Many of my patients come in with an acute, active back issue, and many more present with a more chronic condition which flares up periodically. Granted, my patient population is fairly self-selecting, and perhaps 2/3 of them are physically active and take relatively good care of themselves. But even with this “enlightened” population, I find that when back pain is an issue, patients often avoid exercises or certain movements due to the fear of pain and further damage to their backs. It becomes the job of the health practitioner as coach to help them shift their motivations from being a pain avoider to a pain manager.
Fear-avoidance behavior leads to deconditioning. 2/3 of acute low back pain patients believe that a wrong movement will cause them serious harm, and this belief inevitably leads to decreased activity and deconditioning and lessened back stability. Half believe that avoiding certain movements is the safest way to avoid further pain episodes. Thus a vicious cycle is perpetuated.
The goal with this patient population is to increase their confidence in doing normal daily activities as well as in exercising. Certain movements need to be avoided of course, and this is part of the patient’s education in the office. For example, forward flexion should be avoided first thing in the morning when the low back discs are more hydrated and thus less stable. And brisk walking, with the sternum and chin up and the upper arms swinging, as well as basic core and spine stabilization exercises such as the McGill Big 3 are safe and effective.
Granted, when the low back is in an acute phase, pain can be extreme and even rolling over is near impossible. I know, I’ve been there myself! A few days of bed rest are appropriate in such cases, but prolonged bed rest is not. Muscle and joints lose their mobility with restricted activities during acute pain, and initial movements will likely cause discomfort but certainly will not harm. Think of inactivity like rust (rest = rust). Movement lubricates the joints and muscles. Even small incremental movements as soon as possible, even while there is still pain. In most cases, pain is caused by dysfunction and not tissue damage or pathology.
Many chronic pain patients initially bring in an MRI or X-Ray showing some disc or arthritic findings, which they believe is the underlying cause of their distress. What’s interesting to note is that such findings are common in non-pain patients (coincidental findings). As common, pain patients often show nothing wrong on similar studies. Structural pathology is more related to age than to symptoms. There may be some correlation between pain and MRI studies, but in most cases it’s not enough to base one’s care on it. Most of the time what’s more effective is to correlate exam findings with the patient’s experience – i.e. what movements cause pain, and develop a treatment plan based on that. The most common cause of chronic back pain is when external load consistently exceeds physical tolerance. This is caused by lack of fitness and not injury in most cases.
In the initial meeting and report of findings, patients generally want reassurance and advice how to get moving again. At this point it is important to identify their concerns, worries and fears around further hurting themselves. They want to know if their problem is serious and if their pain is coming from an injury or degeneration. In most cases pain persists because of controllable factors that we can identify. We need to identify movements the patient needs to avoid and movements the patient needs to do. It is important to give the patient some sense of how long their pain will last, so they can have reasonable expectations of what to expect.
The initial goal is to reduce pain. Traditional medical management has historically been to “let pain be your guide.” But this adage promotes unnecessary fear and limitations to movement. Some basic micro-movement exercises can make a big difference and change the trajectory of the patient’s condition. Some examples are:
- Cat-Camel (the patient is on all fours and gently flexes/extends their back).
- Incidentally, this movement can be applied sitting as well.
- Lie on your back with knees bent and either resting on a chair or with pillows under the knees.
- Brugger relief position: standing, relax arms at your side, palms forward, fingers spread and exhale actively like blowing a candle but not enough to blow it out.
- Brugger overhead: reach your hands overhead gently, take a big breath in and hold it while reaching actively over your head.
- Take micro breaks from sitting every 20 minutes. And when sitting, don’t slouch your back! Keep your back straight. This is most easily accomplished by sitting all the way back in your chair so that the back supports your back, and sit with your “sit-bones” and not your sacrum on the seat.
- Use an umpire position: supporting yourself on your thighs with a straight back. Use this position when brushing your teeth, washing dishes.
- Lift your foot onto a stool with a straight back to put on your shoes, or sit and hinge with a straight back to put on your shoes.
- Carrying a package, hold it close to you and not away from your body. Carrying a bag on one side, tighten your abs and keep your spine straight.
- Lifting a heavy load, keep a straight back, come into a squat, engage your abs and glutes, don’t twist, and stand with the load close to you.
The focus of this Blog is on the initial stage of care. Further steps are important, especially for the patients who have been in pain for a while.
A second stage includes Cognitive and Behavioral Approaches, which address patients’ worries and fears and ways to reduce their apprehensions. This is especially useful since subacute patients are at a heightened risk for becoming chronic pain patients. The phenomenon of central sensitization happens when the nervous system becomes habituated to pain so that its threshold and tolerance drops (known as Allodynia) such that it now responds to non-noxious stimuli as if it were injurious. This is the same phenomenon that happens with phantom limb pain, where an amputee feels pain in a limb which isn’t there.
A third stage of care includes a Multidisciplinary Biopsychosocial Approach, addressing strategies for returning to work and obstacles around this. Studies show that short-term sick leave leads to less days off work whereas long-term sick leave leads to chronic disability. Much of this is initiated by the message pervade by the health care management team. Chiropractors have been more successful than their medical counterparts in giving helpful advice, explaining the cause of pain, and giving simple exercises. Setting expectation is crucial, since if a patient is lead to believe their pain is temporary and manageable, they are much more likely to get better faster.
In summary, focusing patients on function rather than pain is the first step out of the pain cycle. Pain control, activity modification (sitting, lifting), increasing activities (walking), return to work and exercising are all important steps to getting out of the back pain black hole.
Much thanks to the continued input and teachings of Dr. Craig Liebenson. Much of the information for this article was gleaned from his manual Rehabilitation of the Spine, 2nd Ed, Ch 14 ”Active Self-Care.”