Chronic Low Back Pain - What You Need to Know

Why Chronic Back Pain Happens

• Biological factors - disc degeneration, facet joint arthritis, muscle deconditioning
• Psychological factors - anxiety, depression, fear-avoidance behavior, poor sleep
• Social factors - work stress, sedentary lifestyle, obesity

• Inflammatory back pain (e.g., axial spondyloarthritis) - typically in young adults under 45, worse at rest/night, improves with movement, responds to NSAIDs
• Radicular pain (sciatica) - pain radiating down the leg from nerve compression
• Secondary causes - infection, malignancy, fracture (always ruled out with red flags)

Red Flags - See a Doctor Urgently If You Have:

• Pain after a fall or trauma
• Numbness, tingling, or weakness in the legs or feet
• Bladder or bowel problems (inability to urinate, incontinence)
• Fever alongside back pain
• Unexplained weight loss
• Pain that is constant, severe, and worse lying down (possible tumor/infection)
• Age over 50 with new onset back pain

Treatment - What Actually Works

Step 1: Non-Drug Approaches (First Line)

Step 2: Medications (if non-drug approaches are not enough)

• NSAIDs (ibuprofen, naproxen) - first-line for pharmacological treatment; some analgesia, though long-term efficacy evidence is limited
• Acetaminophen (paracetamol) - actually shown to be ineffective for chronic LBP
• Duloxetine (an antidepressant/SNRI) - second-line option with evidence for pain reduction
• Tramadol - second-line, used cautiously
• Opioids - NOT recommended for routine use; clinical trials show opioids are not superior to NSAIDs for improving function over 12 months, carry significant risks of dependence, and should only be considered in severe disabling cases after careful risk assessment. Co-prescribing opioids with benzodiazepines should be avoided. (Firestein & Kelley's Textbook of Rheumatology, p. 2173-2182)

Step 3: Multidisciplinary Rehabilitation

Step 4: Injections and Procedures

• Epidural steroid injections - useful if there's a radicular component (nerve compression), less effective for pure back pain
• Facet joint injections / radiofrequency ablation - for confirmed facet joint pain
• Spinal cord stimulation is used in selected refractory cases

Step 5: Surgery

Practical Self-Management Tips

1. Keep moving - gentle walks, swimming, yoga, or Pilates are excellent
2. Core strengthening exercises - builds a muscular "corset" around the spine
3. Posture awareness - avoid prolonged sitting; take breaks every 30-45 minutes
4. Sleep position - lying on your side with a pillow between knees reduces lumbar stress
5. Stress management - psychological stress amplifies pain perception
6. Healthy weight - every extra kg of body weight adds load to the lumbar spine

When to See a Doctor

• A proper clinical assessment to rule out specific causes
• Referral for physiotherapy/exercise program
• Consideration of imaging (X-ray or MRI) if red flags or failure to improve

Disclaimer: This is general health information, not a substitute for a consultation with a doctor. Please see a healthcare professional for a proper diagnosis and personalized treatment plan.

Nausea, Vomiting & Joint Pain - What Could This Be?

Most Likely Causes

1. Viral Hepatitis (especially Hepatitis B)

• Hepatitis B can cause a prodromal illness with polyarthralgia (multiple joint pain), arthritis, and dermatitis before jaundice even appears. The joint involvement is typically polyarticular, affecting the small joints of the hands and wrists.
• All hepatitis viruses (A, B, C, D, E) can cause: malaise, fever, anorexia, nausea, vomiting, abdominal discomfort, and sometimes jaundice (yellowing of eyes/skin).
• Look for: dark urine, pale stools, yellow eyes/skin, right upper abdominal tenderness.

2. Dengue Fever / Arboviral Infections

• Dengue and Chikungunya are mosquito-transmitted viruses that classically cause fever + severe joint/muscle pain + nausea/vomiting.
• Dengue: headache, retro-orbital (behind the eye) pain, severe myalgia and arthralgia, rash appearing 3-4 days after fever onset.
• Chikungunya: predominantly intense joint pain (can be debilitating), fever, nausea.
• Relevant if you live in or have recently travelled to tropical/subtropical regions.

3. Reactive Arthritis (Post-Infectious)

• Joint pain that develops after a gastrointestinal (GI) or urinary infection.
• Triggered by bacteria such as Salmonella, Shigella, Campylobacter, Yersinia, Chlamydia.
• Yersinia infection specifically presents with abdominal pain, nausea, vomiting, and extraintestinal symptoms including arthralgia and erythema nodosum (tender skin nodules).
• Classic triad of reactive arthritis (Reiter's syndrome): joint pain + eye inflammation (conjunctivitis) + urethritis ("can't see, can't pee, can't climb a tree").
• The GI symptoms often come first, then joint pain follows days to weeks later.

4. Systemic Viral Illness (Flu-like / EBV / CMV)

• Many viral infections cause a combination of GI symptoms (nausea, vomiting) and body/joint aches.
• Epstein-Barr virus (EBV, "mono"), cytomegalovirus (CMV), and parvovirus B19 can all cause joint pain alongside systemic symptoms.
• HIV acute seroconversion: fever, malaise, lymphadenopathy, arthralgia, myalgia, nausea, rash.

5. Systemic Autoimmune Disease (e.g., Lupus/SLE, Rheumatoid Arthritis)

• Conditions like Systemic Lupus Erythematosus (SLE) can cause joint pain alongside GI symptoms (nausea, vomiting, abdominal pain) as part of multi-system inflammation.
• Often accompanied by fatigue, skin rashes (butterfly rash on face), hair loss, sensitivity to sunlight.
• Rheumatoid arthritis is primarily a joint disease but can cause systemic symptoms in flares.

6. Gout / Crystal Arthropathy

• Acute gout causes sudden, severe joint pain (often the big toe, ankle, or knee), and can be accompanied by nausea, especially if the attack is severe or if pain medications cause GI side effects.

7. Medication Side Effects

• Many drugs cause both nausea/vomiting AND joint pain together - for example, certain antibiotics, antivirals, or disease-modifying drugs.

Red Flags - Seek Urgent Medical Care If You Have:

What To Do Now

1. See a doctor - this symptom combination warrants a proper evaluation. A clinician will take a full history (travel history, recent infections, medications, duration, which joints are affected) and order blood tests.
2. Likely tests your doctor will order:
   • Liver function tests (LFTs) - rule out hepatitis
   • Full blood count (FBC) - infection, anaemia
   • Inflammatory markers (CRP, ESR)
   • Hepatitis B & C serology
   • Uric acid (gout)
   • Autoimmune screen (ANA, RF) if indicated
   • Stool culture if recent GI illness
3. Self-care in the meantime:
   • Stay hydrated - sip fluids frequently if vomiting
   • Rest
   • Avoid alcohol completely (especially if liver disease is possible)
   • Avoid NSAIDs (ibuprofen) until liver disease is ruled out, as they can worsen liver/kidney function
   • Paracetamol (acetaminophen) for pain - but use the minimum dose and avoid if you suspect liver disease

Important: This information is for educational purposes only. Given that you have multiple symptoms affecting different body systems, you should see a healthcare professional for a proper examination and diagnosis. Please don't delay if you are vomiting repeatedly, developing yellow eyes, have a high fever, or have severe joint swelling.