Low Back Pain: Should I worry? What you need to know

Don’t Worry

You are not alone, low back pain (LBP) is as common as going to the movies ~57-84% of individuals (depending on which country you’re from) go through LBP at some point in their life. Typically, most LBP completely subsides following 6-8 weeks and in many instances much quicker. Importantly, over this period of weeks the intensity of one’s pain subsides too (so it’s not the same as an on/off switch).

Is my LBP serious?

LBP is rarely serious with <1% of patients presenting with a true red flag indicating a specific definable pathology and requiring further referral. Of those presenting with non-specific LBP a full assessment will offer insights into why an injury may have occurred and how we might best treat and manage a presentation so as to lower the risk of future incidents based on what activities a patient wishes to return to. More on Radicular Syndromes later.

Do I need a Scan?

Scans are seldom required for those with LBP. The results of MRIs, CTs and X-rays often show frightening findings that can be mistakenly attributed to why someone is experiencing pain (this is known as the correlation versus association phenomenon). For example, a 50year old male whom is cleared of any red flags, neurological signs and any referred symptoms may have scans depicting “degenerative disc changes”. Now, it may be tempting to attribute these findings to the cause of their LBP however, as shown below disk degeneration (amongst several other findings) is normal in the low backs of individuals without LBP across several age groups.

(Brinjiki et al., 2015).

On the rare occasion when a scan is indicated, this will only be in cases where imaging is likely to change the course of treatment or to rule out anything more serious if there is clinical suspicion. This is where a physio can help guide you.

If it sounds too good to be true or a healthcare providers asserts that they and only they can “fix” you LBP then find another healthcare provider, here’s why

Most newly acquired pain (due to an injury) generally subsides within 12weeks at the most and this will depend on the severity of an injury. This is known because of our understandings of tissue healing phases and timelines (Kumar, Abbas & Aster, 2015). Differentially, when a person’s pain persists beyond this period the emphasis placed on biological origins of pain (i.e. damaged tissue) shifts somewhat towards psychosocial factors. In these cases clinicians become more suspicious of psychosocial factors sensitising the nervous system (i.e. the brain) erroneously to produce pain as a protective mechanism in reaction to more of a perceived threat. To clarify, all pain is real and an output produced by the brain based on incoming information from several sensory sources. These sources can include damaged tissue, visual, auditory and hearing inputs as well as memories, conscious thoughts and beliefs. This may sound airy-fairy but in persistent pain cases where a person typically becomes more and more worried about their pain this fear only gives more credence to a threat’s validity as well as a patient’s belief that particular movements are bad for their back. 

Depending on how and when a patient presents it may be more or less appropriate to confront painful movements, as a means of re-emphasising to the nervous system that certain movement are safe. Education plays a key part role in desensitising pain mechanisms but active involvement or exercise does so much immense good in these cases. Since, the nervous system remembers traumatic events it needs to be shown what is safe. Seeing is believing.

Food for thought

Consider the schematic below. The upper image shows block A and B appearing to be different shades of grey because of our perception of shadow cast by the green cylinder. However, the lower image proves that block A and B are actually the same shade and that our senses have been tricked. In a similar way it is not such a huge leap to ponder whether our brains might be producing pain mistakenly based on information it has at hand especially in persistent cases when we know that tissues have likely healed.

Can hands-on or manual therapies fix my injury?

Manual therapies or passive treatments are aimed at modulating pain, reducing swelling, improving range of movement and facilitating movement via various trained and skilled techniques. Traditionally, it was thought that manual therapies could achieve these aims by altering a person’s anatomical structures however recent evidence points towards manual therapies evoking complex neurophysiological mechanisms in order to achieve these aims. To give this some context, recall that pain is an output produced by the brain. Accordingly, providing a range of differing stimuli via manual therapies may be beneficial in lowering our brain’s perception of a perceived threat. Additionally, manual therapies have been shown to induce pain-relieving responses whereby the nervous system produces and releases chemicals that provide pain relief. This is not to say that manual therapy is a trick but it certainly does not work in the way we used to think. However, this is why manual therapies generally only provide short-term pain relief and aren’t a fix.

