Focus On: Acute low back pain

low back pain1Low back pain is a very common problem.  Studies estimate that 80-90% of people will experience back pain at some point in their lives, and at any point in time about 25% of all adults in Australia will have back pain. (I should point out at this point that “low back pain” is a massive topic that would take many thousands of words to cover – so this article will focus on acute low back pain).

Acute low back pain refers to a sudden or recent onset of low back pain.  In medical terms acute = recent. It does not necessarily mean severe. (While we’re at it, the term chronic = long term or persistent – usually greater than 3 months duration). As you saw it is an extremely common problem, so chances are you, or someone you know, will have experienced this sudden or recent onset of low back pain.

In most cases, acute low back pain is quite simple, and represents a simple back ‘strain’  associated with a mechanical loading incident or a ‘pain flare’ associated with psychosocial or lifestyle stresses (more on that later).  Only 1-2% of people who suffer an acute episode of low back pain will have any serious injury or illness.

Lower-Back-Pain-Right-Side2Despite this, low back pain has a very bad reputation, and there are a lot of misconceptions and misinformation about your prognosis and the injury itself.  So the following is some information to dispel some myths and fears, as well as some excellent advice as to what you should and shouldn’t do if you have low back pain.

In about 90% of cases, low back pain is a simple mechanical issue (a sprain or strain). It is really no different to pulling a hamstring or rolling your ankle.  Studies show that about 80% of low back pain incidents will resolve with about 6-8 weeks.  Of the ones that don’t, 80% of those will resolve within 6 months – so by and large almost everyone will get better from low back pain.  This is important to remember as I hear in the clinic all the time people saying things like “I know if you hurt your back it will never get completely better”.  We know from the evidence that this is just not true.  For some reason, we seem to think about hurting our back differently from other body parts.  Almost everyone has suffered some kid of musculoskeletal injury in their lives (a sprained ankle at netball or a pulled muscle) and we know those all got better, so why would we think the back is any different?

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So now that we know that your back pain is highly likely to get better, what can you do to help it get better quicker? And what shouldn’t you do to slow your recovery? Let’s start with the DON’TS:

DON’T

Don’t Freak out

So you were lifting in the gym, or gardening, or picking up your socks, etc. and you’ve felt a sudden “twinge/pop/twang/etc” in your back. This is what we referred to as a mechanical loading incident.  Already your mind starts racing with fear and anxiety:

“OMG I’ve stuffed my back!”

“I’m not going to be able to do that Crossfit competition! What if I can never do Crossfit ever again?”

“What if it’s broken? I might be paralysed!”

“What if my back is ruined forever? How am I going to support my family/pay the mortgage?”

And it goes on and on.  To a point this is normal psychology, but you need to remember that your mind is racing to worst case scenarios. This anxiety and fear is just going to make things worse (and there is strong evidence that fear, anxiety and negative beliefs have a negative impact on recovery).  If you honestly believe you’ve ruined your back, it’s going to take a long time to convince you otherwise, regardless of the actual injury.  Negative emotions – fear, anxiety etc. have been shown to worsen your experience of pain as well. So now you know that none of these thoughts are actually true, calm down and approach your injury pragmatically.

Don’t Rush to get an x-ray/CT/MRI

In most cases, imaging such as this is not beneficial – many low back pain cases are “non-specific” meaning we are unable to identify exactly what the painful structure is (especially on imaging).  This also has nothing to do with how bad your pain is – just because you may have high pain levels does not mean you are more likely to need a scan.  There are specific cases that do indicate that a scan should be performed, and your physiotherapist (or well-trained GP or other health practitioner) will be able to identify whether it is necessary.  These include significant, persisting or worsening neurological deficit (significant pins and needles/tingling/numbness, significant weakness, bladder or bowel dysfunction, numbness in your crotch/perineal region – also known as saddle paraesthesia) or indicators of serious pathology or injury (such as fracture, infection, tumour).  As you now know – these are quite rare.

