Back pain (low back pain): causes, treatments and when to see a doctor in Morocco

01Understanding low back pain, the world's leading cause of disability#

Low back pain (lombalgia) refers to pain located in the lower back, between the base of the last ribs and the gluteal cleft, sometimes radiating to the buttocks or the posterior surface of the thighs. It is one of the most universal complaints in general practice, and the World Health Organization now ranks it as the world's leading cause of years lived with disability, ahead of depression and cardiovascular diseases. This colossal epidemiological importance explains why low back pain has become a major public health issue in all developed and emerging countries.

In Morocco, the figures match this global observation. According to a survey by the High Commission for Planning carried out among more than 15,000 households, nearly 70% of Moroccan adults report at least one episode of back pain in the past twelve months, and 8 out of 10 people will suffer from it at some point in their lives. Direct and indirect costs (medical consultations, imaging examinations, physiotherapy, medications, sick leave, loss of productivity) represent one of the heaviest economic burdens on the health system and the national economy, estimated at several billion dirhams per year.

It is essential to understand that low back pain is a symptom, not a disease in itself. It reflects a muscular, articular, ligamentary or discal imbalance which can have very varied causes. The good news, paradoxically reassuring for patients, is that in 85 to 90% of cases, no serious cause is found: this is then called common or non-specific low back pain, with no identifiable underlying pathology and a globally favourable prognosis. The remaining 10 to 15% are due to specific causes (fracture, infection, nerve compression, inflammatory disease, tumour) which must be quickly identified.

02Distinguishing acute, subacute and chronic forms#

The temporal classification of low back pain is crucial because it directly conditions management and prognosis. The recommendations of HAS and WHO distinguish three forms according to duration of evolution.

Acute low back pain lasts less than 4 weeks. It is extremely common, generally triggered by an inappropriate effort or occurring without an obvious cause, and its prognosis is excellent: 90% of acute low back pain heals spontaneously in a few days to a few weeks, provided that gentle physical activity is maintained and prolonged rest avoided. The vast majority requires neither additional examination nor complex treatment — a simple analgesic, maintenance of activity and time are enough.

Subacute low back pain lasts from 4 to 12 weeks. This is a hinge period when the risk of chronification becomes worrying. Low back pain that persists beyond 4 weeks justifies careful medical reassessment to identify possible chronification factors (psychological, social, professional) and to set up more active management (physiotherapy, sometimes infiltrations, psychological support). This is when therapeutic investment is most profitable to avoid the transition to chronic pain.

Chronic low back pain is defined by persistence beyond 12 weeks. It affects only about 7% of patients who have had acute low back pain, but represents the bulk of the health and economic burden of the pathology. Once established, it is much more difficult to treat and requires a multidisciplinary approach involving the doctor, physiotherapist, sometimes rheumatologist, psychologist, occupational therapist, occupational physician. The most striking finding is that prolonged sick leave beyond 4 weeks reduces the chances of returning to work to about 40%, compared with more than 90% before 1 month — hence the crucial importance of maintaining the link with work and gradually returning even partially.

03The most common causes#

The causes of common low back pain are multiple and often intertwined. Identifying the causative factor(s) makes it possible to adapt management and prevent recurrences.

Inappropriate physical efforts account for around 60% of acute low back pain. This may involve poorly performed heavy lifting (with the back flexed rather than the legs), a sudden twisting or straightening movement, a fall, or unusual prolonged effort (moving house, intensive gardening, returning to sport). In Morocco, physical occupations (construction, handling, agriculture, fishing) are particularly at risk, but also sedentary workers who make occasional efforts without preparation.

Prolonged sitting is responsible for approximately 25% of low back pain. Poorly organised teleworking, computer workstations without ergonomics, long hours of driving (taxi drivers, road transport), repeated static positions keep muscles in prolonged contraction and progressively weaken the back. The professional driver's low back pain is a classic in Morocco.

Lumbar osteoarthritis (spondylosis) is a common cause after 50, due to the natural ageing of intervertebral discs and facet joints. It manifests as mechanical pain (triggered by activity, calmed by rest), often with brief morning stiffness. Disc herniation is responsible for 5 to 10% of low back pain, particularly when pain is accompanied by sciatica (radiation into the leg through compression of a nerve root). The hernia results from fissuring of the intervertebral disc with extrusion of the nucleus pulposus that compresses a nerve root.

Several aggravating or favouring factors are worth knowing: sedentary lifestyle which weakens the protective paravertebral muscles, overweight and obesity which overload the lumbar spine, smoking which alters disc vascularisation and accelerates degeneration, psychological stress which causes reflex muscle contractures, depression which amplifies pain perception, lack of regular physical activity. Rarer specific causes include vertebral fractures (post-menopausal osteoporosis, trauma), infections (spondylodiscitis, vertebral tuberculosis still present in Morocco), inflammatory rheumatism (ankylosing spondylitis, particularly in young subjects with nocturnal pain and prolonged morning stiffness), tumours (primary or metastatic).

