Low back pain treatment and prevention are complex issues. Part 1 of this blog series talked about the diagnosis of low back pain, and Part 2 outlined some important treatment techniques to help settle down your pain. This final post gives you an easy-to-understand review of the latest evidence and recommendations about what you can do to reduce your risk of having future problems or recurrent pain episodes.
The research on how to prevent low back pain is often inconclusive, and even directly conflicting in some areas! Furthermore it’s evolving all the time, meaning that some treatments used in the past are now completely refuted – for example the old advice of “lie down for 3 days” has been shown to be one of the worst things for you to do. The same with using a back brace. However, even though there is still much research to be done, there are some definite, reliable and consistent findings to guide both the treatment and prevention of low back pain.
Treatment Principle #1: An Individual Approach To Low Back Pain Treatment And Prevention Is Essential
This is the most important principle of all. There are a huge number of factors that can produce or influence low back pain, and this means that unless you know which particular factors are the main issues for you, you won’t know where to start. This is why what may seem a miracle cure for your friend may make you feel worse or no different.
Whilst the research is yet to clearly define highly consistent risk factors for low back pain across wide population groups, factors that may predispose people to have ongoing back pain in some circumstances may include;
Physiological factors – past injury, weakness, tightness, poor movement or exercise techniques, being overweight or obese
Psychological factors – stress, anxiety and depression have all been shown to increase rates of back pain
Lifestyle/occupational factors – being very sedentary, sustained or repeated awkward postures (note that basic standing or sitting posture in itself has not been shown to be a significant predictor of low back pain), vibration with certain occupations…
Treatment Principle #2: Exercise Is Great For Everybody – But Not Everybody Will Respond To The Same Exercise
This relates to principle #1 above – you need an individual treatment approach. Research does very clearly show that exercise is among the most effective ways to treat and prevent low back pain. However it does not show that there is one particular type of exercise that is best for everybody. A lot of people come in to see us as physio’s saying things like “I need to do some more core exercises to get rid of this pain” (whatever your “core” is anyway… but that’s another discussion!) , or “I had a friend who said Pilates cured her back pain – I need to do that”. But extensive research has not found a specific type of exercise, like “core exercise” or Pilates, is superior to other types of exercise.
What this means is that we need to get you on the right exercise program for you. At Central Performance our back pain exercise programs are completely tailored for each client, and will often include elements of Pilates, functional strengthening, mobility (stretching/foam roller/spiky ball), motor-control/proprioception retraining, and sport/activity/lifestyle-specific exercises.
Even within a given type of exercise, you need to begin at the right level for you, and then progress at the appropriate rate for you. For example squats and deadlifts are often feared by low back pain patients because they are worried (understandably so!) that they will make their pain worse or injure themselves further. However we use squat-type movements every single day – think stand-to-sit, reaching into a low kitchen cupboard, picking up your kids or the shopping bags, putting the washing basket on the ground – we do this multiple times every day! So we need to be confident and capable doing these types of movement, and the way we get this confidence and capability is by training the movement, not by avoiding it! Starting within your capacity, having supervision to ensure you use the right technique, and progressing the exercise appropriately will (often surprisingly quickly!) give you the physical strength and also the confidence to do these movements with ease.
As well as giving you the strength you need to reduce your risk of future back pain with physical activity, doing the right exercise program can also reduce what is called fear avoidance. This is where you stop doing an activity because you’re worried you will make your pain worse, and the longer you avoid it the weaker and less confident you become. This leads to a downward spiral of ever-decreasing physical activity. Research shows this psychological factor can play a significant role in recurrent or chronic low back pain, and can end up significantly limiting the range of leisure, sporting and occupational tasks you feel able to do. Having the right exercise program, guidance, support and supervision in place to avoid or address fear avoidance is very important.
Principle #3: Moving Regularly Is More Important Than Posture, Core Strength And Ergonomics
This relates to both of the principles above, and comes as a surprise to many people. Whilst specific postures or ergonomics (i.e. how your desk, chair, screen, keyboard and mouse are set up) may be relevant for some people in certain occupations, research shows that these factors in isolation are not significant predictors of low back pain. So, people who have a “slouched” or sway-back posture are not consistently more likely to have back pain than anyone else.
So does this mean that posture and ergonomics are irrelevant? Not so fast! Again, it comes down to your individual case. Whilst having a slouched posture in itself may not increase your risk of back pain, it may be that having this posture in addition to having poor ergonomics (eg a chair with poor back support that predisposes you to slouch even more) plus leading a sedentary lifestyle through a combination of long work hours and not doing any regular exercise – put together these things may increase your risk of back pain. Similarly, having a sway (hips forward) posture is not a predictor of back pain generally, but having this posture in combination with being a high-level gymnast or cricket fast bowler (both activities which can repeatedly put your back in to end-range extended/rotated positions) may increase your risk of back pain.
Also, current research attempts to assess “core stability/strength” have failed to consistently show any significant correlation with low back pain rates. This is a complex topic that could fill several blog posts in itself because even the concept of what exactly is your “core”, let alone how to measure it and is it at all important, is all still up for debate! So I’ll just say here that our recent obsession with “core strengthening” as a way to treat and prevent low back pain appears misled. It may well be like the factors mentioned above – relevant for some cases of back pain, but not others, once again highlighting the importance of individual assessment and treatment planning for low back pain.
One thing that has been shown consistently to be important is moving regularly – as they say, motion is lotion! Of course this ties in with principle 2 – overall, exercise (which involves movement) is good. And regular movement has many other benefits apart from just potentially reducing that recurrence rates for back pain. Breaking up sustained sitting plus reducing overall time sitting has many benefits across all areas of health like cardiovascular, metabolic (weight control, diabetes), psychological and even some types of cancer (bowel, ovarian and prostate) are reduced by avoiding sustained sitting. Some of the mechanisms for this are unclear as yet, but in general having a sit-to-stand desk and moving regularly to break up sustained sitting is a great habit to get in to.
So, How Do I Stop My Back Pain Coming Back?
As you can see, both the treatment and prevention of back pain are very complex areas and many factors are at play. This is why an individual approach is essential – a technique or exercise that feels like a miracle cure for you may be completely ineffective for someone else, or in fact could make them worse.
The complexity of low back pain, plus the very varied individual responses to treatment techniques and exercise, is also why establishing clear guidelines for preventing back pain through research is difficult. Basically, research is very good at identifying treatments that will help the majority of people. But, for example, if a particular exercise is highly effective for preventing future pain in a third of low back pain sufferers, has no effect for another third, and makes the final third more likely to have future pain, then the overall effect shown in the research will be that the treatment produces no benefit, even though it was highly effective for one third of back pain sufferers.
A good analogy is antibiotics used to fight infections. A particular antibiotic may be very selective – i.e. it is highly effective at killing a specific type of bacteria, but has basically no effect on any other type of bacteria. So, if you only evaluate it’s effectiveness across a range of bacteria you will find little or no benefit, but if you selectively use it on the right type of bacteria it may be a wonder-drug.
The above paragraph highlights the need for a comprehensive individualised approach for treating and preventing low back pain. Having a personalised assessment and treatment program makes sure you receive the right treatment for your particular presentation. It’s like your GP running blood tests to make sure you receive exactly the right antibiotic for an infection, rather than just giving you a general one and hoping it works!
At Central Performance our physiotherapists effectively treat back pain for clients every single day. We have all of the skills, knowledge and experience that you need for effective pain relief followed by a solid treatment plan to prevent or minimise your risk of future back pain. Plus we work closely with our in-house team of exercise physiologists and Pilates instructors so that once your pain is resolved we can tailor an exercise program precisely to your needs, both to prevent future back pain and also to help you achieve all of your health and fitness goals.