In the majority of acute low back pain imaging is not required, but we do see a lot of over-imaging in health care from well-meaning health care professionals.

lumbarmriAnother reason not to have imaging is that it has been shown that many people who have never had back pain will have “abnormal” findings on scans.  (91% for disc ‘degeneration’, 56% for ‘disc bulges’ 32% for ‘disc protrusion’).  So there is no correlation between “abnormal” findings on your scan and any pain you actually have.  Chances are those findings would have been there long before you had pain – and were causing you no problems whatsoever.  Many of these changes are normal responses your body has to everyday life.  Like wrinkles on your skin, or grey hairs, these changes in the appearance of your back have no impact on how you feel or how it functions.

Finally, having a scan early on after your incident has been proven to actually slow down recovery and increase total costs. Partly this is because of all those incidental findings I just mentioned, and how this is explained to patients.  If a well-meaning health professional didn’t understand that these findings are normal, and then told you how there was all this “damage” in your back – your fear/anxiety levels would go up, and the way you behave to manage your back would change.

So now we know that imaging is largely unnecessary, unless there are specific issues that we identify from your assessment. These are quite rare.

Don’t Listen to the haters

"My Momma hurt her back and now we havta roll her outa bed with a stick"
“My Momma hurt her back and now we havta roll her outa bed with a stick”

Everyone seems to have a story about how their 2nd cousin’s wife’s gardener hurt his back and now he’s in a wheelchair/had to have surgery/ couldn’t work ever again.  For some reason

people love to tell you bad stories about how you’ll never get better.  (Reverse tall poppy syndrome perhaps?) If you venture onto the internet for answers, no doubt you’ll find even more information to back up this negative outlook.  Remember that numbers don’t lie – by and large everyone recovers from low back pain, no matter what cousin Cletus says. Also remember that Dr Google is almost never right.  I can count the number of times on ONE HAND that a patient has come in with a printout from the internet and was actually right about their injury.

Don’t do Bed rest

A long time ago, you used to be told to go to bed and rest if something was wrong with you.  In terms of low back pain, this is a terrible idea.  All studies show that staying active is far superior to resting for low back pain recovery (more on this below).  Inactivity makes you stiff and weak – both of which are risk factors for more low back pain.  Normal recovery requires normal load and normal movement (termed mechanotherapy – it drives a lot of what we do in physiotherapy).

Now you know what NOT to do, what will help your recovery and get you back to full activity faster?

DO’s

Stay Active

All studies show that staying active is a highly effective method of management for acute low back pain.  I can’t stress this enough that trying to maintain normal activity will significantly help with your pain and speed up your recovery.  Conversely, avoiding movement or being over protective can actually increase your pain and prolong you pain.

If you’ve ever attended physiotherapy for low back pain you should have left with a good understanding of this, as well as some specific advice regarding activity and ‘exercises’ that will help.  While different presentation may benefit from different types of activity better – it is usually safe to recommend some walking, activity in the pool and gentle low back mobility exercises (such as rotation and extension)

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Check Your Beliefs

Like I said, low back pain has a bad reputation.  Many people seem to think that a back injury is a lifelong affliction.  Injury to your back really is no different to any other injury – And we see far less people thinking their calf strain will be there forever.  Your body is an incredible self-healing machine, and by and large you will recover!

People also seem to think that the low back is a weak area of the body – and structurally this is not true at all.  There is quite a lot of muscle, ligament and connective tissue that protects and supports this area. Now there are a lot of important structures within your spine (like your spinal cord) so your body is well designed to protect this area.  Because of these important structures, your brain and body are quite sensitive to warning signals (pain) coming from this area – so your brain will often create quite a lot of pain when an issue arises in the low back.  So just because you might have a lot of pain doesn’t even mean you have a lot of injury.

It’s important to understand that hurt ≠ harm.  This means that you can have pain without any actual damage or injury at all.  Pain is a warning or danger system that your brain has to alert you that there is something to be aware of.  Think of times that something hurts but there is no damage done.  When you touch something hot – it hurts and you automatically pull your hand away.  Then when you check your hand there is no burn – the pain just warned you that injury might happen. When you bend you finger back too far (or someone gave you a Chinese burn at school) it hurt because the tension on the tissues reached a certain point that it produced a noxious stimulus. Your brain then interpreted that and told you there is pain, but no harm is done at all.

