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Treatment For Low Back Pain Found to Be Harmful & Ineffective | What Works?





		

The Ultimate A-Z Guide to Treating Low Back Pain & ‘Sciatica’ in 2019.

Lower Back Pain

Fast Facts

  • Up to 25% of Australian citizens suffer from low back pain at any given time
  • Over the past month, 50% of Australian citizens suffered from low back pain
  • The economic burden of low back pain in Australia is $4.8 billion per annum
  • Low back pain is the number one condition keeping working Australians (aged 45-64) out of the workforce

Current Low Back Pain Treatments Are Harmful & Ineffective

Insights from ‘The Lancet’ 2018 global review of the management of low back pain:

 

  • Most patients who see a GP for low back pain are prescribed a pain-killer but not provided with any advice or education on self-managing their condition. Read more about changes to Australian pain medication laws at our blog HERE
  • Up to one third of heath professionals endorse the use of outdated and ineffective forms of treatment for their patients
  • Most health professionals incorrectly believe that imaging is required for patients with acute low back pain
  • Although back pain is best managed out of hospital in community facilities, hospital admissions for back pain have increased in the last decade
  • An increasing number of people are calling an emergency ambulance when they experience low back pain rather than following guideline recommendations to see their GP or physiotherapist
  • In older people with back pain there is a trend for greater use of spinal fusion surgery despite evidence that this procedure is ineffective, costly and potentially harmful
  • Patients with low back pain are being encouraged by their GP to remain off work until pain-free, a practice that delays recovery
  • Medicare, has a limit of five allied health consultations, which is too few to deliver a typical treatment programme for chronic low back pain
  • GPs who report a special interest in low back pain are more likely to provide the wrong treatment for low back pain
 

Background Of Low Back Pain

If you have found yourself reading this, it is likely that you, or someone close to you is suffering from low back pain (you may refer to it as back pain. lower back pain, chronic back pain or Sciatica) and you’re not alone. Musculoskeletal conditions have become the number one national health priority, affecting over 6.9 million Australians. More than half of these musculoskeletal problems are attributed to back pain, or injury. Low back pain is so common that it is predicted up to 85% of us will experience an acute bout of low back pain over our lifetime, with some of these progressing to recurring, or persistent problems. Sifting through the mountains of online blogs and research studies can be a tall task, so below we have brought together a comprehensive, evidence based guide of all things back pain to help you make sense of it all.
Lower Back Pain

What Is Low Back Pain?

Low back pain is a multifactorial issue that can have varying presentations, symptoms and deficits. Put simply, low back pain is a blanket term that describes the region where you feel your pain. This region typically spans the area from below your ribcage to your the top of your pelvis. Low back pain is felt by one in six Australians and is a leading cause of disability, time off work and has strong links to mental health issues. To fully understand the intricacies of low back pain, we must first delve into how we classify lower back pain, what causes it, how it is diagnosed and what can be done to manage, or even
prevent it.

Who Is At Risk Of Suffering From Low Back Pain?

⇒ AGE

It’s no secret that your risk of back pain increases as you age, with the first episode of back pain likely to strike around ages 30 – 50 years. This may increase with normal age related changes, however, there are many things that can be done to reduce the risk, and alleviate the symptoms of low back pain as you age.

 

⇒ FITNESS LEVEL

Individuals with reduced physical fitness are more likely to present with low back pain. In fact, studies show1, engaging in strength training or walking are effective at reducing lumbar pain and improving function.

 

⇒ WEIGHT AND BODY COMPOSITION

Sudden weight gain, or being overweight increases the mechanical load on your back and is strongly associated with low back pain.

 

⇒ GENETICS

Sudden weight gain, or being overweight increases the mechanical load on your back and is strongly associated with low back pain. Some people are also genetically predisposed to pain conditions and central sensitisation (see diagram below). 

