Sunday, February 19, 2012

Managing Low Back Pain with Exercise

Low back pain(LBP) is major health care problem- 80% of the population will suffer from it at some point, it is the second most common symptomatic reason for doctor visits, it is a major cause of work absence. Treatment though is often ineffective, and the recurrence rate is high. Both the incidence and cost of LBP are increasing. Here is an approach to treatment based on my professional and personal experience.

First a disclaimer: I am not a medical authority, and this article should not be construed as medical advice. This general information may not be applicable in an individual case. I am a personal trainer and massage therapist, not a physician.

Reconsidering Back Pain
The traditional way of thinking about pain is that the body gets injured, and the injured spot sends a signal to the brain which we call "pain." (That misleading red "X" in television commercials.) This is certainly often true, however a more nuanced explanation of pain is developing in medicine. The important point for this discussion is this: Pain is a mental phenomenon which may not be caused by physical damage or pathology. That doesn't mean the pain isn't real or unimportant, but that treatment needs to address this aspect.
"Pain can be "learned" in the nervous system so that it is maintained independent of injury, pathology, expectations, or dysfunction. Such pain is called neuropathic and is an important under-recognized  dimension of the chronic problem.
"Neuropathic pain is centrally maintained and therefore does not require peripheral sources of painful irritation or injury." p.296
Chronic LBP seems particularly likely to be neuropathic. Given this, the treatment, after any acute phase of injury and ruling out of other pathology, should be pain management. Rather than "curing" a presumed source of pain, which may no longer exist, functional improvement and reduction in sensitivity may be more realistic.

Note that although pain may begin with a particular event, it is often is the result of a long term problem:
"The most common cause for persistent pain is when external load repeatedly exceeds physical-capacity or tolerance. This is typically caused by deconditioning or lack of fitness, NOT injury or structural pathology." p.299(see References below)
A common perception is suddenly "throwing your back out" but the sudden pain may very likely be from accumulated stress and dysfunction, and the particular moment of injury represents both new trauma and a trigger of a pre-existing condition.

Passive forms of treatment such as medication, massage, and some physical therapy treatments may offer short-term symptom relief and enable resuming simple activities. However, long-term they can create dependency without addressing the cause of LBP susceptibility.

My Personal Experience
About 6 years ago, I had a severe period of low back pain brought on by lifting a large person doing Thai massage. For weeks the pain was excruciating. The best example is that it would take me several minutes to get in and out of my car because bending hurt so much. Pain persisted for months, and I learned a lot of sympathy for my clients. I'm still very aware of the area where the pain was felt, and apprehensive of its return. I have learned though that this does not need to stop me from very vigorous activity. My condition has steadily improved, with minor flare-ups, despite doing far more strenuous exercise than when the condition began.

LBP and Exercise
Perhaps the most fundamental way to influence the body is through deliberate movement. Exercise and other physical activities can be very beneficial for LBP rehabilitation and prevention.  Unfortunately, both personal and medical opinion is often quite different:
"When patients are in pain, they typically worry that they will cause more harm than  good if they are active. Physicians typically prescribe overly restrictive activity restrictions, which are responsible for interfering with the recovery process and promoting chronic pain behavior.
Frequently, advice to "let pain be your guide" is given, which only reinforces attitudes and beliefs that foster pain-avoidance behavior and deconditioning." p. 296
After the onset of pain(acute phase), and receiving medical clearance if the pain is not diminishing(reread the disclaimer above), begin by simply moving more, particularly with walking and other activities of daily life(ADL). AVOID BED REST OR PROLONGED SITTING. Remember pain can be very misleading and not indicative of actual tissue damage. At first, moving at all may seem impossible, yet many find that after starting the pain diminishes. Slowly introduce progressively more challenging movement and exercise. Be cautious, but don't fear catastrophe. The benefits include:
  • improving healing by increasing circulation
  • improving mobility
  • improving stability
  • learning good movement skills and posture
  • building strength at both moving and resisting unwanted movement
  • release of pain mitigating endorphins
  • support from others when exercising in groups
There are specific exercises and practices that may help manage and prevent LBP- from "bird dogs" and planks to deadlifts. A second post will describe some of them. Consultation with a skilled physical therapist or personal trainer is suggested, although learning the basic exercises on your own is possible. Yoga, Feldenkrais, and other methods can be very helpful, being sure that your teacher is knowledgeable about back care. Almost any movement program will be superior to becoming more sedentary, although a program including strength training is recommended. (Note this study comparing weight lifting to cardio: Use Weights, Not Aerobics, To Ease Back Pain, Study Suggests)

Update 5/1/12: My follow-up article Exercises for Low Back Pain is now available.

Long Term LBP Management
While increasing strength and mobility have direct physical benefits for LBP rehabilitation and prevention, it is the psychological aspect of safely controlling the body I believe is critical to successful management of LBP. Back pain tends to create a sense of loss of control over the body; exercise is a way to "take charge" and, literally and figuratively, empower yourself. Rather than the too common fear of reinjury, confidence in one's body improves, which in itself can lessen the likelihood and severity of future pain episodes.

(This sense of empowerment from exercise is an often unappreciated benefit of exercise available to everyone, and it is much more pronounced with weight training than other forms of exercise.)

In the immediate period after the onset of pain, a drastic change in movement is inevitable. The pain and attendant muscle spasms both restrict movement and create new, dysfunctional movement patterns. Not allowing these new movements to become ingrained is paramount. For recovery, maintaining quality of life, and decreasing the probability and severity of future pain episodes, active movement and strength training is highly recommended.)

A major influence on my thinking about low back pain is the book "Rehabilitation of the Spine: A Practitioner's Manual" by Dr. Craig Liebenson. See  (Dr. Liebenson was not involved in writing this article.)

The italicized quotes above are from this book.

