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The location, intensity, and horror stories of back pain can often make back pain seem worse than it is. Interestingly, however; the most threatening types of back pain rarely involve severe pain. Additionally, common causes of back pain are much less likely to be serious than we think. Less than 5 percent of back pain is “serious”, and of that small percentage, most of it is related to breaking your back. Less than 1% of back pain is actual spinal cord damage, autoimmune disease, or cancers. So if you stop reading here and you have a good feeling you don’t have any of those issues; you have a good shot at getting better since you can relax and get back to moving as much as you can without aggravating your symptoms. And little by little, things should improve.
With that being said, do you need medical intervention? Well, if you answer yes to the following questions, it might be a red flag and worthwhile to have it looked at by a doctor. 1 - Has it been bothering you for more than 6-8 weeks? 2- Has there been no improvement in 6 - 8 wks, or has it been getting worse? 3 - Do you also have any of these signs/symptoms: painful tapping/ throbbing sensation, tingling/weakness of legs, fever/malaise, unexpected and sudden weight loss, troubles going to the bathroom (starting or stopping urination), incontinence (can’t poop), or saddle paraesthesia (numbness in the parts of your groin that would be touching a saddle) or you’re over 55/ under 20. If you answered yes to these questions it doesn’t CONFIRM that you have something horribly wrong with you. It just means you should get checked out to be safe. Better to be safe than sorry! Also, not having any of these red flags is not a guarantee that you’re in the clear — but it’s a good start. There’s now potentially a less than a 5% chance that you’re in big danger, and a 95% chance you're going to be ok. Phew!
Here are some causes of Red Flags that you probably aren't experiencing.
Now that you’ve gotten through the red flags section, or a professional has ruled anything sinister out, the next question people usually ask is “do I need an x-ray or an MRI?”. Well, if you have a red flag or are considering surgery as an option, then an X-Ray or an MRI might be important. But, let your doctor of physcial therapist decide. If you’re one of the 95% of people who don’t have red flags, you probably do not need an x-ray. Only 1/2500 back x-rays show a relevant finding anyway, so let’s spare the radiation and the cost of imaging. There are also other advantages to NOT getting imaging done. It turns out, if you get an MRI or X-Ray, the fancy terminology that shows up on your report could cause some YELLOW FLAGS. These lesser known yellow flags are particularly relevant to back pain because they actually predict an increase in the risk of back pain becoming chronic and long lasting. Why? Because receiving a diagnosis via imaging without context can actually become a NOCEBO, an unwanted negative psychological or psychosomatic health effect, which is the opposite of a placebo. Here’s an example. You’re a 55 year old man who injured his back and gets an x-ray. You’re worried something is wrong because you can’t play with your kids and you get a diagnosis of “degenerative disc disease at the L4-L5 vertebrae”. Woah. That must be the reason you have pain right? No, actually, probably not. At that age, finding something like degenerative disc disease on an x-ray is more common than it isn’t! 80% of people aged 50-60 have some disk degeneration with NO BACK PAIN. Take a look at table 2 to see how common some of these findings are in asymptomatic populations. That is, people who have no back pain. However, nobody ever takes the time to explain that to you, and you go home thinking something is wrong, and that you’ll have this problem forever. It becomes part of your psyche that “my back is f*#^*d” and you didn’t even give rehabilitation or even just foam rolling, a try. SAD!
All of those numbers there are the percentage chances of finding something on your imaging without having any back pain... cool. Without the proper context, this type of information could create a yellow flag. Here's a short list of Yellow Flags that lead to poorer outcomes in back pain:
Have you ever heard the expression “ Your attitude determines your latitude?”. If you have any of these yellow flags below, we need to seriously address them before proceeding with an intervention, especially rehab exercises! We'll discuss the top 4 here below and what they might sound like
If any of these sound like you, that’s ok. We just haven’t convinced you you’re wrong yet. Although it is difficult, research shows that if you actually don’t mind SOME pain, the back pain doesn’t really affect you that much. Here are some slightly more helpful ways of thinking about your low back pain
Let's say you did get some imaging, or perhaps even diagnosis. Lets go over some of the common diagnosis possibilities:
Mechanical Low Back Pain - Great diagnosis! The severity of the pain doesn’t always reflect the seriousness of the underlying problem, and the vast majority gets better on it’s own without medical intervention. On the other hand, 30% will have recurrence within 6 months and 40% within 1 year. So look at this as a “vulnerability” that may need to be worked on with a professional to make it resilient. If you have a chronic vulnerability to back pain, perhaps you may choose to improve strength, endurance, or some other function to create a more resilient and robust low back.
