FEEL GOOD PHYSIO CO. 

CHRONIC LOWER BACK PAIN:

The Ultimate Guide

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Chronic Lower Back Pain is one of the most common things I treat as a physio, but despite it’s prevalence there is still so much misinformation out there (looking at you Dr. Google…..). This makes an already confusing condition even more murky. Well, this article will clarify the mysteries around lower back pain and provide you with the confidence to push-through this condition. Now this is a fairly long read, but feel free to read through it at your own leisure because trust me, there is some good stuff in here!

 

 

WHAT IS LOWER BACK PAIN?

Let’s get back to the basics (pun definitely intended!), Lower Back Pain is obviously a pain in the lower back, but you didn’t come here to find that out! Despite its prevalence, there remains a lot of misinformation about lower back pain. The back in general is thought to be a weak and vulnerable structure, and we are so often told not to bend or lift or twist it! The spine itself is a strong and versatile pillar of support and provides a strong, flexible foundation for movement! I hope that by reading this post, that you get a better appreciation of the back, but most importantly, I hope it provides you with a greater level of confidence in your back!

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WHAT DOES NON-SPECIFIC LOWER BACK PAIN MEAN?

Lower Back Pain is a very common condition we see as physios, in fact Chronic Non-Specific Lower Back Pain affects 16% of the Australia population (Owen et al. 2021). This is the million-dollar question and one with an ever-changing answer. The current consensus is that it’s near impossible to implicate a particular anatomical structure as a source of pain. But we rather, refer to back pain such as this as ‘Non-Specific Low Back Pain’ (NSLBP). NSLBP is defined as low back pain which is not attributable to a recognizable, known specific pathology (eg, infection, tumour, osteoporosis, lumbar spine fracture, structural deformity, inflammatory disorder, radicular syndrome, or caudal equine syndrome.

Now while Non-Specific Lower Back Pain might sound like a simple definition, it clarifies and refines an otherwise murky subject. It streamlines our diagnoses as well as our treatment. Why? Well in the absence of trauma or the previously mentioned issues, we do not get too worried about exactly what structures are causing the pain. Sounds harsh right? The reason we do not get too fussed is that it doesn’t change our treatment. Our goal is to relieve our patients of pain and return them to the activities they love. We also know that pain (in NSLBP) is not a sign of damage, therefore, it is safe to work into pain (with the guidance of a health practitioner!), without the risk of long-term impairment.

A LITTLE BIT ABOUT THE BACK

Our backs and in particular, our spines are an impressive, complex, strong, and flexible masterpiece in design. Here’s a basic rundown of the anatomy of the Lumbar Spine (Lower Back). The lumbar spine is made up of 5 vertebrae (the bones of our spine) L1-L5, intervertebral discs (shock absorbers between the vertebrae) as well as muscles and ligaments galore. All this combined provides us with a structure that is designed to do work!

Our Lumbar vertebrae are the larger vertebrae of our spine and are a designed to support the loads of our body. Vertebrae (like the one above) are composed of a vertebral body (1), vertebral arch (2), a spinous process (3), two transverse processes (4) and two facet joints (5). Additionally, we have the notorious Intervertebral Discs (6). Now I say notorious because the discs get a poor wrap, people tend to believe that our discs are weak and vulnerable structures which is simply not true! They are designed to do work and will naturally show signs of ‘degeneration’ on imaging in most people over the age of 20 or so. But this is completely normal and is usually not a source of pain. Our intervertebral discs are an amazingly strong structure and allow our spines to do the things we put it through. They are made up of two main components:

–          The annulus fibrosis – the outer section of our disc, which is made up of concentric rings of cartilage (think of it like a truck tyre!). This make-up allows it to take and distribute load between the vertebrae.

–          The Nucleus Pulposus – This is the inner section of the disc. It has been described as something along the lines of a bunch of chewed chewing gum (but stronger!). Again, this allows load distribution between the vertebrae.

Arguably the most important component of our spine and the section that our spine is equipped to protect, is the spinal cord. This structure runs from our brainstem and terminates in our lumbar spine, and on it’s journey it gives off nerve roots at each vertebral connection. These are the pathways from which we send and receive messages between the brain and body, this allows us to perceive and interact with our world.

 

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DO I NEED TO GET A SCAN IF I’ve GOT LOWER BACK PAIN?

To scan or not to scan? That is the question. In most cases of back pain scans are not warranted unless of course there has been significant trauma, or we’re suspecting something sinister. Otherwise, they often tell us things we don’t need to know! Most scans will always show some stuff, but this stuff is common and a normal part of ageing and loading our spines, just like wrinkles or grey hair. Studies have shown that people can have things such as bulging discs, degeneration, disc protrusions and not have pain at all.

