24 May The Low Down on Low Back Pain – Part 3
The bed rest debate
Go back 10 years (and even some GP’s and clinicians today) and have an episode of back pain and likely you will be told to rest in bed, don’t do much, and avoid movement. Some people still self manage their back pain this way. It’s one of the most common questions I get, “How much should I be doing?” “Should I just rest in bed?” “Moving and doing things will make my back worse right?”. So let’s settle the bed rest debate once and for all, bed rest is never the answer for low back pain! Maintaining activity within comfortable pain limits is the optimal solution to managing lower back pain. The lumbar spine is an incredibly strong structure and unless there are significant contraindications to mobilising (which there really aren’t many) it is always best to stay moving. I always advise clients to utilise pain relief as needed and discuss with their GP or pharmacist if they feel they need more effective pain relief options than what they are using. Hot packs are another godsend for helping to stay active, it helps to settle the muscles and relax the nervous system so that you can gradually move more and more over the next few days. You won’t find that moving is going to happen overnight, but over the space of 4-7 days staying active and moving will start to pay dividends.
How long does back pain usually last?
Research indicates that most back pain episodes will last up to 6 weeks, with most cases resolving within this time period if you maintain activity such as walking and light exercise. Utilising adjunct treatments, such as physiotherapy, along with your exercise will likely expedite the recovery process. I would suggest that most clients with low back pain that I manage resolve symptoms within 3-4 weeks and are living a normal life without concerns. Some cases may take longer depending upon the irritability of their initial presentation and whether they had any nerve pain referral. Cases with nerve referral will often take longer to settle as the process that nerves go through to heal takes longer than most other tissues in the body. As long as the nerve symptoms are either settling or reducing in area/receding up the leg (a process known as centralisation) this is positive improvements. It can be difficult to truly predict how long this process may take as there may be multiple sites of neural tension that require hands on treatment.
Why should I keep moving?
Maintaining movement and activity is one of the key factors in recovering from an episode of low back pain – whether that be an episode of acute back pain or a flare up of persistent back pain. Movement will help to reduce muscle spasm in the short to medium term as long as you move within the range that you are comfortable. If you start to push outside those boundaries and really irritate the sensitised structures the spasm will likely increase. So slow and steady wins the race every time.
I also like to think that keeping moving keeps people in a positive mindset, whether that’s going out for a small walk somewhere nice or just being up and about at home, being active and doing something always beats lying in bed in my opinion (unless it’s a rainy day and there’s a movie on Netflix I want to watch!)
Why does back pain become chronic?
If only someone knew the answer to this we’d rid the world of one of the most frustrating (an expensive) musculoskeletal presentations. Unfortunately there is likely multiple factors at play leading to symptoms becoming persistent, and they are likely different between people so this is actually a very difficult question to answer. In my opinion and through my clinical experience there’s often a few common factors that I see.
The first and most common is clients who aren’t active and mobile from the start of their rehab. This often leads to muscle spasm lasting longer than useful which becomes a negative factor rather than a protective factor which it is right at the initial onset.
The second most common is clients who “want someone to fix them”, as much as I would love to say that I can fix back pain, as with any other presentation I treat it’s a team effort between myself and the client. Hands on treatment is only able to achieve so much, to a certain extent the client has to go and utilise what the hands on treatment allows them to do. Of course, this is dependent upon me educating the client about this and what they are capable of.
Thirdly, the classic client of “I’ll just keep pushing and it’ll get better”, in most cases when someone says this it’s not going to get 100% better. Sometimes we need to get better at recognising when our body needs a chance to take a few days off from work and just rest and reset.
With regards to factors outside of our control, I would say clients who have experienced a significant number of back pain episodes in a short period of time may potentially be at a greater risk, as well as those who have more findings on an MRI scan. Those are purely anecdotal comments from my clinical experience and there isn’t a significant body of research to substantiate those claims.
What can I do to prevent further episodes of low back pain?
The one thing all of my clients and everyone out there loves, exercising and maintaining an active and healthy lifestyle! I would say far and away this is the best preventative advice I could give for just about any musculoskeletal presentation. Don’t try to go out and run a marathon if you haven’t been running, gradually build up your tolerance to your exercise of choice. This could be running, gym, walking, pilates, yoga, powerlifting, or any other number of great choices. As long as it’s a gradual build up it’s an awesome choice. Living a healthy lifestyle involves a huge number of facets ranging from stress management, sleep hygiene/quality/time, nutrition, work/life balance, among many others. So many of these facets feed into musculoskeletal conditions and we are only just beginning to truly understand their impact.