Don’t throw the baby out with the bathwater. The Case for Manual Therapy in specific presentations

For individuals who present with referred symptoms down 1 leg along with altered neurological signs and symptoms and pain, nerve mobilising has shown to provide some benefit. When a patient presents with Radiculopathy and Radicular Pain (previously termed Sciatica) this is very likely associated with nerve root compression from an injured disc leading to inflammation, swelling, pain and increased nerve sensitivity. In these cases the Sciatic nerve can become somewhat impaired in it’s normal function, which is why movements can become sensitised and why a person may experience decreased sensation and muscle weakness. Neural mobilising is theorised to favourably alter the abnormal fluid pressures/volumes within a nerve caused by the abovementioned swelling and thus restore its function and reduce pain and sensitivity. To date multiple systematic reviews have failed to show whether neural mobilising is effective however this may be due to these reviews only having access to poor quality studies and because treatment models in these investigations were inconsistent. Promisingly though, a very high quality 2020 study examining the application of nerve mobilisation in addition to motor control exercises determined that in adult populations who had experienced lumbar radiculopathy for 3months or more (associated with confirmed disc herniation between L4-S1 on MRI) the addition of neural mobilisations provided clinically significant differences in impairment measurements and nerve function signs and symptoms following 4 and 8 treatments compared to motor control exercises alone (Plaza-Manzano et al., 2020).

(Plaza-Manzano et al., 2020).

Where does exercise fit in?

As hinted to above pain can be subdivided into new onsets (more likely biological causal leaning) and persistent pain (more psychosocial leaning) based on the timeline of a person’ symptoms. Depending on where a person falls on this timeline guidelines change slightly but what is clear is that staying active is a key treatment in all LBP presentations. Additionally, the use of education is also recommended whilst medication use is generally discouraged (Oliveira et al., 2018).

Exercise Specificity

Exercise prescription specificity depends on the goal of the patient. Goals may vary from simply reducing symptoms to returning to garden work or, to returning to competitive powerlifting. A systematic review by Gordon and Bloxham (2016) determined that no one exercise programme was more beneficial than another in treating the unpleasant sensation itself in persistent LBP cases while, in new pain cases patients generally improved regardless of exercise prescription. These findings point to the natural and resilient healing abilities of our body. However, what this review does not outline is that exercise is the only treatment that de-threatens movement and restores one’s confidence in returning to meaningful activities. This is why absolute rest is never indicated. Exercise like manual therapy also has been shown to induce pain-relieving responses whereby the nervous system produces and releases chemicals that provide pain relief too. Ultimately, clinicians and patients need to determine whether pain relief is the only goal or if a person wants to return to more meaningful activities, in which case it would be worthwhile to consider other factors in reducing the risk of re-injury.

References 

Brinjikji, W., Luetmer, P., Comstock, B., Bresnahan, B., Chen, L., Deyo, R., Halabi, S., Turner, J., Avins, A., James, K., Wald, J., Kallmes, D., & Jarvik, J. (2014). Systematic literature review of imaging features of spinal degeneration in asymptomatic populations. American Journal of Neuroradiology, 36(4), 811-816. https://doi.org/10.3174/ajnr.a4173

Gordon, R., & Bloxham, S. (2016). A systematic review of the effects of exercise and physical activity on non-specific chronic low back pain. Healthcare, 4(2), 22. https://doi.org/10.3390/healthcare4020022

Kumar, V., Abbas, A. K., & Aster, J. C. (2015). Robbins and Cotran pathologic basis of disease (9th ed.). Saunders.

Oliveira, C.B., Maher, C.G., Pinto, R.Z. et al. Clinical practice guidelines for the management of non-specific low back pain in primary care: an updated overview. Eur Spine J 27, 2791–2803 (2018). https://doi.org/10.1007/s00586-018-5673-2

 Plaza-Manzano, G., Cancela-Cilleruelo, I., Fernández-de-las-Peñas, C., Cleland, J. A., Arias-Buría, J. L., Thoomes-de-Graaf, M., & Ortega-Santiago, R. (2020). Effects of adding a Neurodynamic mobilization to motor control training in patients with lumbar Radiculopathy due to disc Herniation. American Journal of Physical Medicine & Rehabilitation, 99(2), 124-132. https://doi.org/10.1097/phm.0000000000001295