How you approach you r injury and recovery has a significant impact on how you progress.  Stay positive in the knowledge you have gained here and focus on the process you have to go through.  Recovery takes time, so you may need to be patient.

Get Assessed!

Injuries can be stressful and confusing (as well as painful).  Knowing what to do is half the battle. Little twinges usually go away on their own within a few days (particularly if you follow the above advice).  If the pain is persisting, limiting your ability to do things, means you are missing work or other activities you want to participate in or causing distress – then come and get assessed by a qualified professional who can properly diagnose and treat your problem.

All the clinicians at South Perth Physiotherapy are highly qualified and experienced primary contact practitioners.  We can identify if you fall into those less common categories that might require further investigation or referral. We can also provide you with best practice, evidence based advice and treatment based on specific injury to get you back to doing what you love faster.

Now as I said, the large majority of low back pain will resolve on its own within 6-12 weeks.  Studies have shown, however, that physiotherapy treatment results in faster recovery from injury overall. So while there are similar results at 12 week, physiotherapy treatment results are superior at 2 weeks, 4 weeks and 6 weeks.

Recent studies have also shown that early attendance to physiotherapy treatment (within the first two weeks of onset of pain) also resulted in significant cost savings for treatment when compared to later attendance.  This means that the sooner you commence treatment, the cheaper it will be overall.  We do often find in clinical practice that many people wait for 4 or 6 weeks before they attend for treatment, and by that stage they have developed more chronic problems and lots of secondary compensations that also need to be addressed.  This then requires more treatment and a longer recovery time.  I often think that if we had seen those people quickly after their injury, they would have been recovered by 2-4 weeks post injury and back to work/sport etc. before the time they even first attended the clinic.

Take Home Messages:

1. Acute low back pain is very common and by and large most people will fully recover within 6-12 weeks.

2. Usually imaging (such as x-ray, CT or MRI) is not necessary, and may actually lead to slower recovery. Many of the findings on scans are considered ‘normal’ even if they sound bad.

3. Understand that what you are experiencing is quite normal. Try to avoid unhelpful beliefs and behaviours that will slow down your recovery.

4. STAY ACTIVE! This is the most important piece of advice I can give you.

5. Get Assessed.  Early access to appropriate diagnosis, education and management leads to faster recovery and reduced overall costs.

 

Stay tuned for an upcoming article on treatment and rehabilitation of low back injuries. As always please feel free to get in contact with us with any queries regarding anything at all.  We are always happy to hear from you.

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Julian Bowen

Julian is a Director and Senior Physiotherapist at South Perth Physiotherapy.  He has spent  over a decade working exclusively in private physiotherapy practice, and estimates he would have performed over 35,000 individual treatments in that time. He has worked with everyone from Paralympians,  elite athletes, WAFL Footballers, the Defence Forces and weekend warriors, to thousands of everyday people with all manner of issues.  He is passionate about injury prevention and has a special interest in the treatment of headaches, shoulder issues, hypermobility management and exercise rehabilitation for the prevention and treatment of injuries. 

 

 

References:

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Haldeman S, Kopansky-Giles D, Hurwitz EL, et al. (2012) Advancements in the management of spine disorders. Best Prac Res Clin Rheumatol; 26: 263-280

Henschke N, Maher CG, Refshauge KM, et al. (2008) Prognosis in patients with recent onset low back pain in Australian primary care: inception cohort study. BMJ; 337:a171

van Tulder M, Becker A, Bekkering T, et al. (2006) Chapter 3. European guidelines for the management of acute nonspecific low back pain in primary care. Eur Spine J; 15(Suppl 2):S169–91

Henschke N, Maher CG, Refshauge KM, et al. (2009) Prevalence of and screening for serious spinal pathology in patients presenting to primary care settings with acute low back pain. Arthritis Rheum; 60:3072–80

Childs et al. (2015) Implications of early and guideline adherent physical therapy for low back pain on utilization and costs BMC Health Services Research; 15:150

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