In Part 1 of this blog series on back pain we reviewed the three types of low back pain, plus busted some myths about scans and radiology findings. In this post we will review the way physiotherapists can treat back pain, plus the lay out the best advice on what you should do at home or work to make your recovery as quick as possible. In Part 3 of this series we’ll review things that you can do to reduce your risk of future pain episodes.
As we have discussed in Part 1 there are three main types of back pain. Getting a correct diagnosis for your back pain is an important because it guides your initial treatment.
Physiotherapy treatment for this type of back pain focuses initially on relieving your pain and restoring your range of motion. We need to get you back to doing your normal daily activities as fast as possible, allow you to sleep normally, and be able to do your usual work duties. We use a combination of hands-on (manual) treatment together with structured exercise to increase your joint mobility, plus release muscles that are tight or in spasm.
As well as prescribing the right exercises for you, your physio will also clearly explain do’s and don’ts for you at home and work so that you help your back pain to settle as fast as possible. It has been extensively proven through research that staying active within your comfort levels, avoiding bedrest, and returning to your normal work and daily activities as quickly as possible is by far the best way for you to help your back pain resolve. Using basic medications like Panadol, Neurofen or Voltaren can also be very helpful at this stage.
Once your pain is resolving well your physiotherapist can guide you through a progressive exercise program to fully restore your strength, ensure you are moving correctly, and get you confident in returning to the gym or your usual sporting activities. Completing a supervised strength program with an accredited exercise physiologist is the gold-standard later-stage management program for low back pain, especially if you have already had several episodes of pain or are lacking confidence in returning to your full normal gym or exercise activities. If you prefer, Pilates is also an excellent way to exercise following low back pain.
The initial focus for physiotherapy treatment for back pain where a nerve is compressed (or pinched) is to relieve the pressure on the nerve. The degree to which the nerve is pinched or irritated can be gauged by the amount of referred pain that travels down your leg, plus the presence of other neurological symptoms including numbness, pains-and-needles or weakness. Hands-on treatment plus specific exercises are used to relieve these neurological symptoms as quickly as possible, plus medication such as Voltaren can be helpful. You will also be given exercises to do at home by your physio to help you relieve your pain and get moving again.
Once the pressure on your nerve is relieved, the physiotherapy management for radicular or nerve-related low back pain is largely the same as for non-specific low back pain. A combination of hands-on therapy plus structured exercise progression will relieve any remaining pain, restore your movement, and then reactivate your muscles. Staying active within your comfort, returning to work and daily activities as soon as you are able, and avoiding bedrest is strongly shown to be beneficial for this type of back pain.
Once your pain has settled then completing a supervised strength program with one of our physio’s or accredited exercise physiologists will get you fully back to your normal sport, exercise, work and daily activities. Pilates can also be very helpful, if you prefer this style of exercise. Any contributing movement problems that may have contributed to your pain can also be corrected to reduce your chance of future problems.
Serious lumbar (low back) pathology is very rare – present in less than 1% of back pain cases. It includes things like spinal fractures (broken bones), tumors, and some types of infections and inflammatory conditions. During your initial assessment your physio uses specific and effective tools to screen for serious pathology, and they are concerned they will explain their concerns to you and provide you with a referral back to your GP for further investigation.
So, now you know the guidelines for how physiotherapists treat the different types of low back pain. A key take-home message for you is that staying active within comfort, avoiding bedrest, and returning to your normal activity as soon as you are able has clearly been shown to be the best way for you to help yourself recover from back pain. Your physio will give you more guidance on this, plus use hands-on techniques and prescribe the most effective exercises for your specific situation to help you recover as fast as possible.
In the next post in this series on how physiotherapists treat low back pain we’ll review things you can do to reduce your risk of future pain episodes. As always, if you have any questions in the mean time please feel free to contact one of our friendly physio’s to see how they can help!
Low back pain is a very common problem that our physiotherapists treat every day here at Central Performance. There are lots of myths and conflicting advice out there, and this is very confusing and overwhelming for someone looking for treatment during a back pain episode. Although everyone’s presentation is unique and an individual assessment is the foundation of gold-standard treatment, there are some solid research-based guidelines that can really help you understand the process.
