Back Pain from Coughing: Causes, Symptoms, Treatment, Diagnosis

1. Back Muscle Spasm
2. Muscle and Tendon Tear
3. Disc Bulge and Herniation
4. Facet Joint Irritation
5. Vertebral Body Fracture in Patient Suffering with Osteoporosis

A cough is a reflex action in humans to clear their breathing track or throat from microbes, fluids, foreign particles, mucus, and fluids. The reflex action ejects the air following vigorous contraction of abdominal muscle, intercostal muscle and diaphragm. Such forceful contraction creates sudden increase in intrathoracic and intraabdominal pressure.

The paravertebral muscles also contract during coughing. Coughing is either dry coughing or wet coughing. Chronic smoker suffers with dry coughing. Wet coughing is observed when individual is suffering with bronchitis and secretes mucosal secretion from bronchial mucosa. Various study published suggests low back pain is one of the common symptom experienced by 50 to 85 of population in modern industrial society more than once in their life time.1 Chronic coughing that persists for 2 to 3 weeks should be evaluated by primary care physician or specialist to prevent complications such as back pain.

1. Back Muscle Spasm Triggered By Coughing: Cause of Back Pain

   Chronic smoker suffers with repeated coughing.² Repeated non mucosal productive coughing causes repeated contraction of abdominal, intercostal, paravertebral (back) and diaphragm muscle. Prolonged dry coughing causes fatigue of back muscle. In few cases fatigue paravertebral back muscles goes into painful spasm resulting back pain.³ Such muscle spasm frequently restricts activities.

2. Paravertebral Muscle Micro Tear And Sprain Following Coughing: Cause Of Back Pain

   The stability of back depends on normal anatomy and function of muscle tendon and ligaments.4 Spine or vertebral column protects spinal cord and spinal nerve. Vertebral column also transmits the upper body weight to the leg. Dry or wet coughing when persistent causes vigorous back muscle contraction. Lack of exercise, prolonged sickness and malnourishment makes paravertebral muscle weak. The micro tear of paravertebral muscles occurs when individual suffering with muscle weaknesses persistently coughs for several hours. Periodic coughing while carrying heavy object causes additional strain on paravertebral muscles that is already supporting upper body. Pressure changes over contracting muscle during forceful coughing causes separation of muscle fibers that results in micro tear. Such condition is known as muscle sprain. Disruption of normal structure of paravertebral back muscles causes symptoms like back pain. Similarly, severe cough also causes tendon injury that results in back pain.

3. Ligamental Sprain Following Coughing As A Cause of Back Pain

   The vertebra, facet joint and disc are fastened to adjacent bone or cartilage by a ligament. Severe continuous cough rarely causes micro tear of ligament. Such ligamental injury causes severe back pain.⁵ Such ligamental strain is observed following coughing in individual who is malnourished, avoids exercise and suffering with prolonged sickness. Facet joint pain is also caused by ligamental sprain of ligaments that supports facet joint.

4. Disc Bulge and Herniation-

   Disc is formed by central gelatinous substance and peripheral annulus fibrous tissue. Severe bout of coughing increases pressure in central gelatinous substance. The substance occasionally pops through the peripheral fibrous covering known as annulus fibrosus. The coughing followed by displacement of gelatinous disc substance causes micro-tear of fibrous annulus.6 The coughing results in disc gelatinous substance pushing through the fibrous annulus causing disc bulge or in few cases herniates through ruptured fibrous annulus that results in disc herniation. Disc bulge or herniation causes backache.

5. Osteoporotic Vertebral Body Fracture-

   Osteoporosis causes brittle bone because of lack of calcium and weak bony skeletal connective tissue. Persistent repeated coughing causes increased pressure within spinal canal and back. Such pressure change frequently causes fracture of body of vertebra that results in back pain.

1. Pain
2. Tingling and Numbness
3. Restricted Back Movement
4. Restricted Ambulation and
5. Stiff Back

Back pain from coughing can be mild to severe in intensity. The back pain may be associated with symptoms like tingling, numbness and weakness in muscles. Such symptoms suggest possible pinched nerve and disc bulge or herniation. The symptoms of back pain are listed below which will help you identify if you are actually suffering from a back problem or not:

1. Pain-

   1. Unilateral or bilateral back pain following coughing caused by paravertebral muscle spasm is localize on side of spine.
   2. Back pain caused by facet joint irritation or strain during bouts of cough is frequently radiates to back of thigh and buttocks
   3. Back pain following coughing may cause tightness and spasms in muscles of lower back, hips, and pelvis.
   4. Sudden intense back pain runs down the leg immediately following bouts of coughing suggests possible disc bulge or herniation.
   5. Elderly individual suffering with osteoporosis may developed intense back pain following severe coughing because of fracture of vertebra or transverse process.

