Low back pain, which affects 60% to 80% of the adult population at one time or another, is sharp or diffuse pain and often is accompanied by inflexibility and tenderness at the lumbar region. Usually caused by mechanical stress injuries or overload, the pain frequently radiates and affects the buttocks and legs as well. The majority of low back problems are acute or episodic, resulting from sharp or consistent strain. Less frequently, low back pain is a symptom of more serious injury, spinal deterioration, or disease. Back pain can interfere, to a greater or lesser degree, with the patient's ability to engage in work, recreation, and other normal activities.

• The most common cause of low back problems is relatively minor trauma or injury to the supporting muscles, the surrounding soft tissue (tendons, ligaments, or joint capsules) or spinal disks of the lumbar region. Generally, repeated twisting or lifting of heavy objects triggers the injury.
• After significant back strain or injury, a prolapsed or herniated disk is the type of serious low back injury most frequently seen. An incomplete tear in the annulus fibrosus of the intervertebral disk can cause a bulge that then irritates the lower lumbar roots. Some ruptures cause intervertebral fluids to leak, which can induce inflammation.
• Compression fractures at the lower part of the spine occur relatively frequently in older women with osteoporosis. A sudden stress or shock can cause one or more of the vertebrae to collapse on one side, producing a wedge-like distortion, throwing the muscles into spasm, and compressing the nerve root.
• Other causes of low back pain include a number of degenerative and mechanical conditions, most commonly lumbar degenerative disk disease (chronic low back pain) which develops over time as the intervertebral disks wear down and lose elasticity; spondylosis (degenerative spondylolisthesis, arthritis of the spine), which occurs when overuse, injury, or aging causes the intervertebral disks to thin and the spaces between the disks to narrow; and spinal or lumbar stenosis, which develops as the spinal canal narrows, causing crowding around the spinal cord and nerve roots, and buckling of intervertebral disk and interlaminar ligaments.
• Low back pain can be caused by sciatica (lumbar radiculopathy), irritation of the fifth lumbar or first sacral nerve root usually as a result of a herniated disk; and by sacroiliitus, an inflammatory condition usually associated with certain inflammatory bowel diseases and rheumatic disorders. Other seemingly unrelated conditions can produce low back pain, including ovarian cyst, nephrolithiasis, pancreatitis, ulcers, infection (usually indicated by fever, chills, and sweats), or metastatic cancers (usually indicated by night sweats and severe night pain).
• A psychological component may be involved in many back problems.

Men and older people are particularly prone to lower back problems, as are people who regularly lift, twist, bend, and operate vibrating equipment. Trauma, infection, heredity, a history of intermittent sciatica, poor overall fitness, and smoking seem to increase a person's risk for developing degenerative back conditions. In addition, people who suffer from depression or have such personality disorders as hysteria and hypochondriasis have higher incidences of lower back problems. For reasons that are not altogether clear, those who are not particularly satisfied with their work or are paid poorly seem to suffer more lower back injuries or chronic back problems.

• Tenderness, pain, and stiffness in the lower back
• Pain that radiates into the buttocks or legs
• Difficulty standing erect or in one position for an extended time
• Discomfort while sitting
• Weakness and leg fatigue while walking

Since low back pain can be a symptom of other conditions, careful diagnosis is important to determine if the pain is caused by structural abnormalities or inflammatory process, or is referred by organic disease and conditions, and develop a treatment plan.

• Lumbar degenerative disk disease (chronic low back pain)
• Spondylosis (degenerative spondylolisthesis)
• Spinal or lumbar stenosis
• Sciatica (lumbar radiculopathy)
• Spinal fracture
• Herniated nucleus pulposus or ruptured intervertebral disk
• Sacroiliitus
• Ovarian cyst
• Nephrolithiasis
• Pancreatitis
• Ulcers
• Osteomyelitis
• Infection
• Metastatic tumors, myeloma, lymphoma
• Depression
• Osteoporosis with compression fractures
• Spinal tuberculosis
• Fibromyalgia
• Ulcerative colitis
• Reiter's syndrome
• Psoriatic arthritis
• Enteric arthritis
• Prostate or testicular problems

Patients who have acute or episodic back sprain typically experience diffuse tenderness in the low back or sacroiliac region, normal reflexes, and normal motor strength. Range of motion testing may elicit complaints of pain. With chronic back pain, reports of stiffness, especially when rising from a seated position, are more common.