 

⇒ OCCUPATION

Jobs that require a lot of heavy lifting, pushing or pulling may predispose you to low back pain due to increased repetitive load placed on the back. This may be especially true if you haven’t prepared your body for those twisting and vibration type movements. However, if you’re an office worker who sits all day, this doesn’t mean you’re in the clear! Prolonged sitting is linked to back pain, diabetes, cardiovascular disease and even some cancers.

 

⇒ MENTAL HEALTH

Stress, anxiety and depression are all linked to the development and severity of low back pain. Similarly this can occur the other way around with low back pain sufferers more likely to develop anxiety or depression due to the impact it has on their daily life.

 

⇒ PREGNANCY

Pregnancy related back pain is very common with weight, hormonal and body composition changes often being the root cause of this pain. Physiotherapy and clinical pilates have been shown to be an effective way to combat pregnancy related low back pain safely!Typically, low back pain is placed in to two broad categories: acute, or chronic. The symptoms felt with each classification can be similar, it is the timeline of those symptoms, and the management that differs considerably.

 

⇒ ACUTE LOW BACK PAIN

Acute low back pain is one of the most common complaints to medical and allied health professionals. Acute low back pain usually comes on suddenly, lasting from a few days, to a few weeks. Symptoms can range from mild to severe and can be caused by a whole host of reasons. The good news is most back pain in the acute phase clears up in about 6 weeks with appropriate management.

 

⇒ CHRONIC LOW BACK PAIN

Chronic low back pain is back pain that persists for greater than 3 – 6 months and may have regular flare ups or recurrences. This type of low back pain chews up a great deal of direct and indirect health care spending and is a leading cause of work absenteeism and reduced productivity. About 20% of acute back pain sufferers will go on to develop chronic low back pain and the impact of this can be quite relentless. Studies show that chronic low back pain heavily impacts a person’s mental health, quality of life and participation in social activities. Chronic low back pain can be an isolating condition, so I urge you to reach out to someone to help you get back on the right track!
Chronic Pain

Anatomy & Physiology Of Chronic Low Back Pain

The lower back is robustly built, specifically designed for movement and support. As part of this well oiled machine, there are many components that come together to give you the seamless movement that you can experience with twisting and bending. The low back is made up of 5 strong bones (vertebrae) stacked on top of each other. Between each of these bones, there is a shock absorbing feature called your intervertebral disc which helps to distribute day to day forces evenly throughout your back. An intricate series of ligaments join and encase these bones to provide further structural support. As we expand further away from the spine we see many layers of muscles. The job of the muscles is to support and offload the joints in your spine, whilst facilitating each movement that your back can provide. Lower back pain is often blamed on one of these areas, with some common diagnoses of low back pain including:

 

  • Disc injuries
  • Fractures and bony injuries
  • Arthritis
  • Stenosis
  • Sciatic pain
  • Skeletal irregularities such as scoliosis
  • Radiculopathy or referred pain
  • Disc degeneration
  • Ligament sprains
  • Muscle injury or strains
 

On occasion, back pain may even be caused by other underlying conditions such as:

 

  • Kidney stones
  • Tumors
  • Visceral referral
  • Infection
  • Fibromyalgia
  • Osteoporosis
  • Rheumatoid arthritis

 

Each of these above causes of low back pain aim to pinpoint a single structure at fault,however, with many episodes of low back pain it is difficult to correlate pain with a structural injury. To further add weight to the complexities of low back pain, a large chunk of the people are discharged from their health professional with a diagnosis of non-specific low back pain. This means that there may not be a specific structure, condition or injury that can be implicated as the main cause of pain. This can leave people dissatisfied with the information received from their doctor, or physio because they may feel as though they missed something, or weren’t listened to. With this, we must expand on what we now know about how we experience pain and why things hurt.
Low back anatomy

Diagnosis Of Low Back Pain

Low back pain can be diagnosed with a thorough assessment from a skilled physiotherapist. As first contact practitioners, you do not require a referral from a GP or specialist to attend. A physiotherapist can not only diagnose, but treat, and provide exercises, education and lifestyle modification to assist in symptom reduction and elimination. Diagnosis requires a combination of verbal questioning and hands on assessment. This is done to quantify range of motion restrictions, strength deficits and any alterations in movement patterns or coordination. As part of your diagnosis, your physiotherapist should include questions about your lifestyle history. This will help them to understand you as a person, how your back pain is affecting your life and the many thoughts and beliefs you may have regarding your back pain and its impact on your quality of life. If scans or imaging are required to assist with your diagnosis, your physiotherapist can refer you for imaging and can interpret

A Note On Imaging

Imaging may be helpful in diagnosing acute injuries such as broken bones, or ruling out serious pathologies like cancers or tumors. But when it comes to chronic pain, scans such as x-rays and MRIs are unreliable in explaining the cause of your pain. We now understand that most findings on MRI’s poorly correlate to a person’s pain and are more likely to be the result of normal age related changes. Below is a table drawn from a recent study that shows the prevalence of disc injuries found on MRI. All of the participants in the study had no pain or history of previous back pain. We can see that as we age we all have an  increasing likelihood of having a disc “injury” on MRI and this does not necessarily cause us pain. These normal age related changes start at the age of 20 and by age 50 around 60% of pain free individuals were shown to have a disc bulge in their lower back. This shows that there is little correlation between disc degeneration and pain.
Lower Back Pain
So what does this all mean? It means that the ‘abnormal’ finding on your MRI may just be a coincidental finding that has most likely been there for a long time. The main takeaway is to not panic or stress about your imaging findings. Remember that these findings are most likely appropriate for your age! Don’t fear the results as they don’t have to dictate how you move and live your life. It is important to note that, as with all injuries around your body, your discs can, and do heal giving you the ability to get back to the active pain free lifestyle you had prior to your injury. Your body has a great capacity to heal and recover from an injury and understanding how, and why you feel a certain way is an important step in your recovery.

Why Things Hurt

Pain is a very complex topic, our information and understanding in the area is constantly growing and evolving as we learn more. The experience of pain is not as simple as previously thought. We now know that tissue damage is poorly linked to symptom severity in chronic pain. Now, I am in no way saying that structural injuries do not cause pain, but it is how we interpret information from all our senses about an injury that may modulate our experience of pain. Ever stepped on a block of Lego unexpectedly? Ouch! No tissue damage, but lots of pain. Continual subconscious analysis of everything around you happens in a split second.
Your brain is hardwired to protect you and keep you safe and, for the most part, it does a very good job at this. Past experiences make up a lot of the reasons for why we act the way we do. And this is no different for pain. Think of your brain as an overly sensitive alarm that likes to warn you of anything that might be potentially dangerous. It collects an information bank of what you deem, based on past experience, dangerous or safe. Your brain and nervous system has just nanoseconds to weigh up every possible outcome of a situation and decide on its actions. In these nanoseconds, your brain will ask itself: “Is there sufficient evidence that this situation is safe? Or is there MORE evidence to say this situation is dangerous?”. If it is interpreted to be a dangerous situation, you are more likely to have the response of pain. And this pain serves as a warning for the rest of your body to get out of that situation.
This idea has been conceptualised by some of the great minds of the pain revolution – David Butler and Lorimer Mosely. A simple concept that your brain has an internal monitor called a Protectometer. This protectometer is continuously monitoring the outside world and categorising every bit of information in to either “Danger’s in Me (DIMs)” or “Safety’s in me (SIMs)”. If the DIMs outweigh the SIMs your brain perceives a situation as dangerous. It will then go on to create an emotional, or physical response as a way to get you out of that situation.
Treatment of Sciatica
To put this into the context of chronic low back pain, we have to look at a real world example. A young father is organising his daughter in the morning to get to school, he bends down to pick her up and feels a twinge in his back. He doesn’t think much of it at the time and heads to his office job at work where he sits throughout the day whilst his back stiffens up and becomes achey. The back pain remains the same across the next week or so and the man is beginning to get worried. So he seeks help. Consider the two following scenarios:

Scenario 1:

The man attends his health professional who says “you’ve got back pain, sounds like you have slipped a disc, let’s send you off for an MRI of your back to see what shows up”. The young man heads off to an imaging practice where he has to lie in a large machine making sure he doesn’t move so they can get a good image. The man goes back to receive his results and finds out he has a large disc bulge at the level L4/L5 which is compressing his nerve. Then he goes with a referral to a back specialist who gives him the option of further scans, physiotherapy, an injection, or surgery.
Low Back Pain Treatment Melbourne

Scenario 2:

The man attends his health professional who says something like ”you have irritated your back with a twist and lift that you haven’t properly prepared your body to handle. It’s going to be ok though, up to 85% of people experience low back pain at one point in their life and many of the changes on your MRI are considered normal age-related findings. The good news is that most low back pain clears up in around 6 weeks with appropriate management. We are going to send you off to a physio who is going to help reduce your symptoms and get you moving so you can get back to work and look after your kids pain free”.
Low Back Pain Treatment Melbourne
Put yourself in this situation and consider each scenario and how the two different conversations may affect your thought process. Could you see how scenario 1 may be emphasising DIMs, where as the reassuring approach from scenario 2 reinforced the SIMs that provide a safer environment and facilitates recovery rather than fear.
 
Due to the nature of chronic pain, you simply have more time to accumulate DIMs, which may lead you to experience pain more often and more severely. And as you don’t accumulate these consciously, it can be difficult to identify your group of DIMs. Long after the tissue has healed, your brain and nervous system bears the scar of the injury that was. Your beliefs, emotions and past experience about your injury have made it difficult to move on, leading to an increase in your perception of pain and limiting beliefs.
 
With chronic low back pain and a mountain of DIMs, it is difficult not to feel the isolation that comes with ongoing pain and disability. It is important not to fuel the danger fire and find things that grow your list of SIMs. As you grow your list of SIMs, your list of DIMs will begin to shrink, and bit by bit you can help to get your life back on track. Pain free.

Video: Pain Science 101

4 Best Exercises For Low Back Pain

The exercises below are some general suggested exercises that can be helpful to get moving if you are suffering with low back pain. Please check with your Physiotherapist or healthcare professional for specific exercises related to your condition. 

 

Many people also find Pilates particularly helpful for low back pain. Read all about Pilates in 2019 at our blog HERE.

Back Extensions or Cobras

Back extensions are a versatile exercise that can be done in standing, sitting, or lying. Lying on your stomach is a great way to isolate the stretch to your lower back whilst being in a safe position.
 
How to?
Lie on your stomach, arch back and come to rest on your forearms and elbows, look up, extending your neck towards the ceiling. Hold this position for around 10 seconds. Repeat 5 -10 times as required to
Cobra stretch for lower back pain

Child’s Pose

This common yoga pose is an excellent way to stretch out the muscles in your lower back aiming to improve your lower back mobility.
 

 

How to?
Kneel on all fours. Rest your buttocks on your heels and stretch your arms as far out in front of you as you can whilst maintaining your hip position. Aim to hold the pose for around 30 seconds and repeats 3 – 4 times.
Child's pose for lower back pain

Glute Bridges

Glute bridges, or hip thrusts are an important exercise to build the strength in your lower back and glutes.
 
How to?
Lie on your back with your knees bent to 90 degrees, placing your foot and heels flat on the ground. Sqeeze you buttocks and abdominal muscles and drive your heels into the ground in order to lift your hips whilst keeping shoulders on the floor. Hold this pose for around 3-5 seconds, trying to maintain a straight line through your knees, hips and shoulders.
Glute bridges for lower back pain

Knee To Chest

This exercise aims to improve the mobility in your lower back and stretch the muscles around your hips.
 
How to?
Lie on the floor with your knees bent and feet flat on the ground. Reach down and pull your legs towards your chest. Hold for around 5 seconds, then rest your legs down before doing the same again. Repeat 10 times.

 

knees to chest for lower back pain

 Read more about back pain exercises in our blog: What are the best exercises for low back pain?

What Are The Best Things You Can Do About Your Low Back Pain?

Getting back to health after suffering from chronic low back pain can seem like a long road. There is no silver bullet, nor a quick fix. But there is a solution, and one that is ultimately rewarding with the end goal being pain free movement with an improved quality of life. Lifestyle changes are at the heart of breaking free of chronic pain and by making small actions in many areas, you can achieve this. Below are some areas of change which you can add to your rehabilitation to optimise your recovery.
  • EDUCATION / KNOWLEDGE
Coming to this resource is ste one in the treatment of chronic low back pain. The more you know and understand about back pain and why things hurt, the more you can appreciate that pain is not something that has to be around forever and can be beaten.

 

⇒ TOP TIPS:

  • Read and ask questions of your health professional.
  • Pick up resources such as David Butler and Lorimer Moseley’s “Explain pain”.
  • Remember: Pain is one of many  protective outlets that activates when it feels threatened.
  • Pain can be influenced by your past experiences, thoughts and beliefs, things you hear, smell or feel.
  • We are adaptable – just as our protective pain and danger sensors can be turned up, we can work to turn down these systems and lessen our bodies painful response.

 

  • NUTRITION
Good nutrition can improve our energy levels, give you a mood boost and is a key player in reducing chronic pain. There are heaps of great nutrition resources around, but if you unsure of where to start, or how you can implement it into your lifestyle, you may need to consult with a dietitian. A dietician can provide you with expert diet advice and link it to what you are trying to achieve with your own lifestyle.
 
⇒ TOP TIPS:
Prioritise low sugar and low GI foods with a great arrangement of foods containing natural vitamins and minerals to support your lifestyle. Reduce your daily consumption of caffeine and processed foods that provide high energy, for very little nutritional benefit.

 

  • SLEEP
Sleep is the body’s way of recharging and getting ready for the day. It is also where a lot of your healing takes place and this is especially true for chronic pain.

 

⇒ TOP TIPS: Have a designated routine for your rest and sleep time. Try and reduce your stimulation throughout the day including your caffeine and sugar intake and limit screen time before bed.
  
  • MINDSET / PSYCHOLOGY 
As you now understand more about pain, it’s very important to expand on this point as we know that our mindset, thoughts and feelings can impact very heavily on our perception of pain and suffering. It is important to challenge your own thoughts and beliefs, break down the barriers to recovery and seek help for any depression and anxieties you may be feeling about your pain.

 

⇒ TOP TIPS: Align yourself with a competent health practitioner that understands pain and can provide you with the tools to start your pain journey. To help with your mindset find someone that can be your trusted pain advisor. Specialist pain psychologists are available if you would like someone to talk to that understands the mental impact that chronic pain can have on an individual. It is also important to reach out to like minded people because building your social circle and joining a community can have a very positive impact on your pain.

 

  • MOVEMENT
Movement and exercise is considered to be one of the greatest treatments for chronic low back pain. Your back is robust and designed for movement so it’s important to get it moving with regular walking, swimming or at home.

 

⇒ TOP TIPS:
It’s very important to get the right information for your exercise, there is no one size fits all approach to chronic pain. Allied health services such as physiotherapy and exercise physiology have extensive training in prescribing the best exercises to suit each individual’s pain journey. These services don’t require referral from your GP and can be a great first step on you pain pathway

 

  • SELF MANAGEMENT AND WELLNESS (YOGA / MEDITATION / BREATHING)
As chronic low back pain involves an overstimulation and over sensitivity of the nervous system, activities that reduce the bodies stress overall can help manage your pain and symptoms. Stress relief can come in the form of anything you enjoy to do, or find comfort doing. Simple deep breaths can go a long way in reducing your central nervous system stimulation, which may be increasing your pain experience. Couple this with meditation or yoga and you have a powerful tool that will help you get on top of your pain, improve your stress levels and improve your quality of life.

 

⇒ TOP TIPS: Find what helps you relieve stress! This can be anything from listening to music or participating in some regular exercise. For added benefit, find your local yoga or wellness centre and get out in the community while improving your mindset and pain levels.
  
  • MEDICATION
(if required) – Some medications can be helpful in the early stages of your recovery from chronic pain. These can help to reduce your pain during or following exercise and help get you moving to kickstart your recovery.

 

⇒ TOP TIPS: Only take what is required to help reduce your pain levels. Painkillers, or other medications should not be used as a standalone treatment for chronic pain, but may be used as a short term combined approach with the other changes outlined in this document.
 
  •  COMMUNITY / SOCIAL / CONNECTED
Any sufferer of chronic low back pain knows what an isolating condition it can be. Community, and feeling connected are shown to be very important in restoring pain free quality of life.

 

⇒ TOP TIPS:

Reaching out to friends and family can be daunting, but support and care can help you along your journey to reach your end goals. There are also pain specific support groups out there where you can meet like-minded people that are motivated to become pain free such as yourself. Other options are getting out there, joining a exercise group or yoga studio to build personal connections along your pain journey.

 

  • PHYSIOTHERAPY / MANUAL THERAPY / SYMPTOM RELIEF
Symptom relief is a really important part of your pain journey. After all, that is the one of the main reasons for seeking help and advice. It is also important because reducing your symptoms can allow you to get actively involved in your recovery. It can do this by facilitating you participation in exercise, movement, yoga, pilates and can improve your sleep and general quality of life. Hands on treatment or manual therapies such as physiotherapy and massage can help across your pain journey as your pain improves and you work towards your recovery. Physiotherapy can also work as your coordinator, linking you with other health professionals and liaising with them so you can reach your full potential

 

Your physiotherapist should be working with you in all the above facets as we now know this is the best way to achieve full pain free and healthy lifestyle. To put the above into context, here at Upwell Health Collective, we use the 10% rule for our patients with chronic low back pain and individualise it to each client to ensure they can live their best life with great results. To achieve a 100% recovery, you should be gaining your improvements from each of the above categories, and not relying on just one as your magic, silver bullet.
Chronic Pain Treatment

Prevention of Low Back Pain

As always, the best treatment for low back pain is prevention. Exercise and education are the best recommendations for preventing low back pain. For education, reading a resource such as this is a great start to understanding you pain. However, there are so many other great resources and pieces of information out there that can further this knowledge and help apply it to your own situation. As for exercise, any type of exercise is great to get you started, however, if you need more guidance, or need your exercise individualised, an Exercise Physiologist or physiotherapist should be your first point of call. If you are not familiar with exercise physiology, they are university educated exercise professionals that have a deep understanding of pain and can link it to your anatomy, physiology and pathology. An exercise physiologist can, and should be your first point of call when looking for a program to prevent your low back pain.

The Role Of Physiotherapy & Allied Health In Low Back Pain

What is Physiotherapy?
Chronic low back pain is a complex condition that requires an open mind and a motivation to challenge the status quo. As we understand more and more about low back pain and it’s intricacies, we can start to understand the role that health and wellness plays in the full recovery of chronic low back pain. No longer is a medical model of medications and surgery adequate in achieving full pain free movement with a great quality of life. A multidisciplinary approach is considered the best treatment for chronic pain. Your physiotherapist should act as the coordinator in your pathway to a pain free lifestyle by linking you with the necessary people to help you along your journey.
 
At Upwell Health Collective our aim is to provide a holistic approach to musculoskeletal care and chronic pain. We do this by combining the likes of physiotherapy, exercise physiology, remedial massage, podiatry, Pilates and yoga all under the one roof with the latest evidence-based practice. We exist to re-imagine your healthcare experience to ensure the best possible health outcomes. If you need help with low back pain or a similar persistent pain condition, we would cherish the opportunity to care for you.
 
 

The Low Back Pain Bible is Written by Upwell Health Collective Physiotherapist, Michael Stizza. If you need support for your low back pain, sciatica or a chronic pain condition – book with Michael or another of our many motivated health practitioners using the button below

(1.1 Physiotherapy Initial Consult) – Learn more about Physiotherapy HERE.

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