The issue with getting scans is often the after-effect of doing so. It is so common that we see patients who have already had scans, and therefore having had some findings on there have ended up getting injections, trying medication and sometimes even surgery. Now sometimes, these options are warranted, but, not before we have tried more conservative, movement-based treatments.

 

 

SO WHAT CAUSES LOWER BACK PAIN?

As previously mentioned most causes of lower back pain are insidious, meaning they lack a definitive cause. Typically, lower back pain is a result of overloaded tissues meaning our brains then register this as a threat and we get pain and spasm. Now this is not always the situation, I mean people often report that their back went following a heavy lift or twisting awkwardly, but even still this action is often the final straw of a period of overload. Research has shown that our discs, bones and joints in our back do not “slip” or “come out of place”. Not only are the terms inaccurate, but they make our spines sound quite fragile and therefore can create fear of movement. This is where some health professionals will suck their patients in, by telling them that they are moving them back into alignment, which also creates a dependence on their treatment. We should be wanting to give you the power over your body!! We want to get you actually doing the thing we know will get you better, which is graded exercise and movement. The snaps, crackles and pops you may feel during these treatments, might feel good, but it is not actually “fixing” anything. Most hands-on treatment purely desensitises our nervous system, meaning that our brain does not attribute as much pain to the area. So hands-on treatment definitely has a place in therapy, but we need to use it as a tool and not as a solution.

WHAT IS CHRONIC LOWER BACK PAIN?

Acute vs. Chronic Lower Back Pain

Non-specific lower back pain is often sorted into 3 sub-categories based on duration of symptoms: acute, sub-acute and chronic non-specific lower back pain.

–          Acute is pain that has been present for less than 6 weeks. Approximately 95% of acute cases of low back pain in Australia are non-specific (Low et al. 2006).

–          Sub-Acute is between 6-12 weeks. 

–          Chronic Lower Back Pain is a pain that has been present for more than 12 weeks.

Chronic lower back pain does not always have to mean a continuous bout of lower back pain over 3 months, but can be similar to health conditions like migraine, asthma and depression, where there is a recurrent pattern of it coming and going. We know that even in cases of acute pain, that the brain’s response can be exaggerated and not completely reflective of what’s going on at a tissue level. As pain persists, this mismatch gets sloppier, meaning that we can get high levels of pain with minimal or no tissue irritation at all.

WHY DOES LOWER BACK PAIN BECOME CHRONIC? 

This is a huge, complex topic but here is the answer in a nutshell. The creation of pain in our bodies is an intricate process and is not a purely physical experience. In the early stages of an injury pain is a protective mechanism and encourages our body to rest. However, as tissues begin to heal, the pain should decrease too. However, as I said the presentation of pain is not purely physical, there is a psychological component behind it as well. Meaning that pain can not exist without our brain. Now this doesn’t mean that pain is imaginary, pain is created by our brain not our minds. We don’t actually have “pain receptors” in our body, we do have many other receptors though which send signals to our brain. So when we receive these messages from our body, they are interpreted by our brain and are mixed with a decision making process which includes other information such as this: 

    • previous experience with this injury, 
    • your beliefs and perceptions around pain, 
    • the incident related to this injury, 
    • Physical and mental stress, 
    • Sleep, hydration and dietary quality
    • Just to name a few! 

These factors are all considered and our brain decides whether it is under threat or not, and if it does then we get pain. Knowing that pain is complex explains why pain can become chronic. If our brain becomes overprotective due to these other factors, there is a chance that this almost becomes an ingrained behaviour, which persists long beyond the point of healing. Lower back pain is a classic case of this, as there is so much negative information leading people to believe that our backs are fragile and pain is evil. This can really increase the chance that our brain will become a tad too protective!! Now this does not mean that the pain is imaginary at all, but it does reflect how powerful our brains are in the process of pain. 

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HOW LONG DOES IT TAKE FOR CHRONIC LOWER BACK PAIN TO HEAL? 

Again another complex question, but the answer is simple…….. and not one that you’ll like! It will take as long as it takes, and this is because of the complexity of pain itself! We can’t just treat chronic back pain at a physical level, and if you’re reading this you’ve probably experienced this yourself. You’ve most likely tried massage, physio, Chiro, acupuncture, seemingly everything under the sun! It may have provided some short term relief, but the pain just comes back…. This is because we have not addressed the full picture of pain. To properly treat chronic pain we have to de-threaten or desensitise the brain, once we can reduce how protective the brain is too movement, then we get pain-free living!! This process can take months, but by slowly increasing how much you can do and reducing the amount of pain felt, we eliminate the pain.

