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Back Pain

  • Clinical Updates in Women's Health Care CU
  • September 2019

ABSTRACT: Every age group experiences back pain, a common reason for activity limitation. Management of back pain in a woman is challenging because of physiologic and hormonal changes through the woman’s life cycle. The treatment is dictated by etiology and a woman’s stage of life or reproductive events, such as pregnancy, breastfeeding, and menopause. Most episodes of low back pain are temporary with minimal long-term sequelae, but recurrent and long-lasting episodes require more thorough clinical evaluation. This monograph describes the anatomy of the spine; illustrates a focused, thorough evaluation, including obtaining a medical history and performing a physical examination; discusses warning signs and symptoms of more serious etiologies; provides recommendations for further testing or referral; and offers case vignettes of common causes of low back pain as a woman progresses from young adulthood to advanced age.

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Figures & Tables

Figure 1. Normal spine: A. side view, B. back view of spine. (National Institute of Arthritis and Musculoskeletal and Skin Diseases. Normal spine. Available at: https://www.niams.nih.gov/file/820 . Retrieved June 6, 2019.)

Figure 1. Normal spine: A. side view, B. back view of spine. (National Institute of Arthritis and Musculoskeletal and Skin Diseases. Normal spine. Available at: https://www.niams.nih.gov/file/820 . Retrieved June 6, 2019.)

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Figure 2. Structure of the spine. (National Institute of Arthritis and Musculoskeletal and Skin Diseases. Structures of the spine. Available at: https://www.niams.nih.gov/sites/default/files/00002_M.jpg . Retrieved May 31, 2019.)

Figure 2. Structure of the spine. (National Institute of Arthritis and Musculoskeletal and Skin Diseases. Structures of the spine. Available at: https://www.niams.nih.gov/sites/default/files/00002_M.jpg . Retrieved May 31, 2019.)

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Figure 3. Dermatomes. Each region is color-coded, and each nerve root is labeled.

Figure 3. Dermatomes. Each region is color-coded, and each nerve root is labeled.

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Figure 4. Basic treatment and referral algorithm. Typically, self-management, physical therapy, some forms of complementary and alternative medicine, and some psychologic treatments are encouraged over pharmacologic and surgical treatments for patients with nonemergent back pain. Judicious use of medications may aid women to be more active during exercise or physical therapy; therefore, each patient should be approached individually. Activity modifications may include anything that may alleviate pain. For example, if the pain is worsened by running, the patient should stop running and begin a trial of walking for exercise. Data from the following sources were used in this algorithm: Foster NE, Anema JR, Cherkin D, Chou R, Cohen SP, Gross DP, et al. Prevention and treatment of low back pain: evidence, challenges, and promising directions. Lancet Low Back Pain Series Working Group. Lancet 2018;391:2368–83 . Qaseem A, Wilt TJ, McLean RM, Forciea MA. Noninvasive treatments for acute, subacute, and chronic low back pain: a clinical practice guideline from the American College of Physicians. Clinical Guidelines Committee of the American College of Physicians. Ann Intern Med 2017;166:514–30 . Haig AJ, Colwell M. Back pain algorithms. In: Haig AJ, Colwell M, editors. Back Pain. Philadelphia (PA): American College of Physicians; 2005. p. 3–14. Haig AJ, Kesterson S. Chronic low back pain. In: Haig AJ, Colwell M, editors. Back Pain. Philadelphia (PA): American College of Physicians; 2005. p. 317–26. Liebenson C. Active care: its place in the management of spinal disorders. In: Liebenson C, editor. Rehabilitation of the spine. A practitioner’s manual. 2nd ed. Philadelphia (PA): Lippincott Williams and Wilkins; 2007. p. 3–29.

Figure 4. Basic treatment and referral algorithm. Typically, self-management, physical therapy, some forms of complementary and alternative medicine, and some psychologic treatments are encouraged over pharmacologic and surgical treatments for patients with nonemergent back pain. Judicious use of medications may aid women to be more active during exercise or physical therapy; therefore, each patient should be approached individually. Activity modifications may include anything that may alleviate pain. For example, if the pain is worsened by running, the patient should stop running and begin a trial of walking for exercise. Data from the following sources were used in this algorithm: Foster NE, Anema JR, Cherkin D, Chou R, Cohen SP, Gross DP, et al. Prevention and treatment of low back pain: evidence, challenges, and promising directions. Lancet Low Back Pain Series Working Group. Lancet 2018;391:2368–83 . Qaseem A, Wilt TJ, McLean RM, Forciea MA. Noninvasive treatments for acute, subacute, and chronic low back pain: a clinical practice guideline from the American College of Physicians. Clinical Guidelines Committee of the American College of Physicians. Ann Intern Med 2017;166:514–30 . Haig AJ, Colwell M. Back pain algorithms. In: Haig AJ, Colwell M, editors. Back Pain. Philadelphia (PA): American College of Physicians; 2005. p. 3–14. Haig AJ, Kesterson S. Chronic low back pain. In: Haig AJ, Colwell M, editors. Back Pain. Philadelphia (PA): American College of Physicians; 2005. p. 317–26. Liebenson C. Active care: its place in the management of spinal disorders. In: Liebenson C, editor. Rehabilitation of the spine. A practitioner’s manual. 2nd ed. Philadelphia (PA): Lippincott Williams and Wilkins; 2007. p. 3–29.

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Figure 5. Calculation of the Cobb angle.

Figure 5. Calculation of the Cobb angle.

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Table 1. Myotome Distribution and Action

Table 1. Myotome Distribution and Action

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Table 2. Muscles of the Core

Table 2. Muscles of the Core

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Table 3. Warning Signs and Symptoms That Accompany Back Pain

Table 3. Warning Signs and Symptoms That Accompany Back Pain

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Table 4. Components of Focused Physical Examination

Table 4. Components of Focused Physical Examination

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Table 5. Pharmacologic Back Pain Management in Pregnancy and Breastfeeding

Table 5. Pharmacologic Back Pain Management in Pregnancy and Breastfeeding

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Table 6. Waddell signs

Table 6. Waddell signs

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