lift heavy objects using their back muscles instead of their legs. This can lead to a type of back injury called a muscle strain. The erector spinae muscles in the back are most often injured due to their being used in a constant effort to maintain normal posture in the presence of weak abdominal musculature. This is similar to an attempt to lift a weight with the arms held out straight in front of the body; the arm muscles would become tired from the effort even though no specific injury had occurred. The muscles would then become painful and tight the next day. In the case of the back muscles and muscle imbalance, this scenario is a set up for chronic or recurrent pain in the lower back.

Poor posture and body mechanics are pervasive in modern society and are a common cause of lower back pain. Poor posture leads to spinal misalignment, which in turn can lead to muscle imbalances in the affected region. It increases the load on the spinal tissues, leading to possible injury, and it also causes changes in the spine that can lead to serious chronic back problems. The many factors that can cause poor posture include stress, obesity, pregnancy, weak postural muscles, abnormally tight muscles, and high-heeled shoes. It’s the rare individual who has escaped most of these. Despite the mechanical causes described by the biomechanical model, the medical community and society in general have tended to oversimplify the link between poor posture and back pain. This has led to a lack of success in prevention or recovery from most conditions. The reason is simply that most people with poor posture never learn what specific postural changes are detrimental, and many clinicians do not have the education or tools to teach them.

2.3. Herniated discs and spinal conditions

The spine, a marvel of biological engineering, supports the body, protects the spinal cord and nerve roots, and serves as a hinge for movement. The vertebral column in the back is composed of 24 vertebrae plus the sacrum and coccyx. Between each of the first 24 vertebrae are discs which act as shock absorbers and provide flexibility to the spine. The inner part of the disc is made up of a gel-like substance called nucleus pulposus. The discs are designed somewhat like jelly doughnuts because the nucleus is the jelly in the doughnut; it is contained within an outer ring called the annulus fibrosus. When the disc has been herniated, a portion of the nucleus has actually seeped through the annulus and it bulges into the spinal canal. This bulging is what causes the pain in a person with a herniated disc because the bulging can impinge on the nerve root. The exact cause of spondylolysis is not currently known, but it is believed to be genetic and is usually related to another back problem, which is spondylolisthesis. Spondylolisthesis occurs when one vertebra moves forward on the vertebrae below it. This shift causes the usual scissor-like joint between the two vertebrae to become oblique and it can lead to a stress fracture at the pars interarticularis, which becomes spondylolysis. Both of these conditions can cause lower back pain in adults, and spondylolisthesis can also cause compressive leg pains.

2.4. Degenerative conditions and arthritis

The intervertebral discs serve the key function of absorption of shock across the spinal column. They are “fibrocartilaginous structures made from a hard ring on the outside (annulus) and a soft, jelly-like center (nucleus pulposus),” according to Shariq Naseem, MD. When the annulus is weakened as a result of aging, it loses its ability to take shock. When this happens, the center of the disc has a higher chance of pushing through the annulus and herniation occurs. This is particularly common in the lumbar region (lower back) because the weight of the upper body exerts intense force on this area and the most flexibility of the spine occurs at this location. When a disc herniates, it often irritates the adjacent spinal nerve root, causing radiculopathy. The term radiculopathy describes a disease of the spinal nerve roots and nerve. This often causes pain that radiates into the buttock and legs. An MRI of the lumbar spine can confirm the diagnosis of a disc herniation and is often used as a method of determining effective treatment for relief of leg and lower back pain. The indication for surgical treatment of a disc herniation is commonly leg pain that persists for longer than four weeks. An alternative surgical treatment is discectomy where only the part of the disc causing irritation to the nerve root is removed. A combination of medication and physical therapy is always considered as a method of treatment before disc surgery. Evident by this article, herniated discs are a common cause of lower back pain but with effective treatment, the prognosis is quite good.

3. Treatment Options for Lower Back Pain

There are a number of ways to treat chronic lower back pain; however, what works for one individual might not work for another. And often, the cost of treatment is high with a very low success rate. Case in point, the number of back surgeries has been steadily rising in the United States, yet the results often leave much to be desired. According to the AHRQ, in 1999 there were 64,000 spine surgeries; this number increased to 122,000 by 2008. A parallel increase was also demonstrated with an increase in the amount of money spent, with an aggregate cost of $40.3 billion in 2006. Compare this to the UK where the National Health Service has stopped routinely funding spine fusion surgery! After receiving a diagnosis of the cause of your lower back pain, the doctor will have a better idea of how to treat it. It is always best to start with conservative treatment such as physiotherapy to mobilize the sacroiliac joint or traction for addressing a herniated disc. No matter what the diagnosis, often the best place to start is to avoid overload of the muscles and ligaments in the lower back, guidance from a physiotherapist or other back pain professional can be beneficial. Advice will cover use of correct sitting positions, lifting techniques, and ergonomics.

