Low Back Pain Over 60

Let me start with the sentence you have probably been told, and most need to hear questioned.

It is not just your age.

Back pain does get more common as people get older. That much is true. But most people in their sixties, seventies and eighties do not have disabling back pain. And the ones who do are not simply the ones with the oldest spines.

If age alone caused pain, everyone your age would have it. They do not. Something else is going on. The good news is that the something else is usually far easier to change than the calendar.

This guide is not saying your pain is in your head. Your pain is completely real.

One thing before you start. This guide assumes I have examined you and ruled out the serious causes. That check matters more with each decade, not less, because a few of the problems in section 14 do get more common with age. If nobody has examined you yet, read section 14 first.

Read it in chunks. There is no test at the end.

The short version

• Pain is an alarm. It protects you. It does not measure damage.
• There is a gate in your spinal cord. It controls how much of the warning signal reaches your brain.
• When pain lasts a long time, the alarm gets more sensitive. That is learned, so it can be unlearned. There is no age limit on that.
• Nearly every pain free person your age has wear and bulges on a scan. That is normal ageing, not damage.
• Losing strength is a far bigger threat to you than any wear on your spine. And you can get strength back at any age.
• Moving is safe. Resting for long stretches is the risky option now.
• A few problems do get more common with age. Section 14 tells you exactly what to watch for.

1. Pain is an alarm, not a damage meter

It feels obvious that pain comes from your back. It does not, quite.

Your back has danger sensors. They fire when tissue is stretched, squashed or irritated. They send warning signals to your spinal cord, and then to your brain. None of that is pain yet. It is just information.

Then your brain weighs that information against everything else it knows. What were you doing? What happened last time? What do you think this means? How stressed are you? Did you sleep?

Then it decides: how much danger am I in, and how much pain does this person need to feel to keep them safe?

Pain is the answer. Your brain produces it.

That is why damage and pain match up so badly:

• A paper cut really hurts. There is almost no damage.
• Soldiers get badly hurt and feel very little until they are safe.
• People who have lost a leg can still feel pain in it.

So how much pain you feel does not tell you how much damage there is. It tells you how protective your body is being right now.

2. The pain gate

In 1965, two researchers called Ronald Melzack and Patrick Wall came up with an idea that changed pain medicine. It is still one of the most useful pictures we have.

Picture a gate in your spinal cord. Warning signals from your back have to pass through it to reach your brain. When the gate is open, lots get through and you feel more pain. When it is closed, fewer get through and you feel less. Your back has not changed at all. Only the gate has.

What closes the gate

• Touch, rubbing, heat and hands-on treatment. Touch signals travel on bigger, faster nerves than danger signals, and they crowd them out. It is why you rub your elbow after you bang it.
• Moving and exercise. They release your body's own painkillers.
• Feeling safe and calm.
• A decent night's sleep.
• Company. Being lonely genuinely makes pain worse, and this matters more in later life than most people admit.
• Understanding what is going on. Reading this counts.

What opens the gate

• Stress and worry. Especially worrying about what this means for your independence.
• Broken sleep.
• Low mood, and feeling written off because of your age.
• Fear of falling. This is one of the most powerful gate openers there is in people over sixty.
• Being afraid of a movement, usually bending.
• Being told frightening things about your spine. Phrases like your spine is crumbling and there is nothing left do real harm.

Here is the key bit. Your brain does not just receive signals at that gate. It sends signals down and changes the settings. That is why the same bit of gardening is fine one week and floors you the next.

3. When the alarm gets too sensitive

When a pain system has been busy for months or years, it does not wear out. It gets better at its job. The sensors fire more easily. The spinal cord turns the signal up. The brain decides there is danger more quickly.

Think of a car alarm. When it was fitted, it went off if someone tried to force the door. Years later it goes off when a cat walks past.

The alarm is not broken. It is not lying. It is just set far too sensitive for the actual level of threat. That is what long lasting back pain usually is. And because your body learned it, your body can unlearn it. There is no age limit on this. Studies of pain education and gradual activity show benefit in people in their seventies and eighties, not just the young.

4. What scans show at your age

This is the section I would most like you to remember.

Researchers scanned lots of people who had no back pain at all. Then they counted what showed up.

