Back pain: why the advice is to keep moving

About one Australian in six has a back problem. In the Australian Bureau of Statistics National Health Survey for 2022, 15.7% of people reported one, which made back problems the second most common chronic condition in the country. Only mental and behavioural conditions were more widespread.

With numbers like that, most households know what a bad back looks like: the careful walk to the kettle, the slow turn to reverse the car. What has changed over the past few decades is the advice. Bed rest is out and so, in most cases, is the early scan.

Most back pain has no serious cause

Healthdirect states that more than 9 out of 10 cases of back pain are not caused by a serious medical problem. In most cases a doctor will not find a specific cause at all, and the pain is labelled “non-specific”. That can be frustrating to hear. Healthdirect suggests it should also be reassuring, because it means nothing serious is behind the pain.

Its page on low back pain explains that the pain usually stems from the muscles, ligaments or joints around the spine, and that in most cases there is no significant damage to the spine itself. About 8 in 10 people will have non-specific low back pain at some point in their lives.

The usual course is short. A patient handout from the Royal Australian College of General Practitioners (RACGP) says most people with low back pain get better on their own within 4 to 6 weeks.

Why bed rest fell out of favour

The same RACGP handout is direct about rest. Staying active is better for recovery than long periods in bed or on the lounge, and bed rest or not moving can slow recovery. Muscles that are not used much become weaker. The back, it says, is strong and made to move.

The national Clinical Care Standard takes the same line. In 2022 the Australian Commission on Safety and Quality in Health Care released its Low Back Pain Clinical Care Standard. A journal article introducing the Standard, written by clinicians and Commission staff, sets out its eight quality statements. One of them says a person with low back pain should be encouraged to stay active and to continue or return to usual activity, including work, as soon as possible. The authors note that imaging, pain medicines, bed rest and surgery are now accepted as having a limited role for most people with low back pain.

What staying active means in practice

It does not mean a gym program. The RACGP describes staying active as carrying on with everyday activities as much as possible: going to work, cooking, shopping, a walk to the park. No special exercises are required in the early weeks.

It may mean doing things differently for a while. The handout suggests adjusting how long, how hard or how often you do an activity. Someone who sits for long stretches can stand and take a short walk about every 20 minutes. Shopping can be carried in lighter bags over an extra trip or two.

Some pain along the way is expected. The RACGP tells patients that staying active is safe for the back, and that pain flaring after an activity does not mean the back is being damaged.

Healthdirect offers a few practical additions. It advises against resting the back for more than a day or two. Heat applied to the back can ease pain and help muscles relax. Walking, walking in a pool, swimming and floor stretches are good ways to begin exercising, and a GP or physiotherapist can advise if you are unsure which exercises suit you.

Why a scan is usually not the first step

Many people expect an X-ray or MRI to find the cause. Healthdirect says most cases of back pain can be diagnosed without imaging, from the history and a physical examination.

The Clinical Care Standard reserves imaging for people with signs of a specific or serious condition, and the journal article explains why: routine imaging does not improve patient outcomes. Scans also tend to turn up findings that sound alarming and mean little. An article in the Australian Journal of General Practice on the Standard points out that imaging shows changes that occur normally with age, even in people with no back pain, and that incidental findings can lead to further unnecessary tests.

Where medicines fit

The Standard asks clinicians to explain that the goal of pain medicines is to make physical activity possible, not to remove pain completely. Healthdirect says anti-inflammatory medicines may be used for short-term relief, and that opioid medicines are not usually recommended because of the risk of side effects and harm. Which medicine is suitable, if any, is a question for a GP or pharmacist.

Warning signs that need urgent attention

A small share of back pain does have a serious cause. Healthdirect’s back pain page says to call triple zero (000) or go to the nearest emergency department if:

• the pain came on very quickly and is severe
• the pain follows a significant injury or accident
• there is a fever, or you are unwell, along with the pain
• the pain stops you from walking or moving
• there is muscle weakness or numbness in the legs, or a change in bladder or bowel function such as incontinence or being unable to pass urine
• there has been unexplained weight loss.

Healthdirect’s low back pain page adds a group who should see a doctor as soon as possible about back pain: people with a history of cancer, people who are prone to infections, anyone who develops a fever above 38°C, and people who use intravenous drugs. It also advises people with osteoporosis to have back pain checked.

When ordinary back pain lingers

Healthdirect recommends seeing a doctor if back pain is not improving after about six weeks, or if it is disturbing sleep or getting in the way of daily activities. Pain that lasts longer than three months is classed as chronic and is often managed differently.

The Clinical Care Standard says a person whose symptoms persist or worsen should be reassessed early to work out what is holding up recovery. Treatment at that point can include physical therapies and psychological ones. Healthdirect notes that a physiotherapist can assess the pain and suggest exercises, and that cognitive behavioural therapy may help people develop ways of coping with long-term pain. It adds that managing stress, and getting treatment for anxiety or depression, can also help recovery.

For the more common story, the one that starts with lifting a pot plant on Saturday, the guidance is to keep up with normal life as far as the pain allows. Most episodes ease over the following weeks.

Sources

1. Australian Bureau of Statistics, Health conditions prevalence, 2022.
2. Healthdirect Australia, Back pain — an overview.
3. Healthdirect Australia, Low back pain: causes, symptoms, diagnosis.
4. Royal Australian College of General Practitioners, Staying active for acute low back pain (HANDI patient resource).
5. Maher CG, Archambeau A, Buchbinder R, et al., Chiropractic & Manual Therapies, Introducing Australia’s clinical care standard for low back pain.
6. Australian Journal of General Practice (RACGP), Best practice care for acute low back pain: A new clinical standard to assist general practitioners.