3.1. Rest, ice, and heat therapy

Rest, ice, and heat therapy are still perhaps the most traditionally used and well known treatments for pulled back muscles today. There is little scientific data to prove that these treatments actually work, but many patients find them beneficial. Although the ice pack would be considered the more conventional approach, in recent years, usage of specialized cooling gels has been promoted. These gels are rubbed into the skin, and according to some claims, help to reduce inflammation in the muscle. People always ask how to use heat and ice in the right way. I always recommend heat before stretching and exercising the lower back because I find it provides more relief with that kind of activity. The use of ice or cooling gels can be applied following the exercise, or at the end of the day. At times, when the pain is most severe, alternating between the two every 20 minutes has been found to be most effective.

3.2. Physical therapy and exercise

Walking is a common form of exercise therapy. A randomized controlled trial revealed that a 2-month treadmill walking program showed vastly better improvement in pain reduction than lumbar extension exercises and medical treatment. Another study also revealed that more frequently conducted physical activities involving greater intensity lowered the risk of developing a disability due to LSS symptoms.

Exercise Therapy Exercise therapy is another common conservative treatment option for lumbar spine stenosis. Similar to how physical therapy was defined, exercise therapy was also a term used to define exercises that were given under the supervision of a therapist. Specifically, exercises that increase cardiovascular endurance, muscle strength, and flexibility are often performed.

A pooled analysis of randomized controlled trials compared the results from high and low back pain episodes in patients. It was found that there is no difference between the two groups in pain reduction and functional status. Because of these results, lower back pain was used interchangeably with low back pain in my study.

3.3. Medications for pain relief

It is very important to take medications as directed. For example, you may be directed to take a NSAID for a short period of time, or you may be directed to take a muscle relaxant several times each day, but to save the narcotic for just before going to bed. Medications for back pain: different medications can be used to relieve back pain. The span ranges from Paracetamol to the use of narcotics. Each medication should be monitored closely for efficacy and changed accordingly. Always check with a doctor or pharmacist before combining with other medication. This is mainly due to NSAID having side effects when combined with other medication. A relatively newer medication for pain relief of osteoarthritis and lower back pain are Selective COX-2 inhibitors.

Medications are often used to treat acute and chronic low back pain. Effective pain relief may involve a combination of prescription drugs and over-the-counter remedies. Patients may be required to consult a physician prior to starting any drug therapy.

3.4. Alternative treatments and complementary therapies

There are times when standard treatment therapies do not bring relief from back pain. At these times, patients may be turned to a pain clinic or a specialist in physical medicine. The doctor may suggest a change to an alternative medicine such as acupuncture, TENS treatment, ultrasound, using psychological therapy or simply supplement the care with a prescription for an SSRI or tricyclic antidepressant. Furthermore, there are some individuals who turn to alternative medicines earlier in the pursuit of relief. It is not uncommon for patients to try the alternative treatments. A recent survey done by the National Institute of Health Statistics shows that 36% of Americans use some form of complementary or alternative therapy with the most frequently used being natural products including herbs, deep breathing exercises, meditation, chiropractic and massage therapy. These therapies are commonly done in an attempt to avoid the side effects from medications and to try more conservative treatments. Such treatments should be approached with moderation. While considered safe for back pain, chiropractic manipulation and massage have the potential to do more harm than good if done improperly. Always inform your therapist or chiropractor of the cause of pain and relevant medical history before proceeding with treatments.

4. Singapore’s Approach to Lower Back Pain

It is therefore hoped that Singaporeans will place a higher priority on seeking treatment early and not allow chronic conditions to deteriorate to a severe state, which will also reduce the financial burden on healthcare expenses.

In Singapore, the public sector often serves as a safety net for those who cannot afford treatment in the private sector. This approach was inspired by the British health system. The Singaporean government has also been encouraging society to use Medisave accounts. This basically involves using one’s own money to pay for treatments, which are not limited to only chronic or severe diseases. This is an initiative to promote self-awareness and extend the responsibility of taking care of oneself.

Healthcare in Singapore is mainly administered by the Ministry of Health Singapore, which is in charge of providing universal healthcare to all citizens of Singapore. Singapore’s healthcare delivery system is a mix of public and private providers. Some Singaporeans use the public system for healthcare, while others opt for the private sector.

Singapore’s healthcare system has often been recognized as one of the best in the world, whether it is in terms of infrastructure or the quality of services provided. The Ministry of Health has often been accused of spending huge amounts on healthcare administration compared to neighboring countries. However, it is believed that better management will improve healthcare in the nation. The government has recently introduced Six Sigma measures to be implemented into the public sector.