“Core strengthening” is a term thrown out there a lot, and I’d agree that developing adequate core strength is important but it isn’t the be all and end all to preventing back pain. Ensuring you have mobility around your hips, mid back, and pelvis all feed into the “core”. I would definitely be recommending that my clients develop their core strength but don’t feel the need to go and do 100 crunches day in day out. A generalised full body strengthening program with core exercises included would be a much better option.
Self managing low back pain episodes
Some clients with lower back pain who don’t have significant levels of pain may be able to potentially self manage at home. My best tips would be to stay active and mobile, keep bending your back and twisting both within your comfort limits. Utilise heat packs as often as possible, 25min of a heat pack can both provide symptomatic relief as well as assisting in getting more movement. They key to using hot packs is to get up and move and do some stretches after using them, if you simply put a hot pack on and watch 2 seasons of Brooklyn 9-9 on Netflix and then say it didn’t work just simply didn’t make use of the benefit that it gave them. I would also suggest use pain relief as needed, some clients like to “tough it out” or don’t want to mask the pain, but the benefits often outweigh the cons, if you are taking other medications discussing your best options with a local pharmacist or your GP would be your best avenue.
Should I get a scan?
I don’t believe many clients truly have a need to have further investigations such as an MRI or CT scan completed to assist in the diagnosis of their lower back pain. My belief is based on two things, firstly, it is unlikely that imaging is going to determine a diagnosis in most cases, and secondly, more often than not my treatment plan is unlikely to change. Interestingly, in a study performed in 2019, they found that utilising imaging (x-ray, CT, or MRI) was found to increase healthcare utilisation, increase cost of care, and increase absence from work in comparison to people who didn’t access imaging. Some people may argue that this is due to the fact that only people who should be getting imaging are getting it and therefore they should be more acute or complex cases, but in my clinical experience that is often not the case. Routine presentations of acute low back pain are sent for imaging far too often leading to increased costs to clients for little to no clinical benefit. In certain circumstances, imaging may be recommended, but it’s important that a differential diagnosis is in mind and not just a process of “this seems bad, lets get an MRI and see what’s there”.
Should I get surgery?
When researching some of the most common questions people put into Google relating to low back pain it was surprising that this was up there with one of the most common. It’s quite disheartening as a physio that the public perception of lower back pain is that non-surgical techniques aren’t fully and completely explored before considering whether surgery is an option. I don’t believe many cases of lower back pain truly require surgical input, most of these cases are quite rare and upon assessment there will either be things that aren’t matching or there are certain clinical symptoms that definitively require further investigation and potential treatment. For the vast majority of clients who I see that present with lower back pain, surgery should be well and truly far far down their list of treatment options. Unfortunately I may not be able to fix every single client with back pain, but that doesn’t mean that non-surgical treatment options have failed, potentially another physio, or an osteopath could provide a different slightly more effective treatment that happens to work really well. So my advice would be that a few sessions of treatment (be that physio, chiro, osteo, or whichever) without effect doesn’t mean you should throw the baby out with the bathwater and come to the conclusion that your back pain cannot be fixed with non-surgical care.
The role of psychological factors on low back pain
Psychological factors have been found to play a huge role in low back pain, and particularly in persistent low back pain. Thoughts and beliefs around low back pain, what causes it, how you believe you should move, your belief about your prognosis all have an impact on your experience of low back pain. In most cases if people believe they have a worse prognosis and are unlikely to recover, chances are they won’t have the same outcome as someone with a more positive outlook.
Beliefs surrounding what is causing your back pain have largely been perpetuated by a medical system that has focus on structures and anatomy. At the time that was what we knew and we believed was the cause, but research has been able to identify that in most cases it may not be the cause. With this shift from a very structural medical point of view to what is termed a “biopsychosocial” approach (just a fancy word for holistic I guess?) it’s important that our clients are on board that journey with us. It can be difficult to change your perception of something that you have likely been told is the issue 100 times by people before but being adaptable in your thinking and considering it as a potential option is important.
Negative beliefs about the strength and support systems surrounding your back often lead to clients developing abnormal movement patterns that are initially utilised to avoid movements (most often bending forwards). After a period of time – say a week or so – these movements are much less useful and can often become a negative. The old belief of “lift with your knees” has gone a little too far on occasions, I have had clients tell me they can’t lift a pillow off of the floor without “lifting with their knees”. When we think about it, when did people ever do this before they had back pain? It becomes a movement pattern for people to avoid using their backs and becomes an ingrained movement pattern, learning to relax and move the back is integral as it’s how the back is designed to move. It is designed to bend, and twist, and move side to side, it wasn’t designed to be held rigid by my back and abdominal muscles as I lift. Research has actually found that lifting a weight from the ground is mechanically more efficient to do with a slightly rounded back than with a straight back.
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