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Physical Therapist

The majority of us will suffer from back pain during our lifetime, and fortunately, it resolves spontaneously. The origin of symptoms (Pain Generator) can be from simple mechanical reasons, including ligament, muscle or from structural reasons like disc and facet joints. The overall well-being of an individual is impacted due to these symptoms. The physical and psychological effect of it is well-known to interfere with activities of daily living.

In general, back pain can be broadly divided into acute and chronic. The acute pain is spontaneous in nature and is preceded by an event or activity like gym, gardening etc. The symptoms usually tend to settle down after a  couple of days to weeks, and sometimes you may need appropriate painkillers and to do gentle stretching exercise. The chronic pain, on the other hand, tends to last longer and is often due to an underlying spinal condition. It is a constant pain and is known to impede on quality of life. It is essential that you seek medical advice if back pain symptoms do not settle with time.

If unaddressed it can lead to complex interaction between pain and psychological pathways in brain. This can impede on the quality of life and start a vicious cycle whereby; frustration and sleep deprivation follow. It is crucial to intervene before it becomes a long-term issue. 

Yellow Flag Signs

The medical fraternity often uses the Yellow Flag Signs across the world to identify individuals at risk of developing chronic pain related disability. I would suggest, patients should use it as a self-risk assessment tool in identifying themselves and to seek appropriate help from friends, family and GP.

The main Yellow Flag Signs are;

  • Negative thoughts about back pain being harmful

  • Fear that pain will increase with activity

  • Low moral thoughts, depression and social withdrawal

  • Increased intake of alcohol and other substances

  • Social and financial problems

Red Flag Signs

I am often asked “How serious is my back pain?”

I would say, majority of back pains are not serious and do settle down in couple of weeks. However, we should watch out for Red Flag Signs

  • NEW onset of back pain under age 16 and above age 55.

  • Unexplained weight loss and fever.

  • Thoracic pain (In between your shoulder blade)

  • Previous or recent significant history of illness (e.g. HIV / AIDS, end stage renal disease, osteoporosis, alcohol or drug abuse) and long-term use of medication, like steroid.

  • History of cancer

  • Presence of neurology (e.g. Numbness, weakness and balance issues)

  • Bladder and bowel dysfunction

  • Night pain (pain while resting – Non mechanical)

Further, those patients not improving after conservative measures, like simple analgesia and physiotherapy, should seek medical advice.

Secondly, I am asked “What is the cause of my back pain?” 

There can be multiple of reasons for back pain and often it is difficult to pinpoint them. There are lots of terms used like spondylosis, spondylolisthesis, dehydrated disc, arthropathy and so on. Patients often find it difficult to go through this maze of medical terminology and to actually understand their basic problem. I strongly believe that half of the battle is won if we understand our condition.

In order to make things simple for you, I would split back pain into cushion (Disc), roof tile (Facet) and surrounding structure (Muscle and ligament) related problems (Please read The Basic spine). Each of these issues have a specific pain pattern and needs to be assessed individually by appropriate medical personal and treated accordingly.

Cushion Related Problem​

Age, trauma and other factors (genetic, overweight, smoking) reduces the water content of the disc (dehydrated disc), and thereby diminishes the shock absorber property. Pain from the disc is often on bending forward, coughing, sneezing and standing for long periods. In response to this, back muscle goes on overdrive as a protective mechanism, leading to spasm. These symptoms, after assessment, need to be managed with lifestyle modification and physiotherapy. If these measures fail, then other options can be explored, and surgery is rarely needed.

Roof Tile Related Problem​

We have evolved from being ape to two-legged humans. This puts a lot of strain on the roof tiles, or the facet joints. These joints, like your hip and knee, are lined with cartilage and undergo similar degenerative or arthritic changes. Unfortunately, unlike knee joint it does not have enough space to accumulate excess of lubricating fluid. Abnormal increase in fluid leads to a balloon effect, causing the facet joint capsule to swell and stimulate nerve endings and pain. The pain pattern is more movement related and patients describe it as sharp and catching in nature; especially, when bending backwards as the tiles move on each other. It can wake you up while twisting and turning in bed. These symptoms, after assessment, need to be managed with lifestyle modification and physiotherapy initially. Other management options such as facet joint injection, denervation and surgery can be explored once initial management has failed.   

Surrounding Structure Problem​

Life is often called a Kyphotic process, which means with age we stoop more. When young, we walk with a broad shoulder and chin up, and as we grow mature, we crouch. The muscle and ligament structures around the spine play a crucial role in keeping us upright. Balance between abdominal (tummy) and back muscle has to be in harmony for the overall well-being of spine. These together make the core strength muscles, and at times we need to retrain them with the help of physiotherapy, yoga, Pilates, etc.

Treatment Options

The management of back pain can be split into Non-operative and Operative options. The Non-operative options consist of lifestyle changes, physical and psychosomatic (emotional) elements.

Lifestyle Changes: The importance of a healthy diet and regular exercise cannot be ignored. As explained earlier, our spine takes a lot of force while we are up and about. Increased weight, smoking etc. are known to damage healthy disc. It is well documented that weight reduction helps in back pain, and above all makes your quality of life better. I also think that it is never too late to quit smoking, you just need to ask for help.


Non-operative Measures: There is good evidence for the role of various forms of physical therapy and alternative medicine. Physiotherapy programmes to facilitate truncal control and core strength building is an example of it. Other measures such as osteopathy, chiropractic treatment, Pilates, yoga, Tai Chi, aqua-aerobics, acupuncture, reflexology and massage, are also known to benefit.


Emotional Measures: Living with constant debilitating back pain can cause emotional and psychological strain on us. It is crucial to acknowledge it early and ask for help from appropriate medical personnel. There are various pain management programmes, which are run in combination with Pain Specialists and Clinical Psychologists. These services can be explored if other measures have failed.


Once all the conservative options are exhausted, the operative options consist of facet joint injection, facet joint denervation and rarely fusion surgery should be explored.

Summary ​

  • Back pain is common and fortunately settles on  its own. If despite analgesia and physical therapy the pain persists, I would suggest seeking medical attention early.

  • Remember RED FLAG SIGNS means urgent medical attention.

  • Lookout for YELLOW FLAG SIGNS and act early.

  • Understand your pain better – Cushion/ Roof Tiles/ Surrounding related problems.

  • Treatment option initially Non-operative followed by Operative measures.

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