‘Conquering Back Pain: Low Back Pain Management’
Claire Whelan

Good evening and welcome to my presentation on the management of low back pain. So let’s just start off with some, statistics around low back pain. Low back pain is the leading cause of disability worldwide and rising, and it’s estimated that over 80% of people will experience an episode of back pain at some point in their lifetime. In 2020, a staggering 619 million people suffered from low back pain. So if you have low back pain tonight, you’re definitely not alone. Tonight, as part of my talk I’d like to bring you through some historical low back pain treatments. What an evidence-based care looks like and tips on how to manage a flare up of your back pain

So historical treatments – low back pain is nothing new and it’s been documented that potions and spells have been used by ancient civilisations. Hippocrates, the father of medicine and Greek philosopher and physician, even documented exercise and manipulation. So, I hear you ask the question, what has changed? In truth, not much there’s multiple non-surgical treatments out there, and these kind of range from core strengthening exercises, dry needling, manipulation and wearing back braces, taking even painkillers and having a you know a spinal injection. The list is endless and we can’t forget our conflicting advice between colleagues and friends and a good old Google, but in essence, a lot of these treatments are actually quite costly and when used in isolation often ineffective. A really good example I have is, I had a young patient coming to me, last week, and she’s been having weekly treatments for the last few months and her back pain is still there, it’s actually getting worse and she comes in, and she tells me that everyone’s quite puzzled as it’s why she still has back pain. So she went on to have an MRI scan. This is where a picture isn’t a thousand words. Her MRI scan came back completely normal, and we know from the evidence that having some age-related changes in an MRI scan is quite normal and these changes increase with age and I typically describe them as, it’s like having wrinkles and grey hairs, and it doesn’t necessarily correlate to a person’s back pain. Another issue I suppose an MRI scan is it’s a static picture. It doesn’t tell me how you move. It doesn’t tell me about muscle imbalances between your core muscles and your leg muscles. But more importantly, it doesn’t tell me about your thoughts and your feelings.

So this particular patient came into me, and because she wasn’t getting better, she really felt that something seriously was wrong. She was scared to move her back, and she really felt that she was going to do more damage if she was going to move into a pain. So she was protecting her back, having really good posture and not lifting anything heavy and I’m going to talk about these thoughts tiny bit later on in my presentation.

So if we move on to current day, what is evidence-based care look like? So there’s guidelines out there to help guide physicians as into how to manage back pain. These guidelines recommend that we kind of have a combined care, tailored to each person’s needs and this may consist of education around some about your back and your dos and your don’ts, exercise prescription, manual therapy and for some people, psychological therapy. Again, for us as physicians, we want to use some tools to help manage your back pain.

So when we go on, what does recovery look like? So when we adopt a kind of an evidence-based care approach what does recovery look like. While most people would love to see the graph on the left-hand side. In essence, back pain, the recovery can be quite complex. I always describe in the beginning, it’s like an annoying squiggle. This is where having for us as clinicians having a deep understanding about what’s going on is really important. So we want to take a kind of an in-depth history about what’s going on in your life, but also about some fears that you have around your back pain. So many people are quite fearful of moving their back and causing the current pain, and I want to know about your expectations. Do you think it’s going to get better? Because it’s really important that for all of you out there who suffer from back pain that you have this hope and hope that it will get better. But as I said, kind of listening to your story is so important because it helps us to tailor that exercise program to your needs. Once we kind of get on track, you know, recovery is still going to have its peaks and troughs. A good example of where I really want to figure out what’s going on in your life is, a patient a few weeks ago who came into me and he had three weeks of really disabling low back pain, and he’d seen three other physicians prior to coming to see myself and throughout the assessment we were able to change his pain through exercise, and I was like this is great. Brought him back a week later, and he was kind of over 70% better. I was really curious about, why, what got you better? He actually said to me that it was a phone call with his boss and his boss had given him some reassurance, go and look at it don’t worry about work, come back whenever you’re better, I pay you for while you’re off and he came back and he told me it was that reassurance that helped him to kind of not panic about getting better. In essence that social stress that was removed from him that allowed him to progress with his rehab.

So after kind of getting a history from you, what do I want to see? I want to know, are you breathing? How do you bend? How are you standing up from a chair? What is your posture like? For me, these four key questions are really important because unless we get the basics right it’s very hard to make improvements within an exercise program.

So let’s talk about breath. So many patients come in to me, and I’m like going, are you breathing? And when they go, no, and I’m going, are you protecting your back? They’re going, yeah. They’re all protecting their back because they’re so fearful of causing damage. That’s really important to know that your back is strong, over 90% of people have back pain. There’s no one specific cause for it. Most people say it’s non-specific or it’s benign in nature, but it’s not serious and it’s not harmful, but it’s really impacting your life and causing you distress. It’s not harmful. When people come into me and I see that they’re bracing and they’re protecting, I kind of go to kind of a clenched fist. I use this analogy and I get my patients to make a clenched fist. If you can all make a clenched fist now for me, and you need to really squeeze your fist as hard as you can. Now I want you to try to move that fist up and down. It doesn’t feel that nice. I hear a bit of clicking and cracking, and I feel my knuckles are beginning to get a bit sore. Your knuckles and your wrist are actually the same as the joints in your back. So if you’re bracing or holding your breath you’re probably increasing the amount of stress and strain going through those joints, and also if I’m holding my fist all day long, I’m beginning to feel my forearm muscles get a bit sore. I’m sure you are too there and now I want you to move it. Now I want you to relax your fingers and just move your wrist up and down. It feels so much nicer. That’s the same with your back. So you need to breathe, you need to relax, that’s what really is the key. This most probably comes natural to you, so it’s important that you’re telling yourself, ok breathe, relax feel your tummy, Does it feel soft?

The next thing I want to look at is how do you bend? So your spine is made up of segments stacked upon each other. Within each kind of bony segment, you have a disc, and it’s designed to twist and turn. So when you are keeping your back very straight, you’re not allowing your back to do its function. Hence it kind of may feel a bit stiff, a little bit tight. These are some videos that I’m just going to show you. All how some people typically move when they come in to see me. So, the first video is someone kind of hinging forward.

You can see here he’s keeping his back really straight, and he’s just hinging from his hips. Another movement pattern that I typically see is actually bend from your legs and your knees, and you’re trying to keep that back really straight, but what I want to see when you come in to see me is that we’re flexing, we’re bending from your upper back, your mid back, your lower back from your hips and this movement is quite nice. Again, when you’re bending I want to make sure that you’re breathing and when you’re bending, it’s okay to feel pain and discomfort. You’re not going to do any harm, but if you can on a daily basis throughout your tasks think about every time you’re bending to pick up your socks or you do the laundry, you know that you’re actively going, let’s breathe, let’s move through my back normally, that would really help in your recovery.

So next we go on to posture, everyone comes into me thinking that you should have this real upright posture and when we have back pain, I typically see that people probably try to overcorrect their posture. If we can go back to that clenched fist analogy, if you are holding yourself upright and squeezing your shoulder blades and trying to have that nice straight posture, in essence, your kind of going around with that clenched fist all day long. So you kind of have that increased activation of your back muscles. So what I generally like to see is that perhaps you’re a bit more slumped, you’re relaxed. When rising from sitting we’ll go on to kind of looking at how people typically come in, when they’ve back pain and how they stand up. Most people come in to me, they’re keeping their backs straight. You’re using your hands to come up. This is like a co-contraction, you know, so people pushing down through their arms, increasing that intrabdominal pressure within your tummy, and increasing activation of your trunk muscles. If you can see in this video, you know, Steven here is going right upright he’s not flexing through the back, he’s pushing through the arms, trying to keep his back straight. When we look at the function of your arms, your arms are for reaching and for pulling, not for standing. Your legs are for standing. So it’s really important that when you’re rising from your chair that your using your legs. So this is an example of where we get Steven trying to keep his arms relaxed and you can see his nose is coming over his knees. He’s not using his hands and he’s kind of really send those hips backwards when he wants to come down so he’s utilizing his legs. This is a lot nicer, on your lower back and it’s actually a lot easier to do. So next time at home when you’re rising from a chair and you have back pain, think about bringing your nose over your knees, think about really trying to use those legs instead of pushing through your arms.

So next, what I want to look at, once we kind of have those functional movements done, I did an in-depth analysis of how your muscles are functioning and, it’s been shown that a lot of people who have back pain and even who’ve recovered from back pain have this kind of altered muscle activation. What I typically see is that patient’s back muscles and core muscles are actually quite strong and it’s the leg muscles that are weak. From a retraining point of view, what I want to do is kind of try to get those leg muscles and those core muscles stronger and I want to be really specific when, we’re exercising.

So the next slide will show kind of some examples of some specific exercises, and any exercise that we did at this stage can be tailored to your needs. But what I’m looking for is that when you’re exercising it, you’re feeling it is that right muscle improves. So, when I give you kind of a bum strengthening exercise, I want to know that, yes, it’s your bum that’s working, and not maybe the muscles in the front of your thigh or the muscles in the back of your thigh. The first exercise here is, you can see Ciaran using what we call a hip thrust and this can be modified into a lower level by perhaps doing what’s called a bridge, or can be made slightly harder by going into single leg hip thrust or adding on a weight. The next one you see, we think that what we call a kind of side line hip abduction and you’ll see that this green band, this is called the TheraBand and it’s a resistance band. So he’s pulling up against a bit of resistance, and this resistance is really important because what we’re looking for is that we’re looking for that we’re developing some changes in those muscle fibres so that you’re getting kind of like those strength changes that you need in order to help with your recovery. When we’re bringing you through an exercise program, it’s really important that you’re kind of working at a level where those changes will happen. So I generally say an effort of seven out of ten is what we’re aiming for, and when we’re looking at repetitions, do eight reps, seven out of ten should be sufficient to kind of allow me to get the changes that we need, but it is all about being specific within that muscle group.

So next we kind of go on to what we call, strength training. So we’re kind of looking at the whole body. There’s guidelines from the World Health Organization, they say that all adults should be doing at least two days of training, per week. In order to see changes kind of in your pain levels and in your function, it has to be a progressive strengthening exercise program. This can take 3 to 4 months, so this is where what I typically see in clinic is some patients come back to me and they go, I’m doing the exercises, I’m not seeing any changes in my pain levels, but what I’m actually seeing is I’m seeing changes in your strength, and it takes time for some of these strength changes to kind of correlate to a reduction in your pain level. This is where you’re not giving up on your exercise program and keeping that hope is still really, really important. You can see to the right of my screen, I have some cross-sectional pictures of an MRI scan. What I’m looking at here, I’m looking kind of after the two kind of black circles at the back of it, and they’re called your paraspinal muscles and your multifidus. The, picture to the top, left hand, side, kind of is normal, good muscle fibre and then as you go down through the other three pictures, you can see there’s a lot more white within these back muscles and that’s what we call, fatty muscle infiltration. That gives us some idea that those back muscles just are not working and that may be contributing to your pain. A study that was done here in Sports Surgery Clinic back in 2015 found that patients who did a kind of a progressive loading free weight exercise program, actually, had a reduction in their pain and improved quality of life, improved function, and this correlated to an increase in muscle fibre architecture on these MRI scans. So, strength training does work. But you just need to give it time, you need to put in the effort and you need to be consistent.

So what else kind of is evidence-based care? We need to look at cardiovascular exercise and the research will tell us there’s no right and wrong and my recommendation for you tonight is to really pick something that you enjoy. It’s about that consistency, so again, the guideline is recommending that we’re doing between 150 and 300 minutes, of moderate cardiovascular exercise, per week. Now, obviously, you’re going to say to me, I have pain, I’m not able to do that, and that’s okay. I suppose my tip is to start small, and to gradually build it up, and there is a ton of research to show that actually walking is such a great exercise for people who have back pain and this was a study that was on the Guardian newspaper, and it was it was published in The Lancet journal and it was done in Australia. They looked at people who had recovered from lower back pain and they put them on a walking program and what they found, all the people who engaged in a consistent walking program actually had a reduction in their flare up and the severity of that flare, so a simple exercise you can go outside, it doesn’t cost you anything, and again, you can just start small. Even walking around house with an amount of back pain, building it up and, and then gradually trying to progress it.

So the next – managing a flare-up. So what do we do? Flare-ups can be very distressing. Again, it can be quite disheartening, especially if you’re improving in this journey of managing your back pain, and once you have an episode of back pain, you have had an increased risk of developing another episode of back pain. The first thing I would suggest is don’t panic. You haven’t done anything serious and it will get better and if you’ve had previous flare-ups and back pain, you know that it will get better. Again, what we want to kind of see that you’re trying to still keep those normal and functional movements going. So, you’re still using your breath work, you’re not trying to protect your back. Trying to do some simple exercises while you’re in this flare-up will actually help you recover quicker. So it’s all about keeping moving or pacing yourself. So if you typically would have gone for half an hour a walk, perhaps during a flare-up, you’re going for two, five minutes each walks, spaced throughout the day.