TREATMENT FOR CHRONIC LOWER BACK PAIN

It can be hard to know what to do when you’ve tried what seems like everything. But here are some principles that I follow with lower back pain relief:

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REST IS NOT ALWAYS BEST

While it might seem tempting to lay in bed or sit down all day, this does not really help with chronic back pain, in fact, it can actually make things worse sometimes. Our bodies, including our backs, love to move. Those who continue to move even when in pain tend to do better in the long-run. Not only does movement ultimately help with pain relief, but by remaining in bed or on the couch, we’re only reinforcing the fear of movement. Think of it similar to a rolled ankle, pain and a limp are normal. It encourages us to off-load the injured ankle, but then after a few days we want to get cracking! Of course there is a happy-medium, we don’t want to over-do-it and end up with a flare-up, but we do want to achieve a healthy level of movement. Bearing in mind the principle that pain does not equal damage. Therefore, it is safe to move into pain, in the worst case scenario it may cause a flare-up which is essentially an over-protective reaction from the brain.

 

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THE SHOW MUST GO ON!

Similar to the last point, but we know that those who get back into their activities, jobs, sport etc do better in the long-run. This is due to multiple reasons, the first of which is movement is medicine, we want to get our backs and bodies moving. Secondly, by getting back into your usual activities, we leap over that mental hurdle. It is common, as a physio to see a patient who has avoided work or exercise etc. for a while, only for that return to activity to become an increasingly larger mountain. This also creates a snowball effect. As we discussed earlier, pain is influenced by stress and other psychological factors. So when we see someone who has not been able to work, not been able to provide, this obviously creates a higher level of stress, which compounds the whole pain presentation. So as soon as we can, we want to get you back into life as normal!

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SHOULD YOU USE HEAT OR ICE FOR LOWER BACK PAIN?

I’m sure you’ve already tried researching or you’ve been told a million different do’s and don’ts for lower back pain treatment. But, at the end of the day there is no silver-bullet when it comes to pain relief. There are a lot of gimmick treatments out there, and the stance I usually take is this – if it causes you no harm then try it. Ice works for some, just as heat works for others neither will cause a deterioration of your physical tissue (unless you go absolutely over-board!). This is the same for any hands-on treatment as well, like previously mentioned most treatment works purely in the way of desensitising tissues or what we call neuromodulation. This literally means that the brain and nervous system will be “turned down” and therefore not as likely to produce pain. All this allows us to do is facilitate pain-free (or less pain at least) during movement, which is ultimately the key to success!

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EAT WELL, SLEEP well, hydrate well, REPEAT And all that other good stuff too

We know that pain is driven by more than purely physical factors. It is super important to make sure the rest of our ducks are in a row. If we are not sleeping, eating, hydrating and all the other healthy things properly, then our brains are going to perceive a greater level of stress. If our brains perceive more stress, then it lowers the threshold for producing pain. Now this sounds simpler than it is, obviously with chronic lower back pain, sleeping can be disturbed which can throw a lot of other health practices out of whack, but by attempting to keep everything else in check, can go a long way to reducing your overall pain.

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KNOWLEDGE IS POWER

We know that the more you understand pain, the better you are going to be able to manage it. Or to use a sporting analogy, you have to study the opposition, how do you expect to win if you don’t even have a game plan?! Once we understand that in pain is not equal to damage then we are able to start making in-roads into recovery. Resources such as this article are crucial in shaping the way you perceive pain. But knowing it is one thing, getting our brains on board is another! Pain is created in our brains, not our minds and we know our brains can be quite difficult to boss around!

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What are the best exercises for LOWER BACK PAIN

Now at the risk of sounding like a broken record …… movement is medicine! (I think you’re starting to see a trend now!). But, in all seriousness exercise is crucial in the treatment of chronic lower back pain. When we have long-term bouts of pain it is normal to get de-conditioning in the affected tissues. This obviously means that these tissues are now less efficient at tolerating loads, meaning they are more likely to get sore and angry! It may sound counter-intuitive, but people who under-load their backs are probably more likely to get back pain. Think about it, if we don’t regularly run but then attempt a marathon, chances are we’d get injured. Our backs are the exact same! When it comes to exercise, it is best to do it under the guidance of a health professional, purely because we want to gradually expose your back to these loads. Not in the fear of injury, but we want to avoid flare-ups. Overtime, we expect to see an increase in exercise tolerance and a decrease in the pain response. This is because we are acting at both a physical and mental level. Like we chatted about before, we need to desensitise the brain and nervous systems response to movement. Now on this topic, there is no such thing as the “best” exercise for chronic lower back pain. This is despite all the Instagram fitness experts out there! But, the best exercise for your back is the exercises that you can consistently repeat over time. Here are a few examples.