i.e.: Sprains and strains - these account for most acute back pains caused by stretching or tearing of ligaments, tendons, or muscles due to falls, improper lifting, or over-stretching. Such moments may trigger spams which can be painful. They tend to heal on their own and can be prevented with strength and conditioning.
Radiculopathy - This type of pain is caused by compression, inflammation and/or injury to a spinal nerve root. Radiculopathy may occur when spinal stenosis, spondylolisthesis, neurogenic claudication, herniated or ruptured disc, or other forces compresses the nerve root. Medications, gentle movement, and time can be very helpful in this scenario, and sometimes; but very rarely, is a surgical intervention necessary.
Back Dominant Pain - This pain radiates down the back and into the glutes, and/or around the hips. Some people have pain only in the back or around the legs but it’s the back pain that is dominant. There is usually a position of relief (arching forwards or backwards). This pain is good because there’s no damage to the nerves or spinal cord and no surgery is needed. Moving in the correct direction allows for easy management of this type of problem.
Leg Dominant Low Back Pain - This can come from sciatica or nerve compression in the low back that can go from the buttock to the foot. It tends to feel better when we lie down. Sciatica often gets better on it’s own. A narrowing of the canals that nerves travel through in the low back, also known as stenosis can cause neurogenic claudication that is present in the legs when standing up or walking around, and is relieved by bending forward or sitting. It can be anywhere in the legs, and the legs feel “heavy” when walking. Flexing the spine opens the spinal canals and provides relief.
Now that we’ve gone over what to watch for and what isn’t helpful, let’s go over some things that are proven to work well.
What does rest mean? How much should you rest? Is there such a thing as too much rest? How do you prevent getting out of shape? Is “taking it easy” enough, and for how long? How do you know when to lay off and when to “use it or lose it”? These questions aren’t especially difficult to answer with regards to most ordinary injuries — for example, if you sprain an ankle, you stay off it for a while, take it easy for many weeks, slowly get back to normal … no big deal. No “art” needed there! But sometimes it just isn’t obvious if you’re actually resting. For example, a nagging shoulder. I work out, it hurts. I stop working out, it still hurts. What about the neck?
Let’s start with an easy one: should I be on bed rest? We already know the answer is “No”. Especially not after the first 3 days. The earlier you get going on returning to regular life, the better off you will be. In the vast majority of studies we look at, from hip replacements to achilles ruptures, the early mobilization group recovers faster than the bed rest group. As for everything else, there are no evidence based guidelines on how much rest is effective, or what tactics work best. So here are things you can do to maximize recovery:
- Specific rest: rest the area where you feel pain. Identify the painful movement direction and temporarily limit that movement, but use every other movement
- Sleep: get at least 8 hours of sleep. Most of your muscle repair happens here.
- Nutrition: consume adequate protein sources and avoid pro-inflammatory foods.
- Hydration: Drink lots of water (within reason i.e. 8-10glasses, more if exercising)
- Pain relief: doctor prescribed pills, or creams, can help but so can ice or heat.
- Stretching/Exercise: more details on this in a later section.
Is back stiffness serious? Sometimes, but not that often. Again, less than 5% of low back symptoms indicate serious pathology. One type of back stiffness is the rigidity associated with meningitis, which makes it very difficult to bring the knees to the chest and comes with other usually comes with other symptoms of illness that would be screened by our “red flags” checklist. Other back stiffness that could be a serious problem is ankylosing spondylitis, but that gets BETTER with movement. However, when in doubt, (get a doctor to) check it out!