04Recognising warning signs or red flags#

While common low back pain is generally benign, certain signs should alert and lead to an urgent medical consultation because they may reflect a serious cause requiring specific management. These signs are called "red flags" in the international medical literature.

Pain occurring after violent trauma (fall from a height, road traffic accident, direct shock) should raise suspicion of vertebral fracture and justifies urgent imaging, particularly in elderly or osteoporotic subjects in whom fractures can occur with minor trauma.

Loss of strength in one or both legs, sensory disturbances in the perineum ("saddle anaesthesia"), recent-onset urinary or faecal incontinence are major signs evoking cauda equina syndrome through medullary compression — an absolute neurosurgical emergency requiring an MRI within hours and rapid surgical decompression. Any delay exposes to permanent sequelae.

The association with fever or recent history of infection should evoke spondylodiscitis (vertebral infection) or epidural abscess, particularly in at-risk patients (diabetics, immunocompromised, intravenous drug use, post-surgery). Unexplained weight loss, night sweats, or history of cancer (breast, prostate, lung, kidney, thyroid — which frequently metastasise to bone) should prompt a search for vertebral metastases.

Intense nocturnal pain that wakes the patient and is resistant to classic analgesics may reflect an inflammatory cause (spondyloarthritis) or tumour, in contrast to classic mechanical pain which is calmed by rest. Age over 50 with new-onset low back pain justifies increased vigilance, as the differential diagnosis broadens at this age. Any rapid deterioration of symptoms or appearance of new neurological signs also justifies rapid consultation.

05Diagnosis: is a systematic MRI necessary?#

A frequent question is that of medical imaging. Many patients demand an MRI to "see what they have", convinced that this examination will provide the answer. The recommendations of French HAS and international scientific societies are however clear and counter-intuitive: no imaging should be prescribed in the first 6 weeks of common low back pain without a red flag.

Several reasons justify this restraint. First, imaging does not generally change management in the first weeks — treatment remains conservative (analgesics, mobilisation, physiotherapy) whether the MRI shows abnormalities or not. Second, and this is essential, MRI very frequently reveals asymptomatic abnormalities in subjects without pain: disc protrusions, disc dehydration, facet osteoarthritis, moderate spinal canal stenosis. These abnormalities increase with age and often have no link to the pain experienced. An MRI performed too early therefore risks discovering "abnormalities" without significance, which unnecessarily worry the patient and sometimes lead to aggressive useless treatments (surgery, infiltrations). Third, imaging has a cost that weighs on the health system and exposes to sometimes invasive examinations (X-rays, contrast).

The lumbar MRI is on the other hand indicated in several well-defined situations: presence of a red flag, failure of well-conducted treatment after 6 weeks, strong suspicion of disc hernia with disabling sciatica (particularly if infiltration or surgery is being considered), suspicion of infection or tumour, significant neurological signs. In Morocco, a lumbar MRI costs between 1,500 and 2,500 MAD in the private sector, reimbursed at 70% by CNSS and 80% by CNOPS on the ANAM reference tariff. The waiting time varies from a few days in the private sector to several weeks in the public sector depending on the centres.

06Therapeutic management#

The treatment of low back pain has evolved considerably over the past twenty years, with international consensus on now well-established and sometimes counter-intuitive principles.

During the acute phase (0 to 4 weeks)

Maintenance of physical activity is the first measure, paradoxical but validated. Prolonged bed rest is harmful: it worsens muscle deconditioning, prolongs pain and increases the risk of chronification. Current recommendations advocate the fastest possible return to usual activities compatible with pain, and only 24 to 48 hours of relative rest if pain is very intense. Walking, even short and slow, is largely preferable to immobilisation.

On the medication front, paracetamol remains the first-line analgesic (up to 3 grams per day). Its efficacy in low back pain is modest but its tolerance is excellent. Non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen (400-600 mg three times a day), diclofenac, naproxen, are effective on the inflammatory component and provide clearer relief. They should be used as a short course (7 to 10 days maximum) due to digestive (ulcer, haemorrhage), renal and cardiovascular risks linked to prolonged use. Muscle relaxants (methocarbamol, thiocolchicoside) may be prescribed in case of significant muscle contracture, on medical advice and for a few days only.

Step 2 analgesics (codeine, tramadol) are reserved for severe pain refractory to step 1, on prescription, due to the risk of side effects (constipation, drowsiness, dependence). Strong opioids (morphine and derivatives) are not indicated in common low back pain, their prolonged use being counterproductive and exposing to dependence.