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MYTH-BUSTING TIME

I’m going to get on my soap-box here – The following are a list of bugbears of mine that I couldn’t really fit in to the article but are important nevertheless!

 

THERE’S NO SUCH THING AS A “BAD BACK”<br />
This is a common thing we hear as physios, and again it’s not the person’s fault it is a result of all the negative information about back pain out there! While it might seem like you have a bad back, due to constant pain or constantly recurring bouts of pain, this is not because your back is weak or fragile. The reason this does happen is like we have chatted about throughout this article, because of an overprotective pain response. I think eliminating beliefs such as this go along way to healing, it’s impossible to trust your back if you’ve been told its fragile!<br />

THERE’S NO SUCH THING AS A “BAD BACK”

This is a common thing we hear as physios, and again it’s not the person’s fault it is a result of all the negative information about back pain out there! While it might seem like you have a bad back, due to constant pain or constantly recurring bouts of pain, this is not because your back is weak or fragile. The reason this does happen is like we have chatted about throughout this article, because of an overprotective pain response. I think eliminating beliefs such as this go along way to healing, it’s impossible to trust your back if you’ve been told its fragile!

THERE’S NO SUCH THING AS A “BAD BACK”<br />
This is a common thing we hear as physios, and again it’s not the person’s fault it is a result of all the negative information about back pain out there! While it might seem like you have a bad back, due to constant pain or constantly recurring bouts of pain, this is not because your back is weak or fragile. The reason this does happen is like we have chatted about throughout this article, because of an overprotective pain response. I think eliminating beliefs such as this go along way to healing, it’s impossible to trust your back if you’ve been told its fragile!<br />

GENETICS AND BACK PAIN

I’ve got a bad back because my mum/dad has a bad back. You can blame your parents for a lot of things, but not for chronic lower back pain! This is a kind of follow on from the last point, but chronic non-specific lower back pain is not a genetic condition. But, this does not mean that a friend or family member’s experience with chronic back pain can’t influence you. As we previously mentioned, the presentation of pain is influenced by psychological factors, one of these being beliefs around pain and injuries. If we have seen someone we know go through hell with back pain, it obviously increases our fear and concerns around a similar thing happening to us. It is this fear that can create an increased level of pain if we do injure our back. It is a similar phenomena to being told that an injection is going to hurt, that influence primes our brains for pain.

THERE’S NO SUCH THING AS A “BAD BACK”<br />
This is a common thing we hear as physios, and again it’s not the person’s fault it is a result of all the negative information about back pain out there! While it might seem like you have a bad back, due to constant pain or constantly recurring bouts of pain, this is not because your back is weak or fragile. The reason this does happen is like we have chatted about throughout this article, because of an overprotective pain response. I think eliminating beliefs such as this go along way to healing, it’s impossible to trust your back if you’ve been told its fragile!<br />

POSTURE AND PAIN

This is another huge misconception in any kind of pain, but especially with back pain. The evidence tells us that that posture is not associated with pain. Even if you spent all day sitting in the “perfect” posture, chances are you’d end up sore. The key is not what posture you spend your time in, but how much time you spend in these postures. I recommend regular changes of posture and more importantly trying to offset the amount of time spent in stationary postures with regular movement and exercise. Lower back pain with sitting is not damage, but our brains way of telling us to move. It’s the exact same feeling you get in your bum-cheeks when you’re sitting, but in this case we just shuffle around, we don’t think we’ve damaged our rear-end! Unfortunately, our lifestyles demand a lot of time spent in the same positions, so we need to get moving!

THERE’S NO SUCH THING AS A “BAD BACK”<br />
This is a common thing we hear as physios, and again it’s not the person’s fault it is a result of all the negative information about back pain out there! While it might seem like you have a bad back, due to constant pain or constantly recurring bouts of pain, this is not because your back is weak or fragile. The reason this does happen is like we have chatted about throughout this article, because of an overprotective pain response. I think eliminating beliefs such as this go along way to healing, it’s impossible to trust your back if you’ve been told its fragile!<br />

NOw, it’s time for the dismount

Just trying to write something other than “in conclusion” or “in summary”! But, the main take away from this article is that Chronic Lower Back Pain is not an incurable condition. It is however, often mistreated and misunderstood. So the key to ultimately overcoming this beast of a condition, is to empower yourself with knowledge which allows you to gradually load your spine back to it’s former glory!

Thank you for taking the time to read this and I really hope it has helped!

 

If you have any questions please feel free to get in touch!

 

 

 

James,

The Feel Good Physio.

 

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