As the patient sits and raises a straightened leg, a midline bulge of the intervertebral disk coupled with mild bilateral discomfort may indicate a ruptured disk. With the patient prone, observe for pain with hip extension. Patient may also have difficulty standing erect, electing to assume a stooped posture.

Diminished knee and/or ankle reflexes may indicate stenosis. As the patient stands with the spine extended (leaning backwards), the pain may become immediately more severe. In some cases, neurologic examinations reveal loss of normal nerve function as evidenced in weakness, loss of sensation, or loss of reflexes. The patient may present with a history of bowel and bladder dysfunction.

Alkaline phosphatase to rule out bone tumor. CBC, ANA, ESR, rheumatoid factor to rule out rheumatoid arthritis, infection, and osteomyelitis.

Blood tests that reveal elevated erythrocyte sedimentation rate or WBC suggest infection.

Plain radiographs are usually not helpful in determining back sprain. However, X rays may be recommended to rule out more serious conditions. For example, if the patient complains of pain at rest or at night, or history of trauma, AO and lateral radiographs are indicated to rule out infection or tumor. Although a prolapsed or bulging disk may not be evident in routine X rays, it may be seen on an MRI or CT scan.

AP and lateral radiographs may show age-appropriate changes in the case of degenerative disk disease, such as anterior osteophytes and reduced height of the intervertebral disk. There may also be a "vacuum sign" with apparent air (nitrogen) in the disk space.

In stenosis, radiographs may reveal degeneration, marked narrowing of the intervertebral disk, and degenerative scoliosis. End plate changes around the disk space and marginal osteophyte formation around the facet joints may also be evident.

If the pain does not subside and functioning does not return after a few days of bed rest and limited activity, further tests and specific imaging may be necessary to rule out long-term chronic or degenerative back problems. In some cases, strength testing on a treadmill will reveal weakness in toe or heel walking, or in large toe dorsiflexion. This may indicate stenosis. Testing for sensation with pinprick, temperature, and light touch test may be helpful in making an accurate diagnosis.

For most low back problems, 1 to 2 days of bed rest and 10 days of NSAIDs or other non-narcotic pain-relieving medication is all that is needed until the inflammation and muscle spasm subsides. For chronic back pain, managing pain and minimizing disability over time becomes the focus of treatment. Physical therapy and manipulation are beneficial in muscle spasm and in correcting biomechanical dysfunction.

NSAIDs or other non-narcotic pain medications such as aspirin or acetaminophen are usually sufficient to manage the pain. Muscle relaxants in the first week or two may also be advisable.

For chronic back pain, a continuous course of NSAIDs may be necessary. Occasional low-dose, rapidly tapered oral steroids, or an epidural steroid injection, may be used to reduce inflammation. While steroids can produce dramatic results, they have little lasting benefit and tend to become less effective over time.

Other therapies—Physical therapy and spinal manipulation may be helpful in the first three to four weeks following an episode of low back pain. Once the acute pain has diminished, exercises, aerobic conditionings, and strengthening can help prevent long-term back problems. Proper posture is essential.

If other treatments are not effective in relieving pain and restoring function, surgery may be recommended. For example, in the case of a prolapsed or herniated disk, surgery may be necessary to remove part or all of a disk to prevent long-term nerve damage. Newer procedures, including percutaneous diskectomy, laser diskectomy, and endoscopic diskectomy use a large needle or tube inserted through the skin to remove the disks. For severe cases of lumbar stenosis, a laminectomy may be recommended to stabilize the spinal column.

