Low Back Pain Treatment

One of the most common types of pain in the world is lower back pain ( LBP ). Lower back pain is a sensation of pain in the lumbosacral and sacroiliac regions; this pain in the lower back is accompanied by pain radiating down the legs to the feet. Low back pain (LBP) is chronic pain in the lumbar region, usually caused by pressing the paravertebral muscles, herniation and regeneration of the nucleus pulposus, as well as lumbosacral osteoarthritis of the spine. Low back pain (LBP) or low back pain is a painful sensation felt in the lumbosacral and sacroiliac regions or in the intervertebral discs, generally in the lower lumbar, L4–L5 and L5–S1. This lower back pain is often accompanied by spreading to the legs to the feet.

Low back pain (LBP ) can range from mild to severe pain. This Complaint can arise suddenly or develop slowly within a few hours to several days. The pain can be felt on the back of the body, from the last rib to the bottom of the buttocks, and can also radiate to the legs.

Classification of Low Back Pain (LBP ) By Clinical Duration :

• Acute Low Back Pain ( LBP): Occurs due to sudden movement, usually due to direct injury or muscle strain, with an attack duration of less than 6 weeks. Most acute cases resolve on their own (self-limiting).
• Sub-acute Low Back Pain ( LBP): Pain that occurs in patients within a time span of 6 to 12 weeks. This phase is crucial because it is a transitional period in which the wrong intervention can trigger a chronic condition.
• Chronic Low Back Pain ( LBP): Pain that lasts continuously for more than 12 weeks or in the long term. Chronic LBP often involves a psychosocial component and changes in the sensitivity of the central nervous system.

Classification Of Low Back Pain (LBP ) By Anatomical Etiology :

• Specific LBP: it can be done by structural examination, such as the presence of infection (spondylitis), fracture ( compression fracture), tumor, or apparent compression of the nerve root ( HNP ).
• Non-specific LBP: accounts for 85-90% of total LBP cases in the world that occur without any apparent structural pathology, and are usually caused by mechanical imbalance, muscle fatigue, or poor posture.

According To The Journal Of The American Academy Of Orthopaedic Surgeons And The International Journal Of Clinical Medicine, Low Back Pain (LBP) Comprises:

• Strains and sprains: conditions in which muscles and ligaments are injured due to excessive activity.
• Herniated disc: occurs when a spinal disc protrudes and presses on a nerve.
• Disc degeneration: a condition in which the intervertebral discs deteriorate due to ageing. There are also conditions affecting the lower back caused by malignant tumours in the vertebral region, which may be either primary or secondary.

CAUSES AND PATHOPHYSIOLOGY OF LOW BACK PAIN (LBP )

Biomechanical And Mechanical Factors :

• Muscle strains and ligament sprains : Occur when the back muscles (erector spinae) are forced to work beyond their capacity, so that the muscle fibers will experience microscopic tears that trigger intense muscle spasms (cramps) as a protective mechanism of the body.
• Hernia of the nucleus Pulposus (HNP) : The occurrence of HNP due to the aging process or trauma, the outer wall can tear, causing the spongy core to bulge out and clamp the spinal nerve roots.
• Spondylosis and Osteoarthritis of the Spine : A natural degenerative process that occurs as a person ages. The cartilage in the facet joints (the joints connecting the vertebrae) wears away, causing friction between the bones, which triggers the growth of bone spurs (osteophytes) that compress the nerve pathways.
• Spondylolisthesis is a condition in which one vertebra slips forwards over the vertebra below it, causing structural instability and chronic nerve compression.

Systemic And Lifestyle Risk Factors In Low Back Pain ( LBP ) Patients :

• Age and degenerative factors : The flexibility of intervertebral discs begins to decline in Low Back Pain LBP patients drastically after the age of 30 due to loss of water content, making the lower back more prone to injury.
• Obesity and visceral fat distribution : Excess weight, especially in the abdominal area, alters the body's center of gravity (center of gravity) forward. This forces the lumbar spine to curve excessively (compensatory lordosis) and receive mechanical loads many times over.
• Smoking habit : The nicotine in cigarettes triggers the narrowing of blood vessels (vasoconstriction), which hinders the flow of essential nutrients and oxygen towards the intervertebral discs, accelerating the process of premature degeneration.
• Psychosocial factors (Yellow Flags ) : Work stress, chronic anxiety and depression can increase the pain perception threshold in the brain and trigger constant skeletal muscle tension in the back area.

CLINICAL MANAGEMENT OF LOW BACK PAIN (LBP )

Systematic clinical low back pain ( LBP ) management is needed to distinguish between mild non-specific LBP and specific LBP requiring emergency treatment.

Anamnesis And Screening

Conduct a thorough clinical by a health worker with requisite nowledge and skills to identify which interventions might be appropriate and where futher detailed or urgent clinical review may be indicated.