4.1. Healthcare system in Singapore

In Singapore, a patient can choose to see a family physician in a private GP clinic or a government polyclinic. A government initiative has led to the establishment of the Chronic Disease Management Program (CDMP), which allows patients with chronic diseases to receive subsidized treatment from approved GP and specialist clinics. CDMP has potential benefits in the primary care of chronic lower back pain; however, it involves a complex and lengthy administration process and it is not well publicized. At the level of primary care, management of acute lower back pain tends to be rather homogeneous and is often a case of medical management and referral to orthopedic care. There is potential for greater integration of physiotherapy and chiropractic treatment in the primary care setting. Step-down referrals from the public sector subsidized allied health services may be one way to facilitate this. As with the global trend, there is increasing utilization of complementary medicine and alternative therapies. However, the quality and regulation of practice is variable and this remains a controversial area both locally and internationally.

Singapore has a mixed public and private healthcare financing system. Public health services are heavily subsidized by the government, which has resulted in widespread accessibility. There are also 13 private hospitals with a total of 2,657 beds. Acute hospital care is well catered for in Singapore and this is important in the management of patients with red flags and acute radicular leg pain due to lower back pain. However, the high bed occupancy rate and the high opportunity cost of a hospital bed has resulted in shorter hospital stays and early discharge. In recent years, there has been a shift towards intermediate and long-term home and community-based care, but there is still room for improvement in this area.

Situated in the heart of Asia, Singapore is a multi-racial and multi-cultural city-state with a population of over 4 million people. It is also a rapidly aging society. This demographic transition has resulted in a surge in the number of chronic and degenerative diseases, among which, lower back pain is one of the most common. As such, the demand for optimal prevention and management of lower back pain is rapidly increasing. To meet this demand, an effective healthcare system involving prevention, early intervention, and multidisciplinary management is required.

4.2. Availability of medical professionals and specialists

Singapore offers a range of healthcare services for lower back pain, the first of which are the polyclinics and General Practitioners (GPs). The government has appointed teams of doctors within the polyclinics and created the GP registration programme to ensure that patients receive quality healthcare from physicians who are familiar and experienced with treating lower back pain. These doctors act as gatekeepers to specialist treatment and are able to provide patients with referrals to government and private hospitals. Patients can thus expect to be under the care of a single physician who will be able to oversee the entirety of their treatment. Those who wish to seek treatment at government hospitals may do so via the subsidised Outpatient Specialist Referral System. This enables patients to receive treatment from orthopaedic surgeons or neurosurgeons at a lower cost than private hospitals. A similar treatment pathway exists at the Singapore General Hospital, which has medical teams dedicated to providing specific treatment for lower back pain.

4.3. Rehabilitation centers and pain management clinics

In my opinion, pain management is the strategy used to provide pain relief with the minimal side effects to the patient and at the same time addressing the underlying pain generator. There are various forms of pain management for lower back pain, ranging from oral medications, to injections, to various complimentary therapies. Step one in pain management is identification of the pain source. This may involve a referral to a specialist and various imaging studies. A significant number of individuals with acute onset of lower back pain caused by a trauma or a specific incidence (i.e. lifting or bending over) will experience disc and/or nerve root pain. This type of pain can be predominantly painful and often debilitating. An accurately delivered spinal injection of local anesthetic and/or steroid can give prompt pain relief in these cases. There is also strong evidence supporting various medication and injection therapies for individuals suffering from chronic discogenic pain and spinal stenosis. Having said that, the use of both injections and medications to provide pain relief for lower back pain has to be carefully managed. Due diligence in researching the potential benefits and risks must be taken and it is always best done under the guidance of a knowledgeable physician.

Individuals with work related injuries may find themselves referred to a functional restoration program, specifically designed to return injured workers back to their employment.

Singapore boasts a number of excellent rehabilitation facilities, many of which function within private orthopedic groups. The target of physical therapy is relative to the functional demands of the patient. Manual therapy and various modalities may be employed initially for pain relief in patients who are deconditioned or suffer from a more acute injury. A transition then occurs into a more active rehabilitative phase to restore strength and flexibility, and to address the impairments and functional limitations of chronic sufferers.

Rehabilitation is particularly crucial to recovery from lower back pain. Patients struggling with pain are encouraged to remain active within limits. This may mean a continuation of regular activities of daily living as well as a gradual increase into a formal exercise program. Often a referral to a physical therapist is made in order to ensure the most effective recovery. In some cases, a few sessions with a therapist can be enough to set a patient on the right track, but the more chronic cases or individuals with higher functional demands would be best served in a more comprehensive rehabilitation program.

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