Also invaluable for understanding LBP are the works of Pr. Stuart McGilll. Professor McGill is one of the foremost researchers of low spine injury and treatment.

Copied with permission from the excellent article Low Back Pain - A Contemporary Healthcare Crisis by Dr. Shawn Thistle, Nov. 2011, is this summary of Clinical Practice Guidelines (CPGs). The article is written for medical professionals, but is informative for anyone.

Ten Clinical Practice Guidelines (CPGs) have been published in various countries around the world in the last 10 years or so. CPGs are developed to synthesize the best available evidence and make recommendations regarding the assessment and management of a clinical condition. There are some big brains involved in putting these together – high-level researchers, clinicians and experts – people we should listen to. There is a high level of consistency among these ten CPGs and their methodological quality is high as a collective. Experts suggest one of the major deficits in current management patterns for LBP is a lack of uptake of CPG recommendations. I agree, and this pattern must change!

Taken together, some common general recommendations and guidelines consistently emerge which all health care providers should keep in mind for LBP, regardless of professional background (3, 17):

Assessment & Triage of LBP:
  • Diagnostic Triage: In general, LBP patients can be effectively divided into two broad categories – nonspecific (majority), and specific (small minority). Other guidelines further differentiate into nonspecific, radicular, or serious pathology.
  • The main goal in assessing LBP patients is to rule out potentially harmful spinal pathology even though only about 1% of patients will have such a condition (the small minority mentioned above). Common red flags are discussed across CPGs and include age greater than 50, history of cancer, cauda equina symptoms, urinary retention, history of steroid use, unexplained weight loss, night pain, and so on. In these rare cases, advanced imaging and further clinical work up is clearly required. For the remaining 99%, a thorough history and appropriate physical examination should suffice and preclude the need for imaging or specialist involvement.
  • A second goal is to rule out rare but specific causes of LBP other than serious spinal pathology. This refers to such conditions as Ankylosing Spondylitis, kidney pathology, etc.
  • Substantial neurological involvement should also be evaluated. This can be done primarily via thorough history and physical examination. Routine imaging is not recommended unless patients fail to respond to conservative care. This is one recommendation rarely followed by many health care providers.
  • Pain severity and functional limitations should also be addressed. No consensus exists among the CPGs regarding which questionnaires should be utilized for these aspects.
  • Practitioners in all disciplines should also evaluate the risk of chronicity, as this small percentage of patients account for a disproportionate amount of health care spending. These are biopsychosocial factors such as anxiety, depression, work dissatisfaction etc.
Management of LBP:
  • Acute LBP: Advise patients to stay active (another one that is often ignored!), reassure them and provide education about LBP; employ a short course of paracetamol/acetaminophen or NSAIDs; spinal manipulation; NO bed rest
  • Chronic LBP: Provide advice to stay active, some form of exercise (no consensus), perhaps weak opioid medications or NSAIDs (preferably), spinal manipulation. No CPGs recommend bed rest, decompression surgery, back supports, biofeedback, heat/cold, traction or ultrasound. Recommended secondary interventions include cognitive behavioral therapy, multidisciplinary rehabilitation and adjunctive analgesics.
  • LBP with substantial neurological involvement: Advise patients to stay active, reassure them and provide education about LBP; employ a short course of paracetamol/acetaminophen or NSAIDs +/- muscle relaxants; spinal manipulation; NO bed rest. Back exercises, acupuncture and massage may also help. No CPGs recommended back supports, traction, heat/cold or ultrasound. Recommended secondary interventions include multidisciplinary rehabilitation, behavioral therapy, stronger analgesics, steroid injections or decompression surgery in appropriate cases.
  • No CPG has stated that it is necessary, or even beneficial, to identify a specific anatomical structure involved in LBP if serious pathology or neurological involvement has been adequately ruled out.
  • It has also been consistently suggested that ordering needless diagnostic tests may INCREASE the chance of chronicity. Patients and practitioners should understand that in many cases of LBP, assessment is a more feasible objective than diagnosis, as a specific pain-generating structure can rarely be definitively identified.
  • All CPGs clearly state that most cases of acute LBP improve substantially within a few weeks and recommend against early imaging and aggressive treatment regimens.
  • Practitioners should ensure patients focus on function rather than pain, and all attempts should be made to maintain active working status.
Overall, management of LBP should focus mostly on patient education, with short-term use of paracetamol/acetaminophen, NSAIDs, or SMT for symptomatic relief of acute LBP, with the judicious addition of opioid analgesics, back exercises, behavioural therapy, or acupuncture for additional symptomatic relief for chronic LBP. It is well documented that adherence to these recommendations leads to superior patient outcomes and lower costs. However, an equal amount of literature indicates primary care physicians, chiropractors, physiotherapists and medical specialists routinely fail to comply with these simple recommendations (8, 9). A combination of professional bias, inappropriate patient expectations, and perverse financial incentives may contribute to over-aggressive management.

Most concerning is the overuse of advanced imaging, opioid prescribing and passive physical therapy modalities or manual techniques (10). Further, many physicians still recommend bed rest and feel return to work should not occur until full pain resolution is achieved (11), despite ample evidence that these approaches are harmful for LBP patients! Again, we as a healthcare collective must consciously act for the benefit of our patients. This cannot wait. 

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  9. Deyo RA. Commentary: Managing patients with low back pain: Putting money where our mouths are not.  Spine Journal 2011; 11: 633-635.
  10. Carey TS, Freburger JK, Holmes GM, et al. A long way to go: practice patterns and evidence in chronic low back pain care. Spine 2009; 34: 718-24.
  11. Buchbinder R, Staples M, Jolley D. Doctors with a special interest in back pain have poorer knowledge about how to treat back pain. Spine 2009; 34: 1218-26.
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