The doctor will conduct an interview to find out the characteristics of the pain, factors that trigger or aggravate the pain, and look for danger signs (red flags) that can lead to serious conditions. These warning signs include impaired urination or defecation accompanied by numbness in the groin area leading to cauda equina syndrome, a history of cancer, weight loss without apparent cause, or increasingly severe pain at night that can lead to malignancy, as well as high fever with localized back pain that can indicate an infection in the spine.

Neuromuscular Physical Examination :

• Postural inspection and palpation: it is necessary to observe the curvature of the spine (scoliosis/lordosis) and palpate the area of the back to detect pressure pain points (trigger points) or muscle spasms.
• Straight Leg Raise ( SLR ) / Laseque Test : The patient lies on his back, then the doctor raises the patient's legs in a straight condition. If there is a sharp, shock-like pain from the back radiating to the leg at an angle of 30-70 degrees, the test is positive in favor of HNP.
• Sensory, motor, and reflex tests : Assess the strength of low back pain patients ' leg muscles (such as walking on heels or tiptoes) and test patellar and achilles tendon reflexes to determine the level of nerve damage.

Supporting Examination (Imaging & Lab ) :

• Plain radiography (X-Ray): Initial examination to assess bone alignment, detect narrowing of disc spaces, osteophytes, or fractures. X-rays cannot show soft tissues such as nerves or muscles.
• Magnetic Resonance Imaging (MRI): The gold standard for diagnosing LBP. It uses magnetic waves to produce high-resolution images of the intervertebral discs, visualise nerve compression, and enable the early detection of infections or tumours.
• Electromyography (EMG) : An examination of muscle electrical activity to determine whether the disorder originates purely from the muscles or is due to impaired spinal nerve conduction.

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TREATMENT AND THERAPY OF LOW BACK PAIN (LBP )

Pharmacological Therapy ( Medikamentosa ) :

• Non-Opioid analgesics ( Paracetamol ) : Used as the first line to relieve pain of mild to moderate intensity.
• NSAIDs ( Non-Steroidal Anti-Inflammatory Drugs ) : Drugs such as ibuprofen, diclofenac sodium, Etoricoxib, or Meloxicam. Works directly suppress the production of prostaglandins to reduce inflammation around the injured tissue.
• Muscle Relaxants ( Muscle Relaxants ) : Such as Eperisone or Carisoprodol, given short-term to break the cycle of pain due to spasm of the back muscles.
• Analgesic adjuvants ( Gabapentin / Pregabalin ) : Specifically given to LBP with neuropathic pain components (such as intense tingling or burning due to pinched nerves).

Physiotherapy And Physical Rehabilitation :

• Thermal modality (heat/cold therapy) : Application of ice packs in the first 48 hours to reduce acute swelling, followed by heat therapy (such as Infrared or Short-Wave Diathermy) to increase blood flow and relax stiff muscles.
• TENS ( Transcutaneous Electrical Nerve Stimulation ) : The use of low voltage electrical current through the skin to stimulate the body's nervous system to block pain signals sent to the brain.
• Kinesiology Exercise Therapy : Abdominal and back muscle strengthening exercises (William's Flexion Exercise or McKenzie Extension Exercise) adapted to the patient's specific anatomical conditions.

Minimally Invasive and Surgical Interventions :

• Epidural Steroid Injection ( ESI ) : The injection of high-dose corticosteroids directly into the epidural space near the inflamed nerve under fluoroscopic guidance (real-time X-ray). Effective in relieving severe radicular pain without surgery.
• Surgical Procedures ( Laminectomy / Discectomy ) : Performed if conservative treatment has failed for more than 6 weeks and is accompanied by progressive motor function impairment (e.g. the legs begin to feel weak or drag whilst walking).

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HOW TO AVOID LOW BACK PAIN ( LBP )

Regular Stretching Exercises In Low Back Pain (LBP ) To Maintain Lumbar Muscle Flexibility.

• The Correct Technique for Lifting Objects : Position your body correctly. Never bend your back when picking up a load from the floor. Position your body as close as possible to the object, bend both knees into a squatting position, keep your back straight, then stand up using your thigh and buttock muscles.

• Long-term sitting ergonomics : Use a chair that has lumbar support that follows the natural curve of your spine.
• Adjust the height of the chair so that your feet are flat on the floor and the knee angle is 90 degrees. Position the computer screen at eye level to prevent the body from leaning forward.
• Limit the duration of static sitting. Every 45-60 minutes of work, it is mandatory to stand, walk for a while, or do light stretching (stretching) for 2-3 minutes to restore muscle elasticity.

Physical Exercise And Strengthening For Low Back Pain ( LBP ) :

• Core Strengthening : Regular exercises such as planks, bird-dogs or bridge exercises help to distribute body weight evenly so that it does not rest entirely on the spine.
• Consistent low-impact exercise : Swimming is excellent for treating low back pain (LBP), as the buoyancy of the water reduces the compressive load on the spinal joints whilst still providing a comprehensive workout for the back muscles.
• Nutrition and Weight Management : A diet rich in calcium and vitamin D to maintain bone density, as well as limiting calorie intake to keep the body mass index (BMI) within the normal range

Prevention :

 Engage in regular exercise to strengthen your core and back muscles.

• Maintain good posture when sitting, standing, and lifting objects.
• Avoid prolonged inactivity and take short breaks when sitting.
• Ensure you use a mattress and chair that provide excellent body support.

Lower back pain ( LBP ) is a common condition that can often be managed through self-care; however, recognizing warning signs and seeking prompt medical attention is crucial to prevent complications.

When to Seek Medical Attention :

Most cases of lower back pain improve with rest, self-care, and over-the-counter pain relievers. However, seek medical attention immediately if any of the following signs occur :

• If you feel pain that lasts more than a few weeks or severe pain that does not improve despite rest.

• If the pain radiates down to the knee or accompanied by weakness, numbness, or tingling in the limbs.
• Signs of weakness in your limbs that appear suddenly, impaired urination or defecation (incontinence), or numbness in the groin and buttocks area (saddle anesthesia), which can indicate cauda equina syndrome and is a medical emergency.
• If pain is accompanied by unexplained weight loss or fever, or if it develops following an injury or trauma.

CONCLUSION :

Low Back Pain is a chronic pain in the lumbar, usually caused by the pressing of the paravertebral muscles, herniation and regeneration of the nucleus pulposus, as well as lumbosacral osteoarthritis of the spine. Low back pain can occur in anyone who has musculoskeletal problems such as acute lumbosacral strain, lumbosacral ligament incompetence, muscle weakness, osteoarthritis, spinal stenosis, and problems with intervertebral joints and legs that are not the same length.

Most low back pain is caused by one of a variety of musculoskeletal problems (e.g. acute lumbosacral strain, lumbosacral ligament instability and muscle weakness, spinal osteoarthritis, spinal stenosis, intervertebral disc problems, and limb length inequality).

Other causes include obesity, kidney disorders, pelvic problems, retroperitoneal tumors, abdominal aneurysms, and psychosomatic problems. Most back pain due to musculoskeletal disorders will be aggravated by activity, while pain due to other circumstances is not affected by activity.

Although it causes pain that greatly interferes with activity, LBP can be managed effectively through proper early diagnosis, the use of multimodality therapy (medication and physiotherapy), and a full commitment to modifying daily posture. Preventive measures through strengthening the core muscles and the implementation of work ergonomics are an absolute investment in order to maintain quality of life and long-term productivity without spinal pain disorders.

It is important to note that some of the symptoms mentioned above are not specific to low back pain ( LBP ). This means that these symptoms may also occur in other conditions. Therefore, if you are experiencing symptoms of lower back pain, particularly if the pain radiates to the buttocks or one of your legs, you should consult our doctors at Nusa Medica Clinic; if necessary, you will be referred to a neurologist to ensure you receive an accurate diagnosis.

Please note that the stages of examination and treatment undertaken may differ depending on the respective health facility. Professional medical personnel will determine the stages of examination and treatment tailored to each patient's medical condition.(*)

REFERENCES :

World Health Organization. (2023). WHO guideline for non-surgical management of chronic primary low back pain in adults in primary and community care settings. World Health Organization.

Bittar, M., & Deodhar, A. (2024). A critical view of WHO guidelines on management of low back pain. Nature Reviews Rheumatology, 20, 201–202. https://doi.org/10.1038/s41584-024-01088-7

World Federation of Neurosurgical Societies (WFNS) Spine Committee. (2024). Acute back pain: Clinical and radiologic diagnosis: WFNS Spine Committee recommendations. World Neurosurgery: X, 22, 100278. https://doi.org/10.1016/j.wnsx.2024.100278

Maher, C. G., Oliveira, C. B., Ferreira, M. L., et al. (2026). Towards global clinical practice guidelines for the management of non-specific low back pain in primary care: A review of current guideline recommendations and how they have changed over the last 30 years. The Lancet Rheumatology, 8(6), e470–e485. https://doi.org/10.1016/S2665-9913(26)00077-9

Zhou, T., Salman, D., & McGregor, A. H. (2024). Recent clinical practice guidelines for the management of low back pain: A global comparison. BMC Musculoskeletal Disorders, 25(1), 344. https://doi.org/10.1186/s12891-024-07468-0

Writer: dr. Jhon Travolta Silitonga, AMF - General Practitioner & Chief Medical Officer Nusa Medica Gili Trawangan