Low back pain

Non-specific low back pain is the most common type of back pain. It is diagnosed when

• the pain occurs in the lower back (between your lowest rib and your buttocks), and
• there are no signs of other problems – such as severe pain radiating into your leg or paralysis in the leg muscles for the first time.

The pain is usually associated with tense muscles, and often limits your range of movement. Sometimes it's accompanied by pain in the thigh, too. But the thigh pain usually isn't as bad as the back pain.

In some cases, severe acute low back pain suddenly strikes out of the blue. This is caused by a temporary problem in the lower back. Although it can be very painful and restrict your movement for a while, it's not dangerous and usually improves a lot within a few days.

In more than 85% of people who have back pain, no clear cause can be found. The following factors may play a role in the development of this non-specific back pain:

• Lack of movement
• Abnormal strain from sitting still for too long
• One-sided or unusual strenuous physical activity
• Weak core muscles
• Tense muscles (sometimes due to abnormal strain)
• Psychological stress such as stress at the workplace, financial or family-related worries, severe anxiety or self-doubt, illnesses such as depression
• Changes in the perception of pain in the central nervous system that can cause chronic pain
• Genetic predisposition (your genes)

Sometimes, though, back pain is clearly caused by a specific thing, such as a slipped disc. This kind of pain is often associated with particular symptoms, such as pain radiating into a leg or numb areas. If doctors think there's a specific cause like this, they may suggest using an imaging technique like a magnetic resonance imaging (MRI) scan – especially if the symptoms don't go away within several weeks.

The following table lists possible specific causes of back pain and the typical symptoms in each case.

In rarer cases, back pain is caused by a problem that has nothing to do with the spine or the muscles and ligaments in the back – like kidney stones, pancreatitis, a gallbladder inflammation, endometriosis or shingles.

Non-specific low back pain usually goes away (or at least gets a lot better) within a few days or weeks, even without treatment. In many people, though, the pain keeps coming back: Research has found that this happens within a year in up to half of all cases.

In some people, the pain is more stubborn and only improves slowly over many months. Or it becomes chronic. In other words, it doesn't go away for a long period of time or keeps coming back a lot.

Chronic low back pain can be very different in different people. For instance,

• phases of more severe pain may alternate with phases of milder pain,
• the pain might be constant but always mild, or
• it might be severe and last for quite a long time.

It is not possible to predict exactly how low back pain will develop over time in a specific person.

To rule out an urgent medical problem or other illness, your family doctor or orthopedist will first ask a few questions. For example:

• Where exactly does it hurt?
• Is this the first time you've had low back pain or have you had it before?
• Do you have any other symptoms such as numbness or signs of paralysis?
• Does it only hurt when you move, or when you're resting and in a lying position too?
• Did you have an accident before the pain started?
• Do you regularly take certain medications such as steroids?
• Do you have any other illnesses?

The doctor will also ask about any physical or mental strain that could play a role, and whether you're able to balance it out – for example, through physical exercise or relaxation.

As part of the physical examination, the doctor will do things like feel the muscles in your back to see if there are any painful or tense areas, test your reflexes and check how well you can move.

Your answers to the questions and the physical examination are usually enough to rule out any major health problems. Then no further testing is needed. If there are any signs of specific problems like a bone fracture or a slipped disc, further examinations may be recommended – such as an x-ray scan, a computer tomography (CT) scan or a magnetic resonance imaging (MRI) scan. Further testing may also be done if the symptoms are still there (or have got worse) after a few weeks.

Medical associations do not recommend the routine use of back scans, though. This is because imaging techniques such as MRI scans find irregularities in bones or spinal discs in many people who don't have back pain. These irregularities are usually caused by normal, age-related changes in the body. In research where adults had MRI scans, it was found that about 20% of all 20 to 40-year-olds (and more than 80% of all people over the age of 70) have a protruding spinal disc.

If imaging techniques find an apparent cause of back pain that actually has nothing to do with the symptoms, that can result in unnecessary treatment or the wrong kind of treatment. Seeing "abnormal" things in your MRI scan can also be worrying, although they're just harmless, age-related changes. Then you might feel like you have to be careful and avoid movement or avoid putting strain on your back. That can make back pain worse, though.

