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Low Back Pain - Guiding the Path

In this educational blog, we will discuss the nuances of low back pain. Hopefully you will find this document helpful in managing your own low back pain or can share with a friend who may be having a similar experience.


What is low back pain?

Low back pain is defined as pain that occurs below the 12th ribs to the inferior gluteal folds and may be associated with leg symptoms. Globally, low back pain is the leading cause of disability. In 2017, the global rate of activity limiting low back pain was estimated at 7.5%, which means there were approximately 577 million people dealing with this issue at that time. In other words, if someone is experiencing low back pain, they are not alone. The question becomes, what should be done about the experience?


What is the meaning of low back pain?

Traditionally, healthcare has examined low back pain as a biological issue. Under this premise, clinicians often recommend imaging to find problems to fix. We can think of this biomedical approach similar to a mechanic attempting to diagnose a car problem. Although the biomedical model is popular, the approach has important flaws that often lead to unnecessary investigations in search of a ‘holy grail’ diagnosis to rationalize unhelpful interventions. In the case of low back pain, radiological imaging like x-rays, CT scans, and MRIs are frequently ordered to find deviations from textbook “norms”.


The assumption is all symptoms (including pain) are signs of an underlying disease process or structural pathology. When anchored to the biomedical model, treatments are selected to correct a perceived ‘deficit’ or ‘abnormality’ by placing the person in a diagnostic box, for example, spinal degenerative disc disease. The major issue with this approach, as humans we are not cars. Although this approach is appealing, the drawbacks include increasing patient worry, misdirected problem solving, disability, distress, and increased attention to pain. In the 1970s, a major paradigm shift began occurring via Dr. George Engel, a psychiatrist..Dr. Engel realized the medical approach often overlooked the human by focusing purely on ‘tissue issues’. The approach plunged clinicians and patients down a biological silo, ignoring how individuals’ thoughts, beliefs, prior experiences, and sociocultural norms can influence their experiences. Dr. Engel proposed a more nuanced approach known as the BioPsychoSocial model in an attempt to layer in more variables that may influence someone’s experiences. In regards to pain, this model expanded our horizon beyond simply looking for biological ‘tissue issues’ and provided more avenues for helping individuals with their pain.


Fast forward to now, and we’ve realized many of the prior issues we labeled as causes of low back pain are in fact normative aspects of being human. For example, the prior label mentioned of degenerative disc disease can instead be thought of as the gray hairs of our spine. In other words, many changes we see on imaging are normative aspects of aging as a human and are poorly linked to developing or sustaining low back pain. Specifically we now know the majority (90%) of low back pain is considered to not have a specific diagnosis that necessitates a specific intervention. To be clear, this is a good thing, and means we should generally avoid unnecessarily worrying about finding the cause of low back pain. So if it’s unlikely to require further investigation, what’s next?


What to do about low back pain?


The good news, the overwhelming majority of low back pain resolves with time and continued activity. The prognosis (likely outcome) for low back pain is quite good. In general, people will notice marked reductions in pain and disability within the initial four to six weeks, while others may take a bit longer. So, if low back pain will improve over time - what should be done now?


Evidence Based Recommendations for Low Back Pain Management


  • Reassurance - remember it is highly unlikely there is an underlying disease or pathology warranting further investigation (like imaging).

  • Symptoms will likely improve with time.

  • Try to avoid bed rest.

  • Try to stay active to tolerance


What is meant by staying active to tolerance?

This is a question we receive from remote clients on a regular basis. What’s ‘tolerable‘ pain? Our usual response - we can’t answer that for the individual beyond providing some general guidelines and expectations for activities during and outside of “rehab”:

  • It’s important to remember pain is an experience, with a multitude of influential variables beyond just “tissue”. Which means, having an increase in symptoms with activity doesn’t then mean you’ve hurt yourself or made matters worse.

  • Symptoms tend to be a part of the process but that doesn’t mean ignore them and just keep going disregarding the pain experience.

  • We want symptoms to be tolerable which means not debilitating. We qualify debilitating as not crossing your upper tolerance limit and leaving you feeling unable to go do other life activities and/or distracting your attention away from other tasks.

  • Symptoms will likely ebb and flow through the process and that’s ok. Often it’s tough to pinpoint a singular “cause” to symptoms so we shouldn’t unnecessarily worry ourselves.

  • Over time, as we regulate activity, symptoms tend to regress while being able to still pursue valued life goals to tolerance.

  • Ideally, as we work through this process we can equip the client with tools to self manage in the future but if they need assistance again, there’s nothing wrong with that.

Check out table 1 for 10 Myths vs Facts about low back pain Low Back Pain (LBP) Myths vs Facts


              Myths                

Myth 1:

Low back pain is usually a serious medical condition.

               Facts                

Fact 1:

LBP is not a serious life-threatening medical condition.

 

Myth 2:

Low back pain will become persistent and deteriorate in later life.

 

Fact 2:

Most episodes of LBP improve

and LBP does not get worse as we age.

 

Myth 3:

Persistent low back pain is always related to tissue damage.

 

Fact 3:

A negative mindset, fear-avoidance behavior, negative recovery expectations, and poor pain coping behaviors are more strongly associated

with persistent pain than is tissue damage.

 

Myth 4:

Scans are always needed to detect the cause of low back pain.

 

Fact 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.

 

Myth 5:

Pain related to exercise and movement is always a warning that harm is being done to the spine and a signal to stop or modify activity.

 

Fact 5:

Graduated exercise and movement in all directions is safe and

healthy for the spine.

              Myths                

Myth 6:

LBP is caused by poor posture when sitting, standing and lifting.

               Facts                

Fact6:

Spine posture during sitting, standing and lifting does not predict LBP or its persistence.

Myth 7:

LBP is caused by weak ‘core’ muscles and having a strong core protects against future LBP.

Fact 7:

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.

Myth 8:

Repeated spinal loading results in ‘wear and tear’ and tissue damage.

Fact 8:

Spine movement and loading is safe and builds structural resilience when it is graded.

Myth 9:

Pain flare-ups are a sign of tissue damage and require rest.

Fact 9:

Pain flare-ups are more related

to changes in activity, stress and mood rather than structural damage.

Myth 10:

Treatments such as strong medications, injections and surgery are effective, and necessary, to treat LBP.

Fact 10:

Effective care for LBP is relatively cheap and safe. This includes: education that is patient-centered and fosters a positive mindset, and coaching people to optimize 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). and remaining in employment).

Reference:

O'Sullivan PB, Caneiro J, O'Sullivan K, et al. Back to basics:

10 facts every person should know about back pain Br J Sports Med. 2019.

When to seek healthcare consultation?

If you are struggling to manage your low back pain and in need of some guidance, we’d be happy to consult with you. Please complete our intake paperwork.


When to seek local in-person medical care?

If you begin noticing the following symptoms then we recommend seeking healthcare consultation immediately:

  • Loss of sensation

  • Loss of movement in extremities (like legs), Loss of control over bowel or bladder movements, or

  • Groin numbness


References:

  1. Hartvigsen J, Hancock MJ, Kongsted A, Louw Q, Ferreira ML, Genevay S, Hoy D, Karppinen J, Pransky G, Sieper J, Smeets RJ, Underwood M; Lancet Low Back Pain Series Working Group. What low back pain is and why we need to pay attention. Lancet. 2018 Jun 9;391(10137):2356-2367. doi: 10.1016/S0140-6736(18)30480-X. Epub 2018 Mar 21. PMID: 29573870.

  2. Wu A, March L, Zheng X, et al. Global low back pain prevalence and years lived with disability from 1990 to 2017: estimates from the Global Burden of Disease Study 2017. Ann Transl Med. 2020;8(6):299. doi:10.21037/atm.2020.02.175

  3. Toye F, Seers K, Hannink E, Barker K. A mega-ethnography of eleven qualitative evidence syntheses exploring the experience of living with chronic non-malignant pain. BMC Med Res Methodol. 2017 Aug 1;17(1):116. doi: 10.1186/s12874-017-0392-7. PMID: 28764666; PMCID: PMC5540410

  4. Durnez W, Van Damme S. Let it be? Pain control attempts critically amplify attention to somatosensory input. Psychol Res. 2017 Jan;81(1):309-320. doi: 10.1007/s00426-015-0712-7. Epub 2015 Sep 29. PMID: 26415962.

  5. Engel GL. The need for a new medical model: a challenge for biomedicine. Science (New York, N.Y.). 1977; 196(4286):129

  6. Koes BW, van Tulder MW, Thomas S. Diagnosis and treatment of low back pain. BMJ (Clinical research ed.). 2006; 332(7555):1430-4

  7. da C Menezes Costa L, Maher CG, Hancock MJ, McAuley JH, Herbert RD, Costa LO. The prognosis of acute and persistent low-backpain: a meta-analysis. CMAJ : Canadian Medical Association journal = journal del'Associationmedicalecanadienne. 2012; 184(11):E613-24

  8. Foster NE,AnemaJR,CherkinD, et al. Prevention and treatment of low back pain: evidence, challenges, and promising directions. Lancet(London, England). 2018; 391(10137):2368-2383

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