Several non-medicinal measures provide useful complementary relief: application of local heat (hot water bottle, heat patches such as ThermaCare, prolonged hot shower) which relaxes contracted muscles; wearing a lumbar belt for a few days in case of intense pain, not to be worn for prolonged periods as it eventually weakens the muscles; daily gentle stretching.

During subacute and chronic phases

When low back pain persists beyond 4 weeks, the approach becomes more active and structured to prevent chronification. Active physiotherapy is the pillar of treatment: muscle strengthening exercises (paravertebral, deep abdominal, gluteal muscles), stretches (notably hamstring and psoas muscles which pull on the spine), learning good gestures in daily life and at work. A course of 15 to 30 sessions is generally necessary. In Morocco, several physiotherapists trained in modern approaches (McKenzie method, back schools, functional rehabilitation) practise in all major cities.

Gradual resumption of regular physical activity is essential: daily walking of 30 to 45 minutes, swimming (particularly back crawl which harmoniously strengthens muscles), gentle yoga, Pilates, cycling in an upright position. These activities strengthen support musculature without excessively stressing damaged structures. Therapeutic education within "back schools" teaches patients to understand their pathology, to adopt good gestures in daily life (load carrying, work posture, household movements), to manage pain and associated stress.

The psychological approach is important when chronic low back pain is accompanied by anxiety, depression or catastrophising. Cognitive-behavioural therapy has demonstrated its effectiveness on chronic pain with lasting benefit. Stress management through meditation, sophrology or cardiac coherence usefully complements this approach.

In resistant situations, several interventional treatments may be proposed. Epidural corticosteroid infiltrations are indicated in persistent sciatica from disc herniation, with proven short and medium-term efficacy in approximately 60-70% of cases. Facet infiltrations target osteoarthritis of the posterior interapophyseal joints. Radiofrequency facet denervation is an option in resistant chronic facet pain. Surgery concerns only less than 2% of low back pain, and is strictly reserved for well-defined situations: disc herniation with disabling sciatica not improved after 6 to 8 weeks of well-conducted medical treatment, cauda equina syndrome (neurosurgical emergency), documented vertebral instability, severe lumbar stenosis with disabling neurogenic claudication. Modern endoscopic microdiscectomy, performed in several centres in Morocco (CHU Ibn Rochd, CHU Ibn Sina, several private clinics), gives excellent results on sciatica with rapid recovery.

07Daily prevention#

Prevention is probably the most effective lever for action, particularly in patients who have already had a low back pain episode (50% risk of recurrence within the year).

Regular physical activity is preventive measure number one. At least 150 minutes per week of moderate-intensity aerobic activity according to WHO, supplemented by 2 to 3 weekly sessions of targeted muscle strengthening (core, Pilates exercises, yoga, specific exercises for the back). The simple act of walking 30 to 45 minutes a day at a brisk pace already provides considerable benefit.

In the workplace, ergonomics is essential for sedentary workers. Screen at eye height, keyboard at elbow height (forearms horizontal), a chair with lumbar support, feet flat on the floor, regular breaks every 45 to 60 minutes to get up and move. Poorly arranged teleworking is a major source of low back pain — investing in a proper office chair and an appropriate screen is largely worthwhile.

Maintaining a healthy weight (BMI below 25) limits overload on the lumbar spine. A firm mattress suited to your morphology, to be replaced every 8 to 10 years, contributes to restorative sleep without aggravating pain. Stopping smoking improves disc vascularisation and slows degeneration. Stress management through validated techniques prevents emotionally caused muscle contractures.

Learning good gestures in daily life is crucial: to carry a heavy load, bend the knees and keep the back straight, keep the object close to the body, avoid twisting; to pick up an object, bend the knees rather than lean forward; to make the bed, kneel rather than lean; to drive, adjust the seat to have the knees slightly higher than the hips and take breaks every 2 hours on long journeys.

08Reimbursement and access to care in Morocco#

The financial coverage of low back pain in Morocco is globally satisfactory thanks to the AMO system. Here are the main acts and their reimbursement.

Chronic low back pain with recognised disability may entitle to ALD (Long-Term Disease) coverage for the most severe forms, with 100% coverage of related care. The procedures should be initiated with the medical adviser of your fund with a complete medical file documented by your rheumatologist or pain doctor.

For sick leave, CNSS pays daily allowances of 50-75% of salary after a 3-day waiting period, up to 52 weeks over 3 years. Gradual resumption in therapeutic part-time is possible and helps maintain the professional link while preserving recovery. Occupational medicine can prescribe workstation adjustments (lightening of physical loads, partial teleworking, adapted furniture) which are valuable to avoid relapses upon return to work.