It's easy to take your back for granted—until it hurts. Just ask Glenda Beattie, whose low back pain began nearly 15 years ago and worsened over time. "It started as a hot, searing pain that went from the middle of my buttocks to the left side of my lower back. It eventually became a constant burning sensation like something was stuck there," recalls the 59-year-old hospice caregiver and mother of five in Roanoke, VA. Over time, the pain became so bad that Beattie would have to stop working after a few hours and couldn't walk far. She tried taking ibuprofen and doing physical and aquatic therapy, but nothing helped enough.

Beattie didn't want to take stronger pain medications, so she went to see a neurologist who specialized in pain management. An X-ray revealed the underlying problem: a narrowing and degeneration of her sacroiliac joint, which connects the sacrum (the triangular bone at the base of the spine) with the pelvis. In February 2018, her doctor administered steroid injections into the joint, and her pain improved dramatically.

Common Hurt

Almost 80 percent of adults experience low back pain at some point in their lifetime, says neurologist Shaheen E. Lakhan, MD, PhD, chief of pain management at the Carilion Clinic in Roanoke, VA. A study published in the Journal of Manipulative and Physiological Therapeutics in September 2016 that looked at data from the 2010 National Health Interview Survey noted that 26 percent of workers in the United States had reported experiencing low back pain in the previous three months. "Low back pain becomes more common as people get older because of injuries, weight gain, physical deconditioning, arthritis in the spine, and loss of hydration and height in the discs, which increases the incidence of compression," says Mark Bailey, DO, PhD, professor of neurology and anesthesiology at the University of Alabama at Birmingham.

Sources of Pain

There are two basic types of low back pain: acute and chronic. Acute back pain is short-term, and usually resolves naturally within days or weeks; it tends to be musculoskeletal, meaning it stems from a muscle injury or strain or a disruption in the way the spine, discs, or nerves connect and move. By contrast, chronic low back pain is defined as pain that lasts for 12 weeks or longer, says Ligia Onofrei, MD, assistant professor of neurology at the University of Utah in Salt Lake City. It's usually due to muscle sprains, strains, and spasms; disc degeneration or a ruptured or herniated disc; arthritis in the spine; radiculopathy (nerve root compression in the spine); or spinal stenosis (a narrowing of the spinal canal that puts pressure on the spinal cord and nerves), among other causes.

From Acute to Chronic

It's unclear how or why acute low back pain evolves into chronic back pain. One theory is that the pain evolves out of changes in the brain: The brain begins to produce a sensation of pain even without the presence of a pain-producing stimulus—after an injury has healed, for example. This is known as central sensitization. Another theory relates to psychological factors: "When people catastrophize [believe that their pain is far worse than it actually is] about their disabling pain, it becomes the central part of life," Dr. Lakhan explains.

Certain risk factors—including smoking, occupational activities (such as heavy lifting, pushing, or pulling), depression, and anxiety—can increase the likelihood of developing low back pain, according to a report published in The Lancet in March 2018. Smoking may increase the risk of back pain because it increases inflammation and compromises oxygen flow to tissues throughout the body, explains Daniel Menkes, MD, professor and chair of neurology at the Oakland University William Beaumont School of Medicine in Rochester, MI.

In Beattie's case, her doctor suspects that her back pain stemmed from having five children and lifting patients in her work as a caregiver. Also, "women are more prone to getting lower back pain than men," for reasons that aren't well understood but may have to do with hormonal factors, differences in pelvic structure, and a slightly lower bone density, Dr. Menkes says. And if you have osteoporosis or use corticosteroid medications for long periods of time, you have an increased risk of compression fractures, Dr. Lakhan notes.

A Thorough Exam

In most cases, seeing a doctor for a medical and neurologic history and a physical exam can eliminate concerns that a serious condition, such as a tumor or a fracture, could be causing the pain. During the exam, your doctor will likely check for tender points and changes in your reflexes, muscle strength, and sensation, among other changes. He or she will ask you to describe what the pain feels like, where it's located, when it started, what makes it better or worse, whether you have any movement limitations, and whether you have other medical conditions (such as rheumatoid arthritis or fibromyalgia) that might be related to the pain or any accompanying symptoms (such as weakness or loss of feeling in your extremities). If your doctor is concerned that cancer, an infection, a fracture, or an inflammatory condition could be causing the pain, he or she may order X-rays or an MRI.

3 Ways to Treat Low Back Pain

Most doctors encourage patients to resume their regular routine. "We recommend going back to normal activities such as walking and being active around the house," says Dr. Onofrei.

It may also help patients to know more about what causes their pain. A small study published in JAMA Neurology in April 2018 found that people with chronic back pain are better able to reduce their pain and improve their mental and physical functioning when they learn more about the underlying causes of the pain, in addition to changing the way they think about it.

Gentle Movement

Physical and occupational therapy can help improve functionality; so can gentle mind-body activities such as yoga and tai chi. In a study published in the Annals of Internal Medicine in July 2017, researchers compared yoga and physical therapy for treating chronic low back pain, and found that they were comparably effective at improving pain and functionality. By contrast, "physical inactivity makes back pain worse—the core muscles get weak, and they're what hold your spine straight," Dr. Bailey says.

