Mechanical Low Back Pain
A flare up of back pain can be alarming and even with a minor strain we can sometimes think something dreadful may have happened. However, the facts show this is generally not the case. Low back pain is very common and what you do in the early stages is very important. Fortunately, serious or permanent damage is very rare.
The spine is one of the strongest parts of the body and the way it is put together is designed for movement. Rest or staying still in fact can impede recovery, as the spine needs to move in order to get better.
Due to the significant impact low back pain has, there has been a lot of research into the best way to manage it. The aim of this webpage is to provide you with the most up to date facts about back pain and the best ways to manage your symptoms to return to normal as quickly as possible.
Red Flags!
There are some conditions however, which do need emergency medical care such as Cauda Equina syndrome. This is a rare but serious back condition, which can cause permanent damage and will need the attention of an emergency spinal specialist team.
The warning signs include:
Loss of feeling/pins and needles between your inner thighs or genitals.
Numbness in or around your back passage or buttocks
Altered feeling when using toilet paper to wipe your self
Increasing difficulty when you try to urinate
Increasing difficulty when you try to stop or control your flow of urine
Loss of sensation when you pass urine
Leaking urine or recent need to use pads
Not knowing when your bladder is full or empty
Inability to stop a bowel movement or leaking
Loss of sensation when you pass a bowel motion
Change in ability to achieve an erection or ejaculate
Loss of sensation in genitