BACK PAIN

Low back pain (LBP) is the leading cause of disability worldwide. It is a common condition that emerges during adolescence and throughout adulthood. For some, LBP is self limiting and not disabling, but for others, it can be disabling, distressing and negatively disrupts many aspects of life.

The best practice evidenced management of low back pain includes:

An initial triage process to screen for serious pathology
Screening and profiling a LBP disorder from a broader biopsychosocial perspective so as to identify patients at risk of persistent disabling LBP
A patient centered approach LBP care that addresses biopsychosocial influences relevant to their experience and empowering self management
Tailored LBP management that encourages patients to be active participants for their recovery
Radiological imaging should only be used when there are clear indications for it such as ruling out for serious, unresolved pathology, red flags of the back.

Common medical diagnostic labels for LBP include: Disc degeneration, bulges, prolapses, facet arthropathy, annular tears, spondylosis, spondylolisthesis, stenosis, sacroiliac joint pain.

In specific LBP (i.e. presence of pathology), a small group of patients (5%) who present with LBP from slipped disc with associated radicular leg pain with or without neurological deficit, the natural healing history is good. Prospective studies (i.e. research that tracks people over a period of time) showed high recovery rates (over 80%) and reduction of slipped disc at 12 months follow up. Only in some cases where there is progressive worsening neurology and cauda equina symptoms is surgical opinion warranted.

As for acute radiculopathy where pain levels are distressing, pain management and patient reassurance on the natural healing history is important. As pain settles (usually 3-6months), a graduated rehabilitation program needs to be given to normalize movement and return patient back to daily living activities. In the case of stenosis (e.g. lateral recess and central canal stenosis) where pain is disabling, decompression surgery may be indicated should conservative rehabilitation (exercises targeting spine & hip flexibility, extension spinal load reduction and lifestyle factors (obesity and sedentary) has failed. lumbar spondylolisthesis grade (1 to 2) can be managed well conservatively.

spondylolisthesis is where one of the bones in your spine, known as a vertebra, slips out of position.

can be caused by:

a birth defect in part of the spine – this can cause it to slip forward
repetitive trauma to the spine – this results in a defect developing in the spine, which can cause it to slip; it's more common in athletes such as gymnasts and weightlifters
the joints of the vertebrae becoming worn and arthritic – this is more common in older people
a sudden injury or trauma to the spine – such as a fracture, which can result in the vertebra slipping forward
a bone abnormality – this can be caused by a tumour, for example

degenerative disc disease: disc desiccation, disc bulge, herniated / slipped disc

Lumbar Spinal Stenosis is a degenerative spinal condition characterized by the narrowing of the lumbar spinal canal due to a variety of bony or soft tissues structures.

Its really important to also know that one's pain experience is not just about the back. Evidence has also shown factors such as poor sleep habits, high stress levels sustained over time, low mood and anxiety are strong predictors of LBP. This highlights the role that lifestyle, negative affections and emotions factors play to sensitize spinal structures via one's body nervous pain system. This maybe clinically evidenced from a patient presenting with LBP, reporting high levels of low back pain, distress and muscle spasms without or little mechanical trigger - a history trauma, overuse, overload (e.g. sports).

Negative LBP beliefs have also been shown to predict chronicity - ongoing pain intensity, disability levels and work absenteeism14 such as having a negative future outlook (e.g. ‘I know it will just get worse’) and believing that ‘hurt equals harm’ and that ‘movements that hurt should be avoided’ because of fear of pain and/or harm.

In the absence of trauma, pain behaviors such as protective muscle guarding, limping, fear, distress and grimacing, can reflect pain catastrophic thinking (e.g. ‘my back is damaged and I am never going to get better’ and ‘I am going to end up in a wheel chair). Such unhelpful pain behaviors can result in unhelpful straining of sensitive spinal structures, causing pain to persist. These behaviors lead to poor coping strategies (i.e. avoidance and excessive rest), leaving the person feeling disabled and helpless.

Rabey M, Smith A, Beales D, Slater H, O'Sullivan P. Differing Psychologically Derived Clusters in People With Chronic Low Back Pain are Associated With Different Multidimensional Profiles. Clin J Pain. 2016 Dec;32(12):1015-1027. doi: 10.1097/AJP.0000000000000363. PMID: 26889613.

Muthuri S, Cooper R, Kuh D, Hardy R. Do the associations of body mass index and waist circumference with back pain change as people age? 32 years of follow-up in a British birth cohort. BMJ Open. 2020 Dec 12;10(12):e039197. doi: 10.1136/bmjopen-2020-039197. PMID: 33310796; PMCID: PMC7735102.

lifestyle factors also contribute to low back pain: 3 main areas, poor sleep (less than 6hrs daily), sedentary lifestyle, activity avoidant behaviors, obesity. All these reduces body immunity and increase inflammatory body markers

Physiotherapists are key healthcare providers for conservative LBP care, being tasked to prevent persistent pain and disability, and facilitating a pathway to wellness and functional restoration.

physiotherapist assessing and performing seated motion and posture and pain palpation examination tests on a patients mid -low back spine

physiotherapist teaching
4point kneeling trunk lumbar flexion stretch with hands and arms on exercise ball

patient in distressing low back pain holding the lower back and hips with hands

BACK PAIN GALLERY

Visual summary managing low back pain & sciatica

Person with low back pain with or without sciatica needs to undertake triage where specific causes of low back pain is excluded: cancer infection trauma inflammatory diseases cauda equinae

Assess likely outcomes: consider use of risk stratification, possible indications for poor outcomes (fear & pain avoidance, low mood job dissatisfaction, ongoing litigation),

Only consider medical imaging in specialist care settings and if likely to alter management

Provide self management infomation; info on nature of pain, encourage to continue activities, exercise, manual therapy, psychotherapy

Managing acute sciatica: neuropathic pain medication (lyrica, pregabalin), epidural injections, spinal decompression'; after acute symptoms of sciatica settles its important to reenter exercise programme to manage low back pain

Consider pain relief options:
NSAIDs, weak opioids

Is how i lift important?
occupational advice for lifting

common myths:
1) there is much more pressure on my discs if i lift with my back bent
2) Im likely to slip a disc if i lift something too heavy with a bent back
3) bracing my core will help keep my back safe when i lift
4) I should keep a straight back and bent knees

The evidence
1) only 4 % difference in pressure on the discs between stoop and squat lift
2) disc related back injuries only account for 10%of back pain at most (and discs dont slip anywhere)
3) There is no good evidence that bracing your core prevents injury when lifting. You brace more when you are in pain
4) There is no high quality evidence to suggest that lifting in this way prevents injury. is it likely more to do with the frequency of lifting, how much you lift and if you are used to it

myths and facts around back pain

facts:
1) back pain is common
2) most work is good for low back pain
3) Bending and slouching are ok
4) the spine is strong and robust
5) strong medications are not helpful
6) exercise is great for backs
7) most back pain gets better
8) scans are rarely needed

facts about the intervertebral discs in the lower back

FACTS
1) LBP is not a serious life-threatening medical condition.
2) Most episodes of LBP improve and LBP does not get worse as we age.
3) A negative mindset, fear-avoidance behaviour, negative recovery expectations, and poor pain coping behaviours are more strongly associated with persistent pain than is tissue damage.
4) Scans do not determine prognosis of the current episode of LBP, the likelihood of future LBP disability, and do not improve LBP clinical outcomes.
5) Graduated exercise and movement in all directions is safe and healthy for the spine.
Spine posture during sitting, standing and lifting does not predict LBP or its persistence.
6) A weak core does not cause LBP, and some people with LBP tend to overtense their ‘core’ muscles. While it is good to keep the trunk muscles strong, it is also helpful to relax them when they aren’t needed.
7) Spine movement and loading is safe and builds structural resilience when it is graded.
7) Pain flare-ups are more related to changes in activity, stress and mood rather than structural damage.
8) Effective care for LBP is relatively cheap and safe. This includes: education that is patient-centred and fosters a positive mindset, and coaching people to optimise their physical and mental health (such as engaging in physical activity and exercise, social activities, healthy sleep habits and body weight, and remaining in employment).

Surprising Facts About Posture… ‘Sit Up Straight’: Time to Re-evaluate – Infographic

1) There is no single correct posture
2) differences in posture are a fact of life
3) posture reflects beliefs and moods
4) It is safe to adopt more comfortable postures
5) the spine is robust and can be trusted
6) Sitting is not dangerous
7) one size doesnt fit all - sitting, postures and lifting techniques

lifting more than 1000 tons annually causes a considerable increase in bone mineral density in lumbar vertebrae

Systematic Literature Review of Imaging Features of Spinal Degeneration in Asymptomatic Populations
W. Brinjikji, P.H. Luetmer, B. Comstock, B.W. Bresnahan, L.E. Chen, R.A. Deyo, S. Halabi, J.A. Turner, A.L. Avins, K. James, J.T. Wald, D.F. Kallmes, J.G. Jarvik
American Journal of Neuroradiology Apr 2015, 36 (4) 811-816; DOI: 10.3174/ajnr.A4173

RESULTS: Thirty-three articles reporting imaging findings for 3110 asymptomatic individuals met our study inclusion criteria. The prevalence of disk degeneration in asymptomatic individuals increased from 37% of 20-year-old individuals to 96% of 80-year-old individuals. Disk bulge prevalence increased from 30% of those 20 years of age to 84% of those 80 years of age. Disk protrusion prevalence increased from 29% of those 20 years of age to 43% of those 80 years of age. The prevalence of annular fissure increased from 19% of those 20 years of age to 29% of those 80 years of age.

CONCLUSIONS: Imaging findings of spine degeneration are present in high proportions of asymptomatic individuals, increasing with age. Many imaging-based degenerative features are likely part of normal aging and unassociated with pain. These imaging findings must be interpreted in the context of the patient's clinical condition.

Chiu CC, Chuang TY, Chang KH, Wu CH, Lin PW, Hsu WY. The probability of spontaneous regression of lumbar herniated disc: a systematic review. Clin Rehabil. 2015 Feb;29(2):184-95. doi: 10.1177/0269215514540919. Epub 2014 Jul 9. PMID: 25009200.

Results: The rate of spontaneous regression was found to be 96% for disc sequestration, 70% for disc extrusion, 41% for disc protrusion, and 13% for disc bulging. The rate of complete resolution of disc herniation was 43% for sequestrated discs and 15% for extruded discs.

Conclusions: Spontaneous regression of herniated disc tissue can occur, and can completely resolve after conservative treatment. Patients with disc extrusion and sequestration had a significantly higher possibility of having spontaneous regression than did those with bulging or protruding discs. Disc sequestration had a significantly higher rate of complete regression than did disc extrusion.

Keywords: Low back pain; disc herniation; probability; regression of hernation; systematic review.

developing positive thinking and mindset change for nontraumatic back pain

1) pain does not damage
2) I can trust my back
3) its safe to bend
4) back pain needs movement and graduated load
4) fun activities are best
5) if it hurts, relax breathe and move normally
6) back pain is not all about scans, lifestyle and work factors are important
7) movement and loading makes back strong and healthy

lke Maurer, Christian Klinger, Roberto Lorbeer, Wolfgang Rathmann, Annette Peters, Christopher L. Schlett, Konstantin Nikolaou, Fabian Bamberg, Mike Notohamiprodjo, Sven S. Walter, Long-term effect of physical inactivity on thoracic and lumbar disc degeneration—an MRI-based analysis of 385 individuals from the general population,
The Spine Journal,
Volume 20, Issue 9,
2020, Pages 1386-1396,

RESULTS
In total, 385 individuals (mean age: 56 years, SD ± 9.19; 58.2% male) were included in this study. Mean summed Pfirrmann score was 2.41 (SD ± 4.19) in the thoracic and 1.78 (SD ± 1.81) in the lumbar spine. The level of current exercise in our cohort varied with 113 (29.4%) subjects exercising regularly ≥2 hours per week, 118 (30.7%) regularly 1 hour per week, 57 (14%) irregularly for about 1 hour per week, and 97 (25.2%) stated not to exercise at exam 3. Disc degeneration was more apparent in those with irregular activity <1 hour compared to those with regular activity of ≥1 hour and more per week (p<.01) and in those with no activity compared to those with regular activity of ≥2 (p<.001) measured using exam 3. Less physical activity over a time period of 14 years correlated with an increase of disc degeneration of the thoracic and lumbar spine after adjustment for age, sex, BMI, hypertension and diabetes mellitus (p<.05). There was no statistically significant association between physical labor, walking activity, or cycling activity with disc degeneration. Additionally, no significant correlations between degree of disc degeneration (p=.990), degree of physical inactivity (p=.158), and back pain were observed.

CONCLUSION
Degree of physical inactivity as measured over a time period of 14 years demonstrated a strong correlation with disc degeneration of the thoracic and lumbar spine.

How much physical activity do adults need?