In this post we summarise some of the main things you need to know about the 3 different types of low back pain. The next post talks more about how physio’s can treat the pain, and the final one is about reducing the risk of having more problems in the future.
The first thing to know is that low back pain is REALLY common, with approximately 80% of Australians experiencing at least one episode of back pain in their lives. Whilst back pain can be very severe and debilitating, the good news is that the majority of cases of back pain DO NOT involve serious damage and will improve within 6-8 weeks.
Unfortunately there is a very high recurrence rate for back pain, meaning that if you have one episode you are very likely to have another one. Reducing this risk of future pain episodes is one of the major goals of physiotherapy treatment for low back pain. As well as physio you will often get great benefits from seeing an exercise physiologist who can prescribe an effective exercise program for you to reduce your risk of future problems.
Even though most cases of back pain improve within 6-8 weeks, seeing a physiotherapist early can help you in three major ways;
There are two very important findings to keep in mind from extensive back pain research looking at the use of radiology investigations like x-rays, MRI’s and CT’s;
1. The vast majority of back pains DO NOT need radiology investigations. Except in specific circumstances (see below), early imaging is not needed from a diagnostic or treatment planning point of view, and therefore it is generally unhelpful. Importantly, there is a solid body of evidence to show that merely having the scan in the first place can make your pain worse or persist for longer! This is because unrelated findings that often show up on scans can make people worry more about their pain (see the next point).
2. When people have scans for low back pain the report will almost always show “stuff”. A bit of degeneration here, some wear and tear there, a loss of disc height at this level or a bit of a bulge in a disc or two. But research clearly shows that most of this “stuff” is not actually really related to pain! Extensive research repeatedly shows that people who don’t have low back pain also often have disc bulges, disc degeneration, loss of disc height, facet joint degeneration etc… As a clinician I regularly see situations where a client is being treated for one-sided low back pain yet they bring in scans that they have already had done that show more degenerative findings on the other side. These things are usually just normal parts of the aging process, like getting grey hairs or wrinkles!
So, whilst there ARE times when imaging is indicated and the results ARE helpful when taken in the bigger clinical picture, it is important to remember that most back pains DON’T need imaging. Also, if you do have a scan then get your physio or doctor to thoroughly explain the results to you because many of the scary-sounding words are actually not relevant.
Whilst there are several systems around to classify low back pain, the most useful to the general population uses three categories.
1.Non-Specific Low Back Pain: this is by far the most common type of back pain, accounting for approximately 90% of cases. It describes pain that is felt in and around the low back area, and can sometimes extend down in to the legs. The pain can be anything from mild to severe, however there is no numbness, pins-and-needles or muscle weakness. It can be due to structures including joints, discs, muscles and ligaments. There may have been a specific incident to start the pain, eg a heavy lift, or it may just come on for no identifiable reason.
2. Radicular Pain – Commonly Called Sciatica, Nerve Root Pain or a Pinched Nerve: this type accounts for 5-10% of low back pain cases. It occurs when a nerve is compressed as it exits the spine, causing pain running from the back down into the leg. The pain may also be associated with neurological symptoms including numbness, tingling/pins-&-needles, or weakness. Clinical testing of nerve function may show reduced reflexes, power or sensation, and also positive neural tension tests including the straight leg raise (SLR), prone knee bend (PKB) or slump tests. If this nerve compression is present then it is important to begin treatment to relieve the pressure from the nerve as fast as possible. As with non-specific low back pain, radicular back pain can also be either from a specific incident or for no memorable cause.
3. Serious Pathology: this is very rare – less than 1% of low back pain cases are due to serious pathology. It includes things like spinal fractures (broken bones), tumors, and some types of infections and inflammatory conditions. There are specific and effective screening questions and tests that physiotherapists use to identify possible serious pathology and if they are concerned your physio will refer you for further investigation.
Well, that wraps up part one of our series on physiotherapy treatment for low back pain. Next time we look at how physiotherapists treat back pain, and then finally how to reduce your risk of future pain episodes. As always, if you’d like any further information please feel free to contact one of our friendly physio’s at Central Performance!