On my next slide, we have an example of some exercises. One of my favourite exercises is what I call child’s pose. This is again a really nice, safe exercise. Your kind of getting a nice stretch to those muscles, along your back. Again, you’re using your breath and you can hold this stretch for anywhere between 10 to 30 seconds. You can do simple knee-ups, even just bringing one knee up to your chest at a time, if able you can bring two knees up. This is Ciaran here doing some breathing and I generally kind of recommend patients during a flare-up, if you might go on to YouTube, find a nice meditation video and just focus on that belly breath trying to relax through those back muscles.

Then what do we do after a flare-up? We actually want to get back exercising. Again, you may not be able to get back to the load that you were lifting prior to the flare-up, but as soon as you feel able to you’re getting back into the gym, you’re getting back down onto your exercise mat. This is kind of a picture of Stephen doing some of this strength work. So here is kind of a nice goblet squat and the muscles in front of the leg going, you might be able to go into my split squat, and all of these exercises again really safe for people who have back pain. You’re targeting the leg muscles and the main thing is, after a flare-up were really striving for function. I suppose that’s one thing that I really try to encourage my patients to do is to set goals for yourself, try not to be chasing your pain, but chase your function.

So look, in conclusion, there’s no one magic solution. I suppose everyone’s journey of back pain management is quite different. Consistency is key and it does take time And flare-ups will happen, but what counts is really how you manage them and you get back on track, and you have that kind of end goal in sight.

That’s a really good question and it’s suppose I typically would hear that sometimes people come into me and they’re doing exercise and it’s causing their back pain and it’s not that the Pilates or the exercise is bad sometimes it’s down to your technique so you know I typically say that if you’re feeling it in your back it’s a sign that you’re using your back muscles and not necessarily your core. So a lot of the times it’s just down to your technique of how you doing some of your palates exercises and if you remember my talk I was talking about a lot of diametric breathing and using that breath control and that is really important to help relax some of those back muscles so it might be worthwhile that if you’re finding in a class setting that that’s flaring up your back pain that perhaps you’re kind of going for a one to one session and that you’re kind of really trying to work on you know your technique and how you’re performing you know the exercises so that you can get a lot more specific with how you’re activating your core.

Yeah there is and I suppose you know a lot of the times it’s about if you’re kind of stiff in one segment you’re going to have to gain that movement through moving another segment so a lot of the times if we see patients in our clinic if they’re really stiff in their hips they generally tend to overuse their backs. If you can kind of free up your hips and allow them to move a lot more effectively a lot of the times that can help improve your back pain and some of that stiffness within the hip can be freed up not only through stretches but also through strength training as well so trying to get those kind of like hip muscles working a tiny bit better. So yeah there definitely kind of is that correlation between the lower back and your hips.

Yeah again I suppose you know what we always do is treat the person in front of us and again it’s trying to you know get that flexibility back into your spine and there’s various ways of how you may do that and it’s kind of really that exercise program you know per person so you kind of want to know well maybe what’s driving that stiffness. Is it that there’s that kind of like tension in your trunk muscles and do you need kind of a bit more relaxation techniques. Is it that your back muscles are just not allowing you to move because they’re compensating for weak hips and weak legs and that actually your treatment program needs to be more targeted towards your leg muscles and then you have you know the classic stretching program that some people you know can do kind of on a daily basis to help with that but a lot of the times you’re kind of trying to bring it back to function you know how is that stiff back affecting you day to day and you’re kind of trying to maybe drive your exercise program to your function as opposed to just maybe trying to get a really flexible back.

It’s horrible when you suffer from Sciatica there’s nothing worse than nerve pain so I definitely feel for you but driving I suppose a lot of times with sciatica your nerve just doesn’t like being stretched and when you are driving unfortunately that can put extra stretch on that nerve and cause irritation on it. Best tips I generally say is you know take regular breaks kind of avoid long journeys so if you know that you’re going to be traveling two and a half hours maybe every half an hour 40 minutes get out of the car do a little walk around also maybe try not to have your car seat you know bolt upright so change you know the angle of your car seat and you can kind of variate back and forwards throughout your car journey as well and they’re probably my two main tips of how to limit irritation of that nerve when you’re driving.

The second part maybe you know swimming again it’s I generally kind of again really patient specific if you have a lot of pain on that like backward bending you know through your Lumber spine then you know trying to maybe going into your breath stroke or your back stroke can be quite good and again you’re kind of looking at that whole spine you know if your neck is really stiff you want to avoid the amount of times that you’re rotating it from side to side so sometimes spending as much time in the water with your head and neutral can be better as well.

Yeah I think improvements can be kind of multifactorial and from the talk that like you know different factors can feed into you know patients improvements and one of them is making sure that people are doing it consistently but regards to ages I think once you get kind of over the age of 65 and you’re getting some changes within those muscle fibres and muscle bulk called sarcopenia sometimes it can take a bit longer to build up the strength. That’s where probably adding on resistance and weights is even more you know important so sometimes the older you get the harder it is to build that muscle bulk. Regards to gender again like that postmenopausal woman with the hormonal changes that can influence your ability to put on muscle bulk as well. So yeah there can be that changes kind of in the gender as well.

I suppose as a physiotherapist you I mean we’re not going to I suppose change a structural change within your spine so what Spondylolisthesis  is kind of a forward slip of one bone on top of the other and this can kind of vary to you know different degrees and while it’s nice to know kind of a specific diagnosis we still treat what we see with regards to your movement and your strength deficits so physiotherapy can definitely help improve that  because a lot of the times the first line of treatment is nonsurgical.

We can of use an outcome measure it’s called a start back screening tool and that even helps us guide what’s the best form of treatment for you and we just use it as a guide like everyone has their bespoke treatment program but some people actually just need advice on how to self-manage and they can go and do their own exercise program another kind of cohort might just kind of need kind of you know an exercise you know program and then you have that other cohort which need a bit more for an MDT approach having some you know psychological approach. At work we tend to use that to help guide us but we’re also really listening to you, what’s your preference with regards to your exercise and you know what type of exercise training do you like and we really try to kind of like fit it into your schedule as well so while it’s recommended that you might be doing strength training two to three times a week if you have a really busy life and you can only fit it in once a week then we’ll work around that or you know we’ll give you tips on how to incorporate it into your schedule so there’s various tools that we use to really create that bespoke training program just for you.

Yeah no I love cycling, I think cycling is one you know like it’s suppose there’s no one exercise that’s better than the other but I really like cycling, I think it’s really safe, I think the back is in nice relaxed position, you’re getting the legs working hard and you’re getting a bit of cardiovascular you know fitness as well so I’m a big advocate for cycling.

Yeah I suppose again when you look at kind of any of the guidelines you know manual therapy is part of kind of an evidence-based care I suppose the issue is that you just don’t rely on it, it can definitely help with an acute spasm and acute episode of pain where you do manual therapy. I would typically say like while the majority of my treatment sessions are exercise based in certain cohorts you might need 10 to 15% of that treatment session which is manual therapy just to help get them moving, help reduce their pain. So yeah it’s definitely a good option but not in isolation.

Not necessarily I suppose like when you’re listening to that you’re kind of going okay is it a nerve irritation if it’s paraesthesia alone with a small bit of pain and I suppose one of the advantages of seeing a patient face to face is that you’re doing a thorough examination and I suppose part of that examination is out ruling any kind of signs of something serious going on but also another part of your is your neurological examination. So if patients have those symptoms but your neurological examination is completely normal and you’re happy that it’s definitely coming from the spine then kind of that watch and wait approach you know is fine, where you can bring them through kind of a guided exercise program, so not necessarily opting for concern but it’s something that you’re monitoring because I suppose what we do know with like spines and Lumbers spine is that everything’s can be an involving pathology so what presents to you on a Monday may be completely different in two weeks time and that’s the importance of having that baseline neurological examination.

Yeah and it’s hard because sometimes you get into like this kind of like cycle or pain and stiffness and more stiffness can cause more pain and we tend to stop moving because of the pain but actually if you can gradually build up exercise some of that pain you know will reduce and I suppose you’re not going to do more damage by moving into pain and exercising into pain. It sounds like this person has you know a pain in various different areas and it’s going on for quite a long while so potentially this patient could be good from an MDT approach as well that it’s not just kind of you know physio you’re looking kind of at that wider you know picture but it is important that we’re kind of getting some movement into the body. A lot of times patients who are presenting with chronic pain I tend to try to chase function as opposed to pain so you may still have the same pain levels but can your function improve and so I would in that situation chase function as opposed to pain sometimes.

For physio at the moment I would probably say we’ve no waiting list, I suppose we have a large team so we always kind of we’ll slot you in some place and like we work Monday to Friday and you know so I would say no we we’ll get you in you know within you know a week to 10 days.