Alternative therapies can be effective for easing muscle tension, correcting spinal imbalances, relieving discomfort, and averting long-term back problems by improving muscle and joint health. Relaxation techniques, biofeedback, supervised exercises, and gentle exercises such as tai chi, chi kung, and yoga may be quite helpful to prevent recurrence. Electromyographic (EMG) biofeedback can help, specifically when chronic pain is related to muscle spasms.

• B-complex: B1 (50 to 100 mg), B2 (50 mg), B3 (25 mg), B5 (100 mg), B6 (50 to 100 mg), B12 (100 to 1,000 mcg), folate (400 mcg/day) are reduced when in stress/pain
• Antioxidants: vitamin E (400 IU/day), vitamin C (1,000 to 3,000 mg/day)
• Calcium (1,500 to 2,000 mg) and magnesium (700 to 1,000 mg) to regulate muscle contraction and ease spasm
• Bromelain (250 to 500 mg tid away from food) anti-inflammatory, works especially well with turmeric

Ascertain a diagnosis before pursuing treatment. Herbs may be used as dried extracts (capsules, powders, teas), glycerites (glycerine extracts), or tinctures (alcohol extracts). Unless otherwise indicated, teas should be made with 1 tsp. herb per cup of hot water. Steep covered 5 to 10 minutes for leaf or flowers, and 10 to 20 minutes for roots. Drink 2 to 4 cups/day. Tinctures may be used singly or in combination as noted. Mix three to six of the following herbs (1 cup tea or 30 to 60 drops of tincture three to six times/day).

Relaxants: Black haw (Viburnum prunifolium) spasmolytic; petasites (Petasites hybridus) acute muscle spasm, not for long-term use; valerian (Valeriana officinalis) antispasmodic, especially with sleeplessness; wild yam (Dioscorea villosa) antispasmodic, especially with joint pains and long-term stress; turmeric (Curcuma longa) anti-inflammatory, especially with digestive problems; Jamaica dogwood (Piscidia piscipula) spasmolytic

Pain relief: White willow bark (Salix alba) anti-inflammatory and analgesic; devil's claw (Harpagophytum procumbens) analgesic, anti-inflammatory, especially with joint problems; St. John's wort (Hypericum perforatum) anti-inflammatory, especially with neuralgia and/or anxiety

Circulatory stimulants may be added if there is decreased circulation or congestion in the area: rosemary leaves (Rosmarinus officinalis), especially with digestive problems; ginkgo (Ginkgo biloba), especially with poor circulation

Topical treatment may be quite helpful for acute problems. Mix one to two drops of essential oil or 5 to 10 drops of tincture into 1 tbsp. vegatable oil, and rub into the affected area: St. John's wort for nerve pain; leopard's bane (Arnica montana) anti-inflammatory, external use only; lobelia (Lobelia inflata) anti-spasmodic

An experienced homeopath should assess individual constitutional types and severity of disease to select the correct remedy and potency. For acute prescribing use 3 to 5 pellets of a 12X to 30C remedy every one to four hours until acute symptoms resolve.

• Aesculus for dull pain with muscle weakness and increased circulation to affected area
• Arnica montana especially with a bruised feeling and/or pain as a result of trauma
• Colocynthis for weakness in the small of the back with sudden severe cramping
• Gnaphalium for sciatica that alternates with numbness, especially if sitting makes it better
• Lycopodium for burning pain, especially with gas and/or bloating
• Rhus toxicodendron for stiffness and pain in the small of the back that is worse in the morning; may have restlessness