Low back pain is one of the world’s most common conditions and is a leading causes of disability and work absence worldwide. It affects over 80% of the world population and can result in a significant personal, social and financial burden.1 Low back pain usually settles down within 4-6 weeks but has an 80% chance of reoccurring within 12 months of the initial injury. Exercise therapy is the most common form of treatment for low back pain. It is low cost, easy to access, has a positive biological affect on the body and is recommended in most clinical practice guidelines.2
The Pilates method aims to improve posture and body awareness while building strength. The six basic principle of Pilates includes tightening the ‘powerhouse’ (trunk and gluteal muscles), concentration (cognitive attention), control (postural management), precision (accuracy), flow (smooth transition) and breathing while performing a range of exercises.2
It is a great way to get people moving in a smooth and controlled way. At Central Performance we use the reformer, wunda chair and mat-based exercises in a circuit style approach so that the exercises are varied and fun. These exercises use springs and body weight as resistance and can be adjusted to your ability. Our initial assessment involves a history of your injury and a physical examination to determine your exercise program. Than we get started! Starting on four 1-on-1 sessions to get used to the various exercises on your program. From there the choice is yours. Continue with 1-on-1 sessions or move to our group classes (max 4 people).
But how does this help with low back pain?
Just move! Our backs love movement. The worst thing to do when you have low back pain is to stop moving and stop exercising. Pilates allows you to move and exercise in a nice controlled and monitored way without using heavy weights. It can be a way of progressing your exercise tolerance or to transitions back into gym-based exercise.
I need a stronger core to get rid of my back pain!
This is often a very common perception in today’s society. We are often told to strengthen our core to prevent low back pain. However, if you have had ongoing or episodic low back pain than you may already bracing and overusing your core subconsciously to help ‘protect’ your back. Before strengthening your core it is important to regain normal relaxed movement of the spine. This relaxed spinal movement can fundamentally change the way your back behaves day to day. Pilates is a good way of starting off this process, using controlled movement of the spine before progressing to more progressive strengthening exercises, whether it be at the gym or harder Pilates exercises.
Headaches can really affect your lifestyle. You may find it hard to concentrate at work, & it can make you feel like not socialising so much because lots of noise or bright lights make it feel worse. Exercise is not very appealing & can make the pain worse, & many people become a bit short-tempered when they have a headache. You may also start to catch yourself taking regular painkillers as if it’s become a normal thing to do. If this sounds like you then there are 4 simple checks you can do yourself to see if your neck may be part of the problem.
Headache is the world’s most common pain disorder & affects 66% of the global population. Research shows that up to 22% of headaches are either partly or fully driven by problems in the neck. When the neck, which is officially called the cervical spine, is producing your headache it is called a cervicogenic headache. Studies also show that assessment & treatment by an appropriately trained physiotherapist is effective for treating these neck-related or cervicogenic headaches.
Several structures in the neck, primarily those in the upper neck or “sub occipital (C1-3)” region can produce cervicogenic headaches. They include the spinal joints (facet or zygapophyseal joints), muscles, & discs (especially the C2/3 disc). Restriction, tightness or inflammation in any of these areas can affect neural processing in an area called the trigeminocervical nucleus (TCN) & cause pain referral along the trigeminal nerve to the head & face area.
It is important to remember that many people with neck-related headaches do not have a history of neck trauma or even significant isolated neck pain. At Central Performance we treat a large number of headache sufferers & we find that mostly it is related to their posture, with no specific separate neck issues. Often people have tried regular painkillers, heat/cold or massage, but have only found temporary relief.
Diagnosing different types of headache can be tricky because people may have more than one type of headache at any given time. However cervicogenic headaches do have some common patterns & features, so if you know what to look for you can quickly get an idea of whether your neck is likely to be part of your problems. Use these 4 simple tests to help you decide if you should get your neck checked out to see if it is causing some or all of your headaches.
Most cervicogenic headaches start from the back of the skull & then radiate forwards to the temples, cheek, forehead, eye or jaw area.
The pain is normally on one side or at least worse on one side, & rarely swaps sides.
Often gentle movement or stretching of the neck will at least temporarily ease the headache. Sustained poor postures such as looking down at a screen, iPad or phone will usually increase the headache.
Firm pressure around the upper neck & base of the skull can temporarily increase or relieve the headache.