Alternative Therapies

Other nonpharmacologic treatments such as acupuncture, massage therapy, biofeedback, spinal manipulation/chiropractic therapy, and cognitive behavioral therapy (CBT) can also be beneficial. "The science behind CBT for low back pain is strong," Dr. Bailey says. "[It's about] learning to live with pain and not letting it drive everything." In a study published in JAMA in March 2016, researchers evaluated the effectiveness of mindfulness-based stress reduction (MBSR), a program that teaches people how to calm their minds and bodies to help them cope with pain and stress, versus CBT, which trains people to change their pain-related thoughts and behaviors, and the usual care for adults with chronic low back pain. They found that those who were treated with MBSR or CBT reported significantly greater improvements in their pain and functional limitations after 26 weeks than those treated with usual care.

Medications

A review of the evidence for pharmacologic treatment of low back pain published in The Lancet in June 2018 noted that current best practice guidelines in the United States state that NSAIDs and selective norepinephrine reuptake inhibitors (SNRIs) are good secondary or additional treatments for persistent low back pain. Routine use of opioids is not recommended since the benefits are small and the risks of misuse or addiction are high. Similarly, paracetamol or acetaminophen, once a first-line treatment for low back pain, is no longer recommended because of the long-term risks of liver and kidney damage, among other problems. Anti-seizure drugs such as pregabalin are being reconsidered after a 2017 study found pregabalin ineffective for radicular pain, according to the review in The Lancet. The guidelines also note that doctors should consider pharmacologic treatment only if patients have an inadequate response to first-line nonpharmacologic options.

3 Treatments to Avoid

1. Bed Rest. "We now know that bed rest is associated with poorer functioning, more pain, and greater disability," says Ligia Onofrei, MD, assistant professor of neurology at the University of Utah in Salt Lake City.
2. Opioids. Generally, doctors now try to avoid using opioids to treat back pain. Besides the risk of becoming dependent or addicted, "prolonged use of opioids can lead to opiate-induced hyperalgesia [an increased sensitivity to pain]," explains Shaheen E. Lakhan, MD, PhD, chief of pain management at the Carilion Clinic in Roanoke, VA. "Because opioids suppress pain receptors, your threshold for pain and discomfort gets so low that even touch may bother you."
3. Surgery. In most cases, surgery for low back pain is not recommended, Dr. Onofrei says. "There's no evidence that it will help low back pain without radiculopathy [numbness, tingling, pain, or weakness in the legs]," she notes, "and it can lead to more problems down the line."
   Most people with chronic low back pain find relief with a combination of interventions, as Glenda Beattie has. Thanks to steroid injections, frequent stretching exercises, and improvements to her posture, her low back pain and ability to function have improved dramatically. "My whole demeanor has changed," she says. This spring, she even started working again as a hospice caregiver after being out of work for more than a year.

5 Ways to Keep Back Pain at Bay

Some of the best interventions for low back pain are under your control, in the form of lifestyle adjustments. Here are some effective measures recommended by experts:

1. Lose weight. Besides taking a toll on your back, hips, and knees, carrying excess weight promotes hidden inflammation in your body. If you're overweight, losing weight should be the top priority for improving low back pain, says Mark Bailey, DO, PhD, professor of neurology and anesthesiology at the University of Alabama at Birmingham. If you're unable to slim down by reducing your calorie intake and increasing calorie expenditure through exercise, talk to your doctor about other approaches that might help you.
2. Stay physically active. Do regular aerobic exercise (such as walking, jogging, cycling, or engaging in aquatic workouts), stretching exercises (such as yoga), and strength training workouts (with weights or through a program like Pilates), especially for your core-the muscles in your abdomen, pelvis, hips, and back. "Regular exercise improves function and pain control. And core strength is important because the core muscles support the spine and help you avoid putting excess strain on the joint structures in the spine," says Ligia Onofrei, MD, assistant professor of neurology at the University of Utah in Salt Lake City.
3. Check alignment. "It's impossible to have good posture all the time," says Dr. Onofrei. She recommends setting an alarm on your phone to remind you to check your posture every hour; this will help you become more aware of your posture throughout the day. Make sure your spine and pelvis are in alignment, with a straight line between your head, spine, and pelvis, she says. When you're sitting, keep your feet on the floor and your hips and knees bent at a 90-degree angle, advises Eric Robertson, PT, DPT, adjunct associate professor of clinical physical therapy at the University of Southern California in Los Angeles. "But don't maintain the same position for long periods of time. Get up and move around every 20 minutes at work." Also, be sure to lift properly: That means bending from the knees, not the waist, when picking something up from the floor.
4. Improve your sleep habits. If you don't sleep well, controlling your back pain will be more difficult. Establish regular bedtime and waking times, and stick with them. Use the bed only for sleep and sex, Dr. Onofrei advises. And "check your mattress to make sure it's supportive and comfortable enough," she says. "Use different body pillows to facilitate a comfortable position for your back while you sleep, or place a pillow between your knees," which will reduce stress on your hips and low back.
5. Dial down the stress. Deep breathing or progressive relaxation exercises will help you decompress. Spend at least 30 minutes every night doing something that helps you feel calm and content, like listening to music, taking a warm bath, or going for a walk. "If you're depressed, anxious, or stressed, everything is going to hurt more and take longer to heal," says Daniel Menkes, MD, professor and chair of neurology at the Oakland University William Beaumont School of Medicine in Rochester, MI. If you're struggling with depression or anxiety, talk to your doctor about treatment options.