• Chiropractic or osteopathic manipulation can help to release muscle spasm, improve flexibility, and increase parasympathetic response to induce pain relief. For chronic back pain, postural treatments such as the Alexander Technique or Hellerwork may also be suitable.Electromyographic (EMG) biofeedback may be helpful when chronic pain is related to muscle spasms.
• Contrast hydrotherapy. Alternating hot and cold applications brings nutrients to the site and diffuses metabolic waste from inflammation. The overall effect is decreased inflammation, pain relief, and enhanced healing. If possible, immerse the part being treated. Alternate three minutes hot with one minute cold. Repeat three times to complete one set. Do two to three sets/day. This is useful in both acute and chronic back problems.
• Castor oil pack. Used externally, castor oil is a powerful anti-inflammatory. Apply oil directly to skin, cover with a clean soft cloth (e.g., flannel) and plastic wrap. Place a heat source (hot water bottle or heating pad) over the pack and let sit for 30 to 60 minutes. For best results, use for three consecutive days. This can be very helpful in chronic back problems, especially with ligament involvement.

May help to relieve spasm and pain and increase circulation to the affected area, thus decreasing pain and inflammation.

Massage may be helpful both acutely and to prevent chronic problems. Reflexology can be taught to patients for self-treatment.

Follow closely for treatment compliance in initial acute phase and then for following weeks of therapy.

Appropriate physical activity and exercise will help strengthen back and torso muscles. Maintaining a healthy weight and good posture lowers risk of developing recurrent back strain or chronic back pain. Learning to bend and lift appropriately, sleeping on a firm mattress, sitting in steady and supporting chairs, and wearing good supportive shoes that fit well are important factors in averting and minimizing lower back problems.

People with low back problems may experience mild to marked functional impairment, specifically in walking, and pain while carrying out the simplest of tasks. In addition, they may have trouble sleeping and difficulty concentrating. Severe symptoms may limit vocational and recreational activities and affect mood and sexual interest. While depression is usually not the cause of chronic low back pain, it may complicate treatment, hindering eventual recovery.

Eighty five percent of all patients with back pain improve within one month. For those whose symptoms persist for more than six months, the risk for long-term disability is considerable.

Pregnant women are at increased risk for back problems due to body changes and hormonal relaxation of the ligaments and tendons. Physical medicine techniques, proper body mechanics, and exercise are the safest treatments. Some women actually experience relief of chronic back pain in pregnancy.

Balch JF, Balch PA. Prescription for Nutritional Healing. 2nd ed. Garden City Park, NY: Avery Publishing Group; 1997:149-150.

Bartram T. Encyclopedia of Herbal Medicine. Dorset, England: Grace Publishers; 1995:238-239, 277-278.

Blumenthal M, ed. The Complete German Commission E Monographs: Therapeutic Guide to Herbal Medicines. Boston, Mass: Integrative Medicine Communications; 1998:81-82, 136-137, 183, 197, 222-223, 226-227, 230-231.

Gruenwald J, Brendler T, Jaenicke C, et al., eds. PDR for Herbal Medicines. Montvale, NJ: Medical Economics Co; 1998:662-663, 786-787, 871-872.

Kitade T, Odahara Y, Shinohara S, et al. Studies on the enhanced effect of acupuncture analgesia and acupuncture anesthesia by D-phenylalanine (2nd report): schedule of administration and clinical effects in low back pain and tooth extraction. Acupunct Electrother Res. 1990;15:121-135.

Kruzel T. The Homeopathic Emergency Guide. Berkeley, Calif: North Atlantic Books; 1992:30-38.

Morrison R. Desktop Guide to Keynotes and Confirmatory Symptoms. Albany, Calif: Hahnemann Clinic Publishing; 1993:36-39, 59-61.

Mowrey D. The Scientific Validation of Herbal Medicine. New Canaan, Conn: Keats Publishing; 1986:223-227.

Murray MT, Pizzorno JE. Encyclopedia of Natural Medicine. 2nd ed. Rocklin, Calif: Prima Publishing; 1998:338.

Snider RK, ed. Essentials of Musculoskeletal Care. Rosemont, Ill: American Academy of Orthopaedic Surgeons; 1997.

Werbach M. Nutritional Influences on Illness. New Canaan, Conn: Keats Publishing Inc.; 1988: 342-345.