Using these 4 tests will help you quickly screen if your neck is likely to be contributing to your headaches. If these tests indicate that your neck is involved, seeing a physiotherapist who is trained & experienced in treating cervicogenic headaches is the best front-line management. At Central Performance our physio’s have all of the knowledge & experience required to help you. One of our Director’s, Chris Jackson, has a Master’s degree in Manipulative Physiotherapy which focusses heavily on spinal problems including upper neck pain & headaches, & has been treating cervicogenic patients for over 23 years.
There is extensive evidence showing that physiotherapy is effective in 3 key areas of management for these patients;
If you are unsure whether your headaches are coming from your neck we can assess you to confirm or rule out your neck as a cause of your problems. If we do not feel that your neck is the main cause of your problems we can discuss other possible causes, & can liaise with your GP if other investigation or management is required.
We can often bring patients fast relief from headache pain by using tailored hands-on treatment techniques including joint mobilisations, soft tissue releases, mobilisations-with-movement & trigger point releases. We also start to put you back in control of your symptoms by providing you with a home exercise program designed to re-inforce & build on the improvements made with hands-on treatment in the clinic. Another goal in the early stage is to allow you to significantly reduce or eliminate your medication use.
As your pain settles you get access to our great research-driven exercise programs for effective long-term symptom relief. Our Clinical Pilates program includes private & small-group sessions using individualised exercise programming specifically designed to strengthen the spinal stabiliser muscles. Restoring balance to your spinal mobility & stability systems is critical & effective in keeping you free of headaches into the future. Click for more info on Clinical Pilates or watch the video below.
You may have headaches from different mechanisms at different times, & even different types of headaches occurring at the same time. Often one mechanism can set-off or aggravate another, so seeing a physiotherapist to effectively resolve the cervicogenic component of your headaches can provide significant relief even if some other mechanisms are involved as well.
The key to effective headache treatment lies in the accurate diagnosis of what type of headache you have. We regularly get clients who have had headaches for years & have taken a significant amount of medication that may have been unnecessary because they never really considered their neck as a source of much of their pain. A skilled physiotherapist can effectively assess if your neck is involved, & give you effective & proven treatment to get you feeling better. When this is matched with a tailored spinal mobility & stability exercise program like our Clinical Pilates program you can realistically look forwards to a future without headaches, or at least with greatly reduced symptoms.
Lastly, please remember that whilst headaches are very largely due to relatively benign causes, if you are experiencing lots more severe or frequent headaches, or if they have come on or increased very suddenly, you should definitely get them checked out ASAP. Your GP can help you, or if you are screened by one of our physio’s & we think you need further investigation we can refer you on to see the best person for you.
Research shows that a Pilates-based exercise program specifically targeting core stability is effective for preventing & managing low back pain.
Did you know that once you get back pain the chances of getting another episode of back pain in the next year is 80%? This is a scary statistic, but the good news is that you can more than halve this risk by completing a core stabilisation program.
One major reason behind such high recurrence rates for back pain is pain inhibition of the core stabiliser muscles. Basically, we all have a hard-wired reflex called the pain inhibition reflex that switches off our core stabiliser muscles during back pain. Importantly, research shows that these muscles do not automatically turn back on again once our back pain settles.
The fact that your core stabilisers stay switched off even when your pain has settled is critical because it means that even if your pain goes away you are left with a weak spot in your back. This weak spot is much more prone to re-injury, especially when your pain has gone so you think everything is back to normal & you get back into your normal activities & exercise. A classic example would be someone who just takes pain-killers or anti-inflammatories so they feel much better, then goes back to some exercise & then has a much bigger recurrence of pain. Of course getting rid of the pain as fast as possible is good, but you have to make sure your back gets fully strong again once your pain goes.
Another reason for the development of this weak spot is the disruption to the timingof our core muscles, i.e. the muscles don’t fire at the right time. Normally our core stabilisers fire before we begin moving to prepare our spines for taking load. However after an episode of back pain our stabilisers don’t fire until after we begin moving, which means that our spines are left unsupported for the initial part of movement. This puts our joints & discs under much more load & harmful shearing stresses than they are designed for because our core muscles are working reactively rather than proactively.
A lot of research now shows that re-training our core stabilisers is the most effective way to get rid of that weak spot. But what is “the core”?
Many people think of our core as being our stomach muscles – our abs (six pack) & our obliques. However, this is in fact incorrect. The “core” is a group of deeper muscles including our transversus abdominis, pelvic floor, diaphragm & multifidus. These lie behind our abdominals & obliques, & our multifidus actually extends along the entire length of our spines. Your core is critical for keeping your spine stable, strong, healthy & flexible.
To retrain your core the most important thing you need to do first is to learn how to switch your core on without using your other abdominals to compensate. This is very different to just doing normal abdominal exercises, & this is where many people get into trouble. When you’ve had back pain your core is switched off & your other abdominals become overactive to try & compensate. So if you just do normal abdominal exercises then most of the time you’re just using the wrong muscles & your core stays weak. You have to “wake up” your core first, get it firing, & then gradually integrate it back into higher-level exercises. Think of it like giving you a really stable base to support you as you get back to your normal activities & exercise.
One of the best cues for you to get the feeling of contracting your core stabilisers is by doing a pelvic floor contraction. Your pelvic floor muscles, as well as working as part of your core stabiliser system, also control your bladder & bowel. To switch them on imagine trying to stop your flow of urine half way through. If you put your fingertips just inside your pelvic bones at the front of your hips you should feel the muscles slightly contract & become firm. You may also notice your belly button draw down towards your spine. This is your transversus abdominus contracting.
The easiest position to feel this contraction is lying on your back with your knees bent up & feet on the floor. You need to make sure your breathing stays relaxed & regular during the contraction. You can put a hand on your ribs to make sure they continue to move in and out just like they do with relaxed regular breathing. Practice keeping this contraction going for 5 breaths in & out, then relax. Repeat this for 2 or 3 minutes at least daily (preferably twice a day) to get the hang of it.
Once you can switch on your core you need to build it’s strength & endurance. You also need to start getting it to co-ordinate properly with the other muscles around your body. This process is critical to your long-term success because you need your core to work effectively with all your other muscles during your every-day activities & exercise. If you sit at a desk for 8 hours a day your core needs to have the endurance to stay active for the whole 8 hours. If you go for a 30 minute run your core needs to be firing & working well with your hip & leg muscles the whole time.
Pilates is a great way to train your core. It can help you train the correct muscles with the correct timing to improve stability, mobility, strength & function. If you have recently had back pain you need to do a Pilates-based re-stabilisation program that is specifically targeted to people recovering from a pain episode to ensure that your fundamental core activation is solid before progressing to more general or higher-level exercises.
At Central Physio and Performance Fitness we have a great range of Pilates programs tailored to meet the needs of clients ranging from beginners to experienced Pilates devotees.
Core Control is specifically designed for people recovering from back or neck pain or for those who are new to Pilates. It is a gentle, closely-supervised program that gradually activates & strengthens your core. It’s perfect for you if you have had back pain & want to strengthen your spine but are unsure about how to become stronger without stirring up your pain.
Freedom Pilates is the next level of mat Pilates. It brings in more challenging exercises by increasing resistance, speed & complexity of movement. It is great for integrating core stability into more higher-level exercises & is ideal for you if you already have some Pilates experience.
Studio (Equipment) Pilates hugely expands your exercise options by using equipment including the Reformer, Wunda Chair & Barrel. We individually prescribe your exercise program so that it is perfectly matched to your ability & fitness goals. Individual & small group (max 3 people) sessions are available.
Our Pilates services are run by Helen Hathaway, our physiotherapist with formal DMA qualifications in Clinical Pilates. As well as being formally trained in the Pilates method Helen also incorporates newer technology, equipment & research into her sessions. And because she is a registered physiotherapist you may be eligible for private health fund rebates – check with your fund.
1. Burton AK, McClune TD, Clarke RD, Main CJ. Long-term follow-up of patients with low back pain attending manipulative care: outcomes and predictors. Manual Therapy 2004; 9: 30-35
2. Richardson CA, Snidjers CJ, Hides JA, et al. The relation between the transversus abdominus muscles, sacroiliac joint mechanics, and lower back pain. Spine 2004; 27(4): 399-405
3. La Touche R, Escalante K, Linares M. Treating Non-Specific Lower Back Pain Through the Pilates Method. Journal of Bodywork and Movement Therapies 2008; 12(4): 364-370.
Here at Central Performance, it is a top priority to help those of you suffering from back pain. We want to help you improve your range of movement, core stability and movement patterns, as well as help you understand more about your back pain. Our newest initiative to achieve this goal is our Clinical Pilates program, run by physiotherapist, Helen Hathaway.
Clinical Pilates is exercise rehabilitation based around posture, core/central stability, balance, control and breathing. For each person with lower back pain, there will be a very different history of how the injury started, distinctive traumas and a wide variety of factors that can aggravate or ease the pain. It is for this reason that specific INDIVIDUALISED programs are vital for improving lower back pain by correcting the underlying instability, weakness and poor motor control. New research has found that exercises that are distinctly targeted to a patient and their individual needs have a strong correlation with improved symptoms, both immediately after exercise and over a three month period.
Clinical Pilates incorporates a combination of exercises performed on the mat, with theraband and on the Pilates specific equipment – the reformer, Wunda chair and the barrel.
If you have suffered or are suffering from lower back pain you may recognise the feelings of weakness or instability that can correspond with the pain. This occurs because of our pain inhibition reflex – this is when our brain recognises pain signals from the lower back and subsequently reduces the activity of the lower back and core muscles. These muscles do not then automatically switch back to on to normal full strength after the episode of pain passes and so we are then left with a weak spot. This increases the risk of recurrence or continuing pain.
Research shows that there is a 80% risk of recurrence within 1 year after an episode of lower back pain. This risk can be reduced by 65% with a directionally specific core re-training program such as Clinical Pilates.
Previous trends in core training were to consciously cue the transversus abdominus and pelvic floor muscles prior to and during movement. This means you were instructed to think about contracting your core muscles prior during exercises. More recent research has found that this is ineffective because the messages from the brain to the muscles take too long to process and the muscles do not activate correctly. Clinical Pilates therefore does not focus on consciously cueing the muscles, rather uses specific targeted exercises that stimulate the stabilising muscles to fire. Better results are found with this method.
Clinical Pilates at Central Performance will start off on a 1-on-1 basis for at least the first four sessions. This allows you to familiarize yourself with the Pilates equipment and the nature of the exercises and to allow complete attention from Helen, the treating physiotherapist. This program is known at Central Performance as the QuickStart program, which will then give you baseline ability level to allow you to filter into a small group setting if you’d prefer or continue with 1-on-1 sessions. Even in a group environment, you will each be doing your own individualised program, rather than generic exercises. The group numbers are kept low, with a maximum of 4 people per group, to enable considerable individual attention and feedback, while also encompassing a great social atmosphere.
The first session is a 1 on 1 appointment involving:
Following your initial Clinical Pilates appointment, Helen will develop a specific program for your needs, which will continue to progress as your core stability and confidence improves. Clients who are already on our Clinical Pilates program have achieved excellent results, including reduced lower back pain, as well as improved confidence in their movement patterns and strength.
The Clinical Pilates program at Central Performance is run by certified Clinical Pilates instructor and physiotherapist, Helen Hathaway. Helen has been trained by DMA Clinical Pilates, the experts in Pilates education within Australia and worldwide over the last 25 years. She has vast experience in treating lower back pain and dysfunction from her years in private practice and with elite sporting teams. Please feel free to email Helen if you are interested in participating in Clinical Pilates at Central Performance.
1-on-1s: Can be booked like regular physiotherapy appointments at any time that suits. Sessions are 40minutes long.
Groups: Tuesday 5pm, Wednesday 5:30pm, Thursday 7:15am. More groups are being formed at regular intervals so please let us know if you have requests for times.
Central Physio & Performance Fitness – 418A Elizabeth St, Surry Hills
1-on-1s: $89 per session – able to claim on the spot with your private health fund
Groups: $45 per session – able to claim with health fund at the end of a course
Call 9280 2322 to speak with our friendly staff and book a QuickStart Inititial Appointment, or email firstname.lastname@example.org.
Call us on 9280 2322 or email us.