In people with no pain:

• At 60, about 9 in 10 had disc degeneration. At 80, nearly everyone did.
• At 60, about 7 in 10 had a disc bulge. At 80, more than 8 in 10 did.
• Worn facet joints, narrowed discs, and a bone that has slipped slightly forward on the one below are all found in large numbers of people your age with no symptoms at all.

Read that again. If wear caused pain, essentially every person your age would be in pain. They are not.

These findings are the inside version of grey hair. Finding one on your scan does not, by itself, mean it is causing your pain.

There is a second reason this matters. Degeneration, crumbling, wear and tear, and bone on bone are frightening phrases, and they get used carelessly. Frightening words raise threat. Threat opens the gate. People who believe their spine is falling apart move less, guard more, and hurt more.

I have met a great many people who were more disabled by a sentence than by their spine.

If you have had a scan and been given frightening words, bring the report in. We will go through what it actually says.

5. If walking is the problem

There is a pattern that becomes much more common after sixty. It is worth knowing, because it has its own explanation and its own approach.

The pattern goes like this. Your back may not be bad at rest. But when you walk, after a fairly predictable distance, your legs start to ache, or feel heavy, tired, numb or weak. You stop, sit down or lean forward on something, and within a few minutes it eases and you can go again. Other clues: you can push a trolley round a supermarket far better than you can walk the same distance upright. Cycling is easier than walking. Going uphill is easier than going down.

That is caused by narrowing of the space around the nerves in your lower back. The medical name is lumbar spinal stenosis. Bending forward opens that space up, which is why leaning on a trolley helps.

Things worth knowing:

• It is not an emergency, and it is not a countdown to a wheelchair. For most people it stays stable or changes slowly, rather than steadily getting worse.
• Many people manage well for years without surgery. Activity in tolerable chunks, strength work, and treatment to keep things comfortable all help.
• Cycling, including a stationary bike, and walking with a slight forward lean let you keep your fitness up while working within the pattern. Losing fitness is the thing to avoid.
• Surgery is a reasonable option for some people whose walking is severely limited despite good treatment, and it can work well. That is a decision based on what you can do, not on what a scan looks like.

One important difference. Leg pain when walking can also come from narrowed arteries rather than narrowed nerve spaces.

The clue is what relieves it. With a circulation problem, simply standing still is enough. You do not need to sit or lean forward. It is often worse going uphill rather than down, and it is usually felt in the calves. It is more likely if you smoke or used to, or have diabetes, high blood pressure or heart disease.

This difference matters. If your legs hurt when you walk, please tell me exactly what makes it ease. Circulation problems need checking by your GP.

6. Strength is the thing, and it is not too late

If you take one practical thing from this guide, make it this one.

From around fifty, we lose muscle and strength steadily. Strength goes faster than bulk. Left alone, it speeds up. That is the main reason people become frail.

It is also the main reason a back that was fine at fifty five struggles at seventy. Not because the spine wore out. Because everything around it got weaker while the demands stayed the same. Here is the part people are rarely told. You can get it back, at any age. Strength training builds strength and function in people in their seventies, eighties and nineties. The trials have been done, including in frail care home residents. They work. You are not too old and you are not too late.

What that means in practice:

• The NHS advice for adults over 65 is strength, balance and flexibility work on at least two days a week, plus 150 minutes a week of moderate activity, and breaking up long spells of sitting.
• Strength work means real resistance. Weights, bands, or bodyweight moves like standing up from a chair, done until the last few repetitions are genuinely hard. Walking is valuable, but it does not build strength.
• Standing up from a chair without using your hands is a superb exercise and needs no equipment. Build it up gradually. It improves exactly what you need for getting off a toilet, out of a car, and up from the floor.
• Balance work matters just as much. Confidence on your feet does as much for pain as anything.
• Start lighter than you think. Being sore for a day or two after starting is normal, and it is not damage.

Getting weaker, not wearing out, is the thing most likely to take your independence. It is also the thing most under your control.

7. What turns your pain up and down

• Sleep. Poor sleep is one of the strongest signs of a bad pain day ahead. Sleep changes with age, but pain and sleep still feed each other both ways.
• Stress. Bereavement, caring for a partner, health worries, money.
• Mood. Low mood and pain feed each other. Depression is often missed in older adults, and it is very treatable.
• What you believe. Believing pain is just part of getting old, and nothing can be done, is linked to worse outcomes. It is also not true.
• Fear of falling. Very important, and often the real reason someone has stopped going out.
• Activity. Too much too soon turns it up. So does too little for too long.
• Being isolated. This genuinely matters.
• Other conditions, and the medicines for them. Worth reviewing with your GP if your pain has changed.