Physical activity is anything that gets your body moving. Each week adults need 150 minutes of moderate-intensity physical activity and 2 days of muscle strengthening activity

Example 1
Icon: Walking
Moderate-intensity aerobic activity

(such as brisk walking) for 150 minutes every week (for example, 30 minutes a day, 5 days a week)

AND

Icon: Weight Lifting
Muscle-strengthening activities

on 2 or more days a week that work all major muscle groups (legs, hips, back, abdomen, chest, shoulders, and arms).

Example 2
Icon: Running
Vigorous-intensity aerobic activity

(such as jogging or running) for 75 minutes (1 hour and 15 minutes) every week

AND

Icon: Weight Lifting
Muscle-strengthening activities

on 2 or more days a week that work all major muscle groups (legs, hips, back, abdomen, chest, shoulders, and arms).

3) Example 3
Icons: A combination of walking and running
An equivalent mix of moderate- and vigorous-intensity aerobic activity

on 2 or more days a week

AND

Icon: Weight Lifting
Muscle-strengthening activities

on 2 or more days a week that work all major muscle groups (legs, hips, back, abdomen, chest, shoulders, and arms).

Tataryn N, Simas V, Catterall T, Furness J, Keogh JWL. Posterior-Chain Resistance Training Compared to General Exercise and Walking Programmes for the Treatment of Chronic Low Back Pain in the General Population: A Systematic Review and Meta-Analysis. Sports Med Open. 2021 Mar 8;7(1):17. doi: 10.1186/s40798-021-00306-w. PMID: 33683497; PMCID: PMC7940464.

Background: While chronic exercise training has been demonstrated to be an effective non-pharmacological treatment for chronic low back pain (CLBP), there has been a relative lack of evidence or clinical guidelines for whether a posterior chain resistance training programme provides any benefits over general exercise (GE).

Objectives: To determine if chronic posterior chain resistance training (PCRT), defined as exercise programmes of ≥6 weeks duration focused on the thoracic, lumbar and hip extensor musculature, is more effective than GE in improving pain, level of disability, muscular strength and the number of adverse events in recreationally active and sedentary individuals with CLBP.

Conclusion: Results of the meta-analysis indicated that 12-16 weeks of PCRT had a statistically significantly greater effect than GE on pain, level of disability and muscular strength, with no significant difference in the number of adverse events for recreationally active and sedentary patients with CLBP. Clinicians should strongly consider utilizing PCRT interventions for 12-16 weeks with patients with CLBP to maximize their improvements in pain, disability and muscle strength. Future research should focus on comparing the efficacy and adverse events associated with specific PCRT exercise training and movement patterns (i.e. deadlift, hip lift) in treating this population.

Keywords: Aerobic training; Chronic low back pain; Deadlift; Pain; Posterior chain; Resistance training.

Gellhorn AC, Katz JN, Suri P. Osteoarthritis of the spine: the facet joints. Nat Rev Rheumatol. 2013 Apr;9(4):216-24. doi: 10.1038/nrrheum.2012.199. Epub 2012 Nov 13. PMID: 23147891; PMCID: PMC4012322.

FREQUENTLY ASKED QUESTIONS

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Low back pain and sciatica in over 16s: assessment and management, National Institute for Health and Care Excellence, Nov 2016, https://www.nice.org.uk/guidance/ng59. [PubMed]
Maher C, Underwood M, Buchbinder R, Non-specific low back pain, Lancet 2017 Feb 18;389(10070):736-747. doi: 10.1016/S0140-6736(16)30970-9. [PubMed]
Hartvigsen J, Hancock M, Kongsted A, et al., What low back pain is and why we need to pay attention. Lancet 2018 Jun 9;391(10137):2356-2367. [PubMed]
Lin I, Waller R, Wiles L, et al., What does best practice care for musculoskeletal pain look like? Eleven consistent recommendations from high quality clinical practice guidelines: systematic review, BJSM, 2019, Mar 2: doi: 10.1136/bjsports-2018-099878. [PubMed]
Saragiotto BT, Machado GC, Ferreira ML, Pinheiro MB, Abdel Shaheed C, Maher CG. Paracetamol for low back pain. Cochrane Database Syst Rev. 2016 Jun 7(6):CD012230. PMID: 27271789. doi: 10.1002/14651858.CD012230. [PubMed]
Machado GC, Maher CG, Ferreira PH, Day RO, Pinheiro MB, Ferreira ML. Non-steroidal anti-inflammatory drugs for spinal pain: a systematic review and meta-analysis. Ann Rheum Dis. 2017 Jul;76(7):1269-78. PMID: 28153830. doi: 10.1136/annrheumdis-2016-210597. [PubMed]
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