Low back pain is very common- affecting 85% of the population at some point in their lives. Unfortunately in 20-30% pain can become persistent and impact on daily life and sport.
So what causes back pain?
Interesting a structural cause of low back pain is very rare (only 10-15% cases). Ie pain generated from a specific disc/ facet joint/ ligament. For the most part, low back is a complex interaction of tissue sensitivity, neurophysiology, posture and movement practises, perceived threat associated with pain, genetics, social and lifestyle factors.
Why is persistent low back pain such a common problem?
Well our lifestyles certainly don’t help- most of us are fairly sedentary in our jobs and technology has made everything so easy and convenient, we often doing get to move our backs in the way they crave.
In healthcare, fixation on structure in the diagnosis and treatment of low back pain has also not helped the issue.
The use of MRI has increased (so too has the incidence of low back pain). MRI is very good at showing pathology. Too good. It shows pathology in most people, including those without pain (91% disc degeneration, 56% disc bulges, 32% disc protrusion and 38% annular tears). Many of our highest performing athletes have “abnormal MRI scan, this does not mean they all have pain, or indeed will go on to develop pain.
Injections, manual therapy and surgery then targeted at a specific structure is unsuccessful.
We enter a viscous pain cycle reinforced by suboptimal management. Our backs become more sensitized as we become more efficient at processing painful input (as with practicing a skill, neurons that fire together wire together).
So when do we scan?
If we are concerned there might be more serious pathology (malignancy/ infection/ inflammation or if there has been significant trauma)- this accounts for only 1-2% patients.
If these is progressive neurological loss or cauda equina symptoms. Also if we suspect specific pathology that can be targeted with treatment. This accounts for 15% patients.
The remaining 85% of cases of low back pain do not correlate to a specific structure.
Your Physio will do a thorough assessment- asking detailed questions that would alert them to any serious pathology, and then carry out a full examination. This may include a neurological assessment.
What about acute low back pain?
Acute low back pain refers to a sudden onset of intense pain localized to the back. Pain, stiffness and postural shift are usually due to muscle spasm rather than damage pertaining from a particular structure. Most of the time symptoms improve within 6-12 weeks (or shorter) with simple analgesia and a home exercise program.
So what is the best management?
Your Physio will triage you to rule out any specific or serious pathology
An explanation will be given as to what is likely to be causing symptoms and contributing to tissue sensitivity
Your concerns and beliefs will be discussed
You will be prescribed an individualised graded exercise program- exposing tissues to movement in a way that does not increase sensitivity
Manual therapy (spinal manipulation, mobilisation or soft tissue techniques such as massage), may be considered as a part of your treatment package
Self management strategies will be explored
Lifestyle factors will also be considered and discussed
You will be encouraged to continue your normal activities where possible, perhaps with modification
You will not be told that joints are out of place
We aim to empower you in your recovery, so that you can continue your treatment at home
Here are the NICE guidelines for the management of back pain https://www.nice.org.uk/guidance/ng59/chapter/Recommendations
Lin et al (2019) What does best practice care for musculoskeletal pain look like? Eleven consistent recommendations from high-quality clinical practice guidelines: systematic review
A nice little video by the Chartered Society of Physiotherapists on managing back pain https://www.youtube.com/watch?v=24P7cTQjsVM