Most of those are things you, or the people around you, can influence.

8. Moving is safe, and resting is the risk

Your spine is strong. It is held by some of the most powerful muscles in your body, and that is still true at seventy.

At your stage of life the balance of risk has shifted, and it has shifted in favour of moving.

A week in bed costs a younger person some fitness. It costs you muscle, bone, balance, confidence and independence, and it costs them fast. A week in bed at seventy five is not the same as a week in bed at thirty five.

Some soreness while you build back up is expected. It does not mean damage. A good rule: pain that rises while you move and settles back to normal within about a day is fine. Pain still up the next day means you did a bit too much, not that you did harm.

Walking, swimming, cycling, gardening, dancing, tai chi, strength work. The type matters far less than picking something you will actually keep doing.

9. Pacing, and the boom and bust trap

A good day comes. You seize it and do the whole garden. Then you pay for three days. Over months the trend quietly goes down.

Pacing is the way out:

• Work out what you could manage on almost any day, including a bad one.
• Do that amount every day, good and bad.
• Once it feels easy, add about a tenth more each week.
• Break big jobs into chunks. Two half hours of gardening with a sit down between beats one hour and three bad days.

It feels annoyingly slow for a few weeks. Over a few months it is the fastest route there is.

10. Flare-ups

Flare-ups are normal. They do not mean you are back to square one, and they do not mean something has broken.

They are usually a pile-up: a hard week, two bad nights, a stressful event, a burst of activity.

• Keep moving, gently. Do less rather than stopping. This matters more for you than for a younger person, because you lose ground faster when you stop.
• Drop back to your baseline for a few days, then build again.
• Use whatever settles it: heat, short walks, changing position often, medication as advised.
• Remind yourself that this has settled before and will settle again.
• Get in touch if it is not settling as it normally does, or if anything in section 14 applies.

11. A word about painkillers

I am not your prescriber, and this is not prescribing advice. But one thing is worth knowing at your age.

Anti-inflammatory tablets like ibuprofen and naproxen carry noticeably higher risks after sixty. Stomach bleeding, kidney problems and raised blood pressure. They also interact with several medicines commonly taken later in life, including blood pressure tablets, water tablets and blood thinners.

Anti-inflammatory gels rubbed into the skin carry much less risk than tablets, and are often a better first choice.

If you are taking painkillers regularly rather than now and then, please talk to your GP or your pharmacist. A pharmacist can do a free medicines review, and it is a genuinely useful half hour. Mention anything that makes you drowsy or light headed too, because that feeds straight into falls risk.

12. What treatment does, and what it does not

Hands-on treatment works through everything above. It closes the gate. It calms the sensitivity. It relaxes muscles that have tightened to protect you. It gives you a spell where moving feels easier and safer. That is a real effect and it is worth having.

What it does not do is reverse wear or rearrange your spine. Nothing needs putting back in.

Think of a session as a window. A stretch of time where you can move more freely, and use that freedom to build strength. The moving is what changes things in the long run.

I will also adapt what I do to you. How I position you, which techniques I use, and how much force is involved all change depending on your bone strength, your joints, your medicines and your other health conditions. I will always ask.

Please tell me if you have osteoporosis, take steroids long term, take blood thinners, or have had spinal surgery. All of those change what is right for you. One note on progress. Pain scores bounce around and can be disheartening. A better question is: what can I do now that I could not do three months ago? Can you get out of a low chair? Manage the stairs? Walk to the shop? Get in and out of the car? Get down to the grandchildren and back up again? Function usually improves before pain does, and function is what actually matters.

13. The goals worth aiming at

The target is rarely a pain score. It is usually one of these. It is worth saying yours out loud at your next appointment.

• Getting up off the floor unaided. One of the strongest signs of staying independent, and you can train it.
• Getting out of a low chair or a car without pushing off with your arms.
• Walking far enough to do what you want, whether that is the shop, the church, or eighteen holes.
• Carrying shopping, a watering can, or a grandchild.
• Managing the stairs confidently, both up and down.
• Sleeping through the night.
• Staying in your own home.