In many people, back pain comes and goes in phases. The most effective way to prevent low back pain from returning is by regularly doing exercise. Several studies have shown that this can almost halve the back pain phases:

• Without exercise, about 50 out of 100 people had low back pain again within one year.
• With exercise, about 30 out of 100 people had low back pain again within one year.

Going on regular walks reduces back pain phases almost as well as more strenuous exercise does. This was shown in a large study where the participants walked for half an hour five times a week if possible.

It is important to stay physically active in the long term – and to be aware that doing exercise doesn't always guarantee that you won't have back pain, but it can reduce the frequency and intensity of the pain. So if the pain returns despite doing regular exercise, don't let that discourage you.

The best way to manage back pain depends on various factors, like whether you've had the pain for a short time (acute pain) or a long time (chronic pain). If no clear cause of back pain can be found, surgery is generally not recommended.

If you have severe acute back pain, you should temporarily avoid lifting heavy objects and take care when bending down. But it's important to stay as active as possible. This includes trying to go about your normal daily life, not spending too much time sitting in one position at work, and not lying down for too long. Light forms of exercise such as walking, swimming or loosening exercises can also help.

Acute back pain nearly always goes away on its own. Some people find it soothing to apply heat – for instance, in the form of a hot water bottle or a special heated cushion. Anti-inflammatory painkillers such as ibuprofen can sometimes help, too. But they should only be used over a short time period (up to two weeks).

Over 200 studies have shown that movement is also the best treatment for chronic low back pain. The many types of exercise that have been proven to help include:

• Exercises to stabilize the muscles in the abdomen, back and pelvis
• Exercises to improve posture and strength in the whole body
• Pilates and yoga

It is best to choose a form of exercise that suits your own situation and preferences, and that you can keep up over the long term. In Germany, the costs of movement and exercise programs are often partially covered by your public health insurer or statutory pension fund (Rentenversicherung). This includes the costs of medically prescribed apps (digital health applications, or DiGAs for short), physical therapy, health promotion classes and rehabilitation exercise classes (Rehasport) in a group.

Medication is only recommended as an additional help and should not be taken over the long term because of the risks involved. Mindfulness-based approaches and relaxation exercises such as Jacobson's muscle relaxation are helpful for some people. You can actively relax in this way after doing physical exercise, too.

There are also a wide range of passive treatments on offer. These include acupuncture, massages, mobilization or manipulation of the spine, osteopathy, shoe inserts, ultrasound and laser treatments, as well as transcutaneous electrical nerve stimulation (TENS). Most passive treatments aren't very effective, only help for a short time or haven't been studied enough. Because of this, experts recommend that they only be used in addition to other treatments, if at all.

Chronic back pain can also be treated with cognitive behavioral therapy. This is a type of psychotherapy is used in the treatment of chronic pain.

Frequently recurring or persistent low back pain can affect your daily life and result in long periods of time off work. You may then be able to take part in an outpatient or inpatient rehabilitation program. The aim of rehabilitation programs is to manage your symptoms well enough to be able to go about your normal daily life again. So it's not only meant for people who are at risk of having to work less, but also for those who have been off work for a longer period of time. People in Germany apply for a place in a rehabilitation program through their family doctor's practice.

The program often consists of something known as multimodal pain management. This includes things like physical therapy, exercise, behavioral therapy, patient education and relaxation techniques. The program should be tailored to your personal situation. Rehabilitation programs typically last three weeks.

Multimodal pain management treatments are usually carried out in an outpatient setting. But they sometimes take place in a specialized day clinic or during a hospital stay. Then you need a hospital referral from your doctor.

Chronic low back pain can take its toll physically and emotionally. But a lot of people develop strategies to better cope with the pain and the symptoms over time.

Even if you have chronic pain, it's important to stay physically active and not be restricted too much in daily life. If you do less because of your pain, you risk creating a vicious circle in which pain, harmful thoughts, anxiety, overly cautious behavior and becoming withdrawn constantly reinforce each other. To avoid this, don't let the pain stop you from doing things that you enjoy. After all, those things can distract you from the pain too.

When people are ill or need medical advice, they usually go to see their family doctor first. Information about health care in Germany can help you to navigate the German health care system and find a suitable doctor. You can use this list of questions to prepare for your appointment.