Now we’re left with non life-threatening back stiffness. What is stiffness? It usually doesn’t mean the tissues are shortened or tightened. It’s more of a feeling. Since stiffness is more of a feeling rather than a reflection of the length of tissues, will stretching and soft tissue massage actually help? Yes, it sure could. But so could regular movement! Any gentle strategy that will “loosen up” a back that is reluctant to move is a good idea, at least in the short term. Other strategies include icing, heat, and rest.
Ice — For some people, ice/frozen peas/something cold applied to the sore area can help relieve back pain. In general, for acute injuries, ice is recommended as the initial treatment, especially if swelling is present. The cold source should be wrapped in a thin dry cloth layer before it is placed on the back to protect the skin from frostbite or irritation. Avoid the kidney area, as you don’t want to mess with those too much. You can the ice on the painful/stiff areas for 5-20 minutes and repeat every 90-120 minutes while awake until symptoms improve. But, if you try this and don’t find it helpful? -don’t do it. For some people, ice makes their tightness or stiffness seem worse, so don’t worry if the ice “isn’t helping”, it doesn’t work for everybody and you’re not missing out on quicker healing times or anything special, it’s just for pain relief and most of the results are temporary.
Heat — Heat can also help to reduce back pain. Apply moist heat for 10 to 15 minutes with a shower, hot bath, or moist towel warmed in a microwave. If you use a heated towel, be careful not to overheat, as this can cause injury. Again, avoid the kidney area and think more “warmth” than “heat” so you don’t go overboard with the temperature. More heat doesn’t = more healing or better results, so less is more. Again, it’s just for pain and stiffness relief. If you notice any dizziness, fatigue, or increase in symptoms stop immediately and consult with a professional. It's also a good idea to inspect your skin each time you apply ice or heat. Look for lasting changes in skin-color, and let your health care provider know if you notice any problems.
Stretching exercises — You can help restore and preserve your range of motion with exercises that stretch and strengthen the back muscles. It is best to perform stretching exercises when the muscles are warm, such as after the application of heat (see previous paragraph), or after a few minutes of cardiovascular warm-up exercises; so if you can go for a walk/cycle/pool safely, do it! It’s good for you. If you can’t do that, or choose not to; that’s ok, just start a little slower. Exercises can be done lightly, as needed, but expect mild, achy muscle pain if you are new to exercise. If you have sharp or "electric" pain in your legs or groin from exercise, stop and tell your healthcare provider right away. If you aren’t sure of what you’re doing and feel like it’s not feeling right, get some help.
Gentle movements should begin as soon as possible to help reduce pain and regain function. During the exercises you may feel a stretch or slight discomfort with the exercises; do not move into intolerable pain. Your symptoms should not be worse after exercising immediately after exercise, or throughout the rest of the next day as a result of doing your exercises. We’re going to break down the exercises for three types of back pain. It’s going to include positions to relieve pain, and movement exercises, It’s not intended for anyone who has any red flags or underlying health issues, so if you have any red flags or health problems; please consult with a professional before beginning these exercises.
Pattern #1: Back Pain Aggravated by Spinal Flexion. (bending the spine forwards as in a toe touch).
A patient demonstrating pattern 1 back pain will exhibit more than 50% of their symptoms and symptom intensity in the back or buttocks, and the pain gets worse with bending forward or keeping the spine flexed (curled in i.e. sitting with “bad” posture), the pain can be constant or intermittent, but there are no neurological signs like numbness/tingling, or leg weakness.
Pattern #2: Back Pain Aggravated by Spinal Extension. (bending backwards as in arched back stretch)
A patient demonstrating pattern 2 back pain will exhibit more than 50% of their symptoms and symptom intensity in the back or buttocks, and the pain gets worse with extending backwards or keeping the spine extended (arched backwards in i.e. sitting with “good” posture), the pain can be constant or intermittent, but there are no neurological signs like numbness/tingling, or leg weakness.
Pattern #3: Constant Leg Dominant Back Pain (herniated disc)
These patients experience more than 50% of the pain is below the buttocks, there are symptoms of “radiculopathy” such as decreased sensation, weakness, numbness, or tingling in the legs, and reflexes may be affected.