2. Tingling and Numbness-

   Symptoms of tingling and numbness suggest possible irritation or pinch of spinal nerve. Such condition is observed following fracture of vertebra as seen in individual suffering with osteoporosis and also disc bulge or herniation.

3. Restricted Back Movement-

   Back movement is restricted because of back muscle spasm and also triggering higher intensity of pain. Individual is often afraid to move or change position while sitting or lying down. Such restriction some time worsens the condition and causes sustain back muscle spasm.

4. Restricted Ambulation-

   Individual suffering with sudden occurrence of back pain following coughing is often afraid to ambulate since once in while he may experience jolting pain with higher pain intensity. Severe pain is observed while standing or sitting for prolonged period.

5. Stiff Back-

   The contracted paravertebral muscle on both side of mid spine feel tight and stiff when palpated. Stiff back causes difficulties in changing postures like standing up or sitting down or lying down

Back pain following coughing should be investigated to rule out fracture of vertebra in patient suffering with osteoporosis and also rule out disc herniation or bulge. The immediate radiological investigational study is necessary to diagnose the cause of pain. Symptoms like tingling, numbness and muscle weakness suggests possible nerve injury and should be evaluated immediately.

Radiological Studies-

• X-Ray– X-ray images shoes fracture of vertebra but may not show disc bulge or herniation.
• CT Scan– Images of computerized tomography (CT) scan will show abnormalities like disc bulge, herniation and fracture of vertebra.
• MRI– The magnetic resonance images (MRI) shows finding like disc abnormalities and fracture.

1. Conservative Treatment of Back Pain Caused Due to Coughing-

   Rest- Minor muscle spasm causing backache often gets better with rest. Rest relieves the fatigue muscle that later become less painful and spasm is relieved.

   Heat Therapy- Heat therapy is given by applying hot wet towel or hot rubber bag over the back. In few cases prior to physical therapy individual may receive infrared heat therapy to relax the muscles.

   Cryo or Cold Therapy- Like heat treatment, bag of ice is left over back for 15 to 20 minutes 3 to 4 times a day. Treatment helps to relieve pain.

   Ultrasound Treatment- Ultrasound therapy is done while doing physical therapy. High frequency sound wave passed through the skin over the contracted muscle. Treatment helps to relieve muscle spasm.

   Back Massage- Back massage is either soft massage or deep massage. During the initial phase individual may not tolerate deep massage, so it is always beneficial to start with soft massage and then consider deep massage after 3 to 5 days. The massage is performed 2 to 3 times a week for first 2 weeks then twice a week until spasm is relieved.

2. Medications to Treat Back Pain Caused Due to Coughing-

   Analgesic

   1. NSAIDs-Nonsteroidal anti-inflammatory medication helps to relive the inflammation associated with muscle spasm, disc bulge and fracture of vertebra. NSAIDs help to relive mild to moderate back pain. Motrin, naproxen and celebrex are the NSAIDs most frequently used to treat back pain caused due to coughing.
   2. Tylenol- Tylenol is prescribed for mild to moderate pain when patient cannot tolerate NSAIDs because of side effects like stomach pain and ulcer.
   3. Opioids- Opioids are avoided because of possible dependence and addiction to medication. Severe to very severe pain is treated by opioids. Opioid therapy is restricted to 2 to 3 weeks.

   Muscle Relaxants – Muscle relaxant helps to release the muscle spasm Muscle relaxants also causes drowsiness so dosage has to be titrated to avoid sleepiness and drowsiness. Most often baclofen, soma and relaxin are prescribed as muscle relaxants.

3. Physical Therapy-

   Physical therapy for back pain due to coughing includes heat therapy, ultrasound, stretching and back muscle exercises. The stretching and exercises are performed under the supervision of trained physical therapy.

4. Interventional Treatment for Back Pain Caused Due to Coughing-

   1. Epidural corticosteroid injection- The corticosteroid is injected in epidural space to relieve pain caused by irritation or pinch of spinal nerve. Procedure also helps to relieve epidural inflammatory pain caused by fracture of vertebra.
   2. Facet joint injection- Facet joint pain is treated with injection of corticosteroid in facet joint. Procedure is performed under image guidance.
   3. Muscle Trigger Point Injection- Muscle spasm is treated with injection of corticosteroid in contracted muscles.

5. Surgery

   1. Partial Discectomy- Remove Partial Disc
   2. Discectomy and Partial Laminectomy

One must watch out for the symptoms of back pain from coughing and seek professional help if pain continues after 24 hours. If back pain following cough is associated with numbness and weakness, then you must consult your physician immediately.

References: