Are you one of 600 million people with lower back pain? Osteopaths identify the most common causes – and remedies
Was jet-washing the patio the straw that broke the camel’s – and your – back? That’s a possibility, but experts say the actual causes of back pain may surprise you – and it’s a bigger issue than most may realise. The World Health Organization (WHO) reports that lower back pain is the leading cause of disability worldwide, with cases projected to rise to more than 800 million by 2050, largely as populations grow and age. Here, clinicians reveal some of the unexpected causes, and how to avoid them.
You’re too active (or too sedentary)
“It’s actually very common to wake up with back pain without having sustained an injury,” says Hannah Whitcombe, an osteopath and naturopath. But in most cases, the hardness or softness of your mattress won’t be to blame.
“People often overlook what they did the day before. An unusually active day can leave muscles and joints feeling sore the following morning, but the opposite can be true too – sitting at a desk or simply being less active,” she says. “So if you wake up with a painful back, don’t just look at the eight hours you spent in bed, think about the previous 16.”
Mindy Cairns, a musculoskeletal physiotherapist and clinical researcher, sees a seasonal pattern. “During summertime patients will say, ‘My back’s been much worse,’ and I respond with, ‘Well, what have you done?’” Some will have spent a fortnight in four different hotels with four different beds. Others, she says, “remember that they washed the patio for five hours the other day and haven’t deduced that this may be the reason for a flare”.
Both extremes – too active or too sedentary – can cause back pain. Antony Bush, a physiotherapist and author of The Back Fix, says office workers can be sitting for 12 hours a day once work, travel and Netflix in the evening are counted, “double what we know gives people back pain”. At the opposite extreme, repetitive loading, relevant for rowers or gymnasts, can be too much for the back. In Bush’s experience, half the cases of back pain have several contributing causes, suggesting it is best to look at the whole picture rather than a single trigger.
You’re sitting up too straight
If you were told to sit up straight as a child, that advice may not have served you particularly well. Bush argues that a rigidly held but conventionally “good” posture can itself cause back pain, especially if this isn’t your natural resting position. London-based osteopath Anisha Joshi, who counts Rita Ora and Nick Grimshaw among her clients, still warns against a heavy slouch, but says “a very upright, fixed posture” can create tension in certain muscles, most often from sitting in one position for hours without a break.
“Posture is generally most helpful when it’s relaxed and adaptable, rather than forced or held in one ‘correct’ position for hours at a time,” Joshi says. A bent back isn’t necessarily a bad one as long as your movement varies throughout the day.
Bush goes further, arguing that posture myths extend into lifting. He says lifting with a rounded back, rather than the typical straight-back-bent-knees approach, isn’t as dangerous as it’s made out to be. “Contrary to everything you’ve heard, bending with a rounded back and straight legs is best.” Although reviews have found no evidence that one lifting technique prevents back pain, it’s safe to assume that lifting sensibly and building up strength matter more than one “correct” posture.
You’re stressed
Pain is in the brain, but that doesn’t mean it’s imagined. In fact, stress – and particularly prolonged stress – can be a physical as well as an emotional trigger for back pain, says Kent-based osteopath Emma Hayward. She explains that stress causes contractions in the connective tissue of the back which, over time, can become fibrosed, or “sticky and tethered”, so the body moves less efficiently, and even minor strains can set off an acute episode. “I very rarely see low back pain in my clinic without the person also having experienced some significant life stressor at the same time. Stress essentially turns up the volume of pain,” she says.
Bush also believes mindset plays a huge part in the management of chronic pain. “We can tell who’s going to get chronic pain better from psychometric testing than we can from MRI,” he says. This informs a more multifactorial assessment of his patients’ physical and mental wellbeing when treating back pain.
You’re relying on scans
An MRI can seem like a route to getting answers, but in most cases findings don’t correlate with the degree of pain felt, Bush says. Disc bulges and joint wear can all show up in people with no pain at all.
Bush describes a study in which two groups with back pain each had an MRI showing disc protrusions, tears and facet wear, which are all normal signs of ageing for their age group. One group was told this was within the normal range. The other received no explanation. “Pain increased in the group of people that went without a pat on the back,” Bush says, adding that their confidence and their psychological and physical measures dropped, too.
Neil O’Connell, a physiotherapist who helped develop the 2016 clinical guideline on lower back pain for the National Institute for Health and Care Excellence (NICE) agrees that changes seen on scans largely reflect the natural process of ageing. “They’re like wrinkles on the face,” he says, which is why international clinical guidelines say imaging should not be routinely used for back pain.
Bush wants people with back pain to resist an “I’m broken” mindset. “Back pain is a part of the undulating highway of being a human being and you can’t speed up the rate of healing,” he says.
You’ve learned to fear it
You can, to an extent, blame your parents for your back pain, says Cairns, and not only through your genes. “If I had a pound for every time one of my patients said, ‘Oh, my mum had back pain, my dad had back pain, my aunt has got back pain,’” she says, though it’s rarely a familial disease. Conditions like osteoporosis or rheumatoid arthritis can run in families, but simple mechanical low back pain is often just “bad luck”, she adds, and it will affect more than 80% of us.
Cairns believes some pain could be attributed to inherited fear: “As a child, if you’ve had a parent say: ‘Oh, my back hurts again. Oh, my back, my back, my back,’ there is a degree to which this is learned behaviour, and you’re fearful every time your back twinges.” This isn’t a dismissal of pain, she stresses, but more that a “twinge” isn’t a sign of damage.
The good news, says osteopath Alison Durant, is that “we are adaptable. By understanding pain and learning to view it differently, you can reduce the nervous system’s protective response and improve function and confidence in movement,” she says. Depending on the person, this could mean addressing protective bracing during painful or avoided movement, working with the breath or discussing how to manage a painful flare-up with a clinician.
The cause isn’t your back at all
Back pain with no obvious cause can be symptomatic of another issue. Patients often come in with back pain that doesn’t look particularly mechanical, says Cairns, which can mean it’s down to an underlying problem such as endometriosis.
Endometriosis, in which tissue similar to the womb lining grows elsewhere in the body, most commonly affects the pelvis and abdomen, where pressure on nerve roots can mimic lower back pain. “Endometriosis is very common, yet can often be misdiagnosed,” says Cairns. “It can also involve the bowel and the ligaments linking the pelvis and spine, restricting movement and contributing to pain.”
In a physical examination, this won’t present like mechanical back pain. “That’s where my clinical suspicion comes in”, Cairns says. If she isn’t 99% certain of a mechanical cause, a referral for further investigation follows. “In collaboration with Endometriosis UK, we are looking at back pain associated with endometriosis through a nationwide survey,” says Cairns, who hopes the work will expand understanding of how the conditions interact.
You don’t know your own strength
All the experts agree that the body is more resilient than we expect. “You must make sure you’re not reducing the scope of your existence in the face of pain, but that you’re listening to it and pushing into it a little bit,” says Bush.
Our skeletons are hardy, and built to adapt to the load we place on them. So if the patio needs washing again in two years’ time and your back protests, don’t panic and try to keep moving.