Pattern #4 Intermittent leg dominant pain (spinal stenosis)
These patients also have more than 50% of their pain below the gluteal fold, above or below the knee, and the pain changes positions with activity. These patients are usually over 50 years old and actually prefer to be active in short bouts to manage their back pain.
Positioning will provide a “rest” option before or after exercises, or during a flare up of symptoms. These positions are meant to be used only if they are relieving or comfortable to be in. Below are the recommendations for each of the pain patterns described earlier in the document. Hold each for 1-10 minutes depending on tolerance. It is normal to feel stiffness afterwards.
Pain Pattern #1 & 2
Patients may benefit from a spine position such as the z-laying position, or knees to chest position. These may be beneficial because they open up the spine joints and decompress them.
Positioning for Pain Pattern #3
Patients may benefit from stomach laying or the prone on elbows position that get the discs away from nerves.
Positioning for Pain Pattern #4
Patients with spinal stenosis-like symptoms may benefit from sitting spinal flexion positioning. Sitting in a chair with the feet flat on the floor, lean forward until the belly touches your legs, and let your head and arms hang down.
After a few days, people should be able to perform some basic movements. Here are some recommendations based on the four different classifications mentioned above.
The most important exercise with pain pattern #1 is the sloppy pushup. Patients should lay on their stomach with their arms by their sides, when they get used to this position, they can move into prone on elbows position, and then the cobra exercise, or sloppy pushup. Keep the hips on the ground and legs loose.
The most important exercise for patients with back dominant pain worsened by extension in pain pattern #2 is the Child’s pose. Patients should go on hands and knees and lean back until their butt is touching their heels. Keep the back relaxed and hold for up to 60 seconds. If there are limitations with performing this exercise, it can be done in sitting.
There are no validated recommendations for constant leg dominant pain in pain pattern #3, because everyone is different. These patients may benefit most from medications, heat or cold in the early stages.
The most important exercise for pain pattern #4 are a combination of core strengthening, pelvic tilts, and hip flexion.
General exercises are great for all categories of low back pain. Patients should adhere to the principles of “if it creates lasting or worsening pain, don’t do it unless otherwise directed”.
Low back stretches: 1. Lumbar rotation: Lay on your back and bring your legs up to a comfortable position. Slowly swing your legs left and right while keeping your shoulders on the ground. You should feel a small stretch in your low back or hips. 2. Glute stretch: Pull your knee to the opposite side shoulder and feel a stretch in your butt. Perform each stretch with light intensity for 20-30 seconds, 3x/day.
Back Mobilizations: 1. Pelvic Tilts. Flatten your back into the surface by flexing your abdominals and glutes, hold 1 second, then arch your back off of the floor by slightly contracting your low back muscles. You may need to start with tiny little movements and build on top of them as pain allows. 2. Glute bridge: While on your back, lift your hips off the table as high as is comfortable Squeeze your glutes like you’re pinching a winning lottery ticket between the cheeks. 3. SIJ Isometrics: Lay on back and bring knees to 90degrees. Push into one knee, and pull the other leg for 5 seconds. Repeat 5x and perform on the other side.
Perform these exercises with great technique! You can try to improve your numbers week by week. Here are some “healthy” back numbers, or averages for university aged people with no low back pain and active lifestyles. The average may seem a little high, but they are great targets for you! Endurance scores for trunk extension: 146 seconds (2 minutes, 20 seconds), Flexion:144 seconds (2 minutes, 24 seconds), Side bridge, right: 94 seconds (1 minute, 34 seconds), side bridge left; 97 seconds (1 minute, 37 seconds). Remember: A journey of a thousand miles begins with a single step! Just try to be better next week than you are this week, and celebrate small gains!
We also go over principles of rest and recovery, as well as pain relieving strategies using ice, heat, gentle movement, and postural changes.
Lastly, we went over some basic exercises to get your back moving again. Hopefully you enjoyed this document and learned something useful for the future.
When it comes to pain, the back is notoriously vulnerable to unexplained pain and stiffness. In most cases, it will get better with gentle movement and time as long as you manage it well and avoid being overprotective or paranoid about it once it has been cleared for danger.
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