14. When to get urgent help

Almost all back pain, including a bad flare-up, is not an emergency. A few things are, and a few of them get more common with age.

Go straight to A&E, or call 999

• Sudden severe pain in your back or tummy, especially with faintness, a cold sweat, or a throbbing feeling in your tummy. This can mean a problem with the main artery in the abdomen. It is more likely in men over 65, in smokers and ex-smokers, and with high blood pressure. Call 999.
• Numbness or a changed feeling between your legs, around your back passage or genitals. Including toilet paper feeling different when you wipe.
• Trouble starting to wee. Not being able to feel it coming out. Losing the feeling of a full bladder. Any new loss of control of your bladder or bowels.
• Sciatica in both legs at once, or sciatica that has spread from one leg to the other.
• New or quickly worsening weakness in one or both legs, or legs giving way.
• Severe back pain straight after a bad fall or accident.

The middle four are warning signs that the nerves at the bottom of your spine are being squashed. It is called cauda equina syndrome. It is rare, and it is time critical. The national plan expects a scan within hours. Do not wait to contact me or your GP first. If you are offered a routine appointment, say you are worried about cauda equina syndrome.

Contact your GP or NHS 111 today

• Sudden severe back pain after a minor fall, a bump, a cough or a sneeze, or with no obvious cause at all. Especially if you have osteoporosis, have taken steroids long term, or have broken a bone from a minor injury before. This can be a spinal fracture. It is common, it is treatable, and it is often missed.
• Losing height, or your upper back becoming noticeably more rounded, along with back pain.
• Back pain with fever, shivering, or feeling generally unwell.
• Back pain with weight loss you cannot explain, night sweats, or a past history of any cancer.
• Pain that is much worse at night, wakes you every night, or is not eased by any change of position.
• New leg weakness getting worse day by day, even without the symptoms above.

Worth mentioning at a normal appointment

• Any fall, even one that did not hurt you. Falls are the best predictor of future falls, and a great deal can be done. Your GP can refer you to a falls prevention service.
• Whether you have ever had a bone density scan, if you have broken a bone from a minor fall since you were fifty.
• Leg pain when you walk, so we can work out which of the two patterns in section 5 fits.

Everything else, including a bad flare-up, can wait for a normal appointment.

15. If you want to read or watch more

Start here

• Tame the Beast. A five minute animation by Professor Lorimer Moseley. The best possible starting point. tamethebeast.org
• Flippin' Pain. A UK campaign about long lasting pain. flippinpain.co.uk
• NHS activity guidelines for older adults. nhs.uk/live-well/exercise/physical-activity-guidelines-older-adults
• NHS advice on back pain. nhs.uk/conditions/back-pain

Practical help

• The Pain Toolkit, by Pete Moore. Very good on pacing and boom and bust. paintoolkit.org
• Recovery Strategies, by Greg Lehman. A free illustrated workbook. greglehman.ca/recovery-strategies-pain-guidebook
• Age UK, on staying steady, and strength and balance exercises. ageuk.org.uk
• Royal Osteoporosis Society, if bone health matters for you. theros.org.uk

Books

• Explain Pain, by David Butler and Lorimer Moseley.
• The Explain Pain Handbook: Protectometer, by the same authors.

The research behind this guide

• Melzack R, Wall PD. Pain mechanisms: a new theory. Science, 1965. The original pain gate paper.
• Brinjikji W et al. Imaging features of spinal degeneration in asymptomatic populations. American Journal of Neuroradiology, 2015. The scan figures in section 4.
• Hartvigsen J et al. What low back pain is and why we need to pay attention. The Lancet, 2018.
• Fiatarone MA et al. Exercise training and nutritional supplementation for physical frailty in very elderly people. New England Journal of Medicine, 1994. The classic proof that strength training works in the very old.
• Cruz-Jentoft AJ et al. Sarcopenia: revised European consensus on definition and diagnosis. Age and Ageing, 2019.
• NICE guideline NG59: Low back pain and sciatica in over 16s.
• NICE guideline NG259: Osteoporosis, risk assessment.

Bring any of this to your next appointment. Especially the parts that did not sit right, or that felt uncomfortably familiar.

This guide is general information. It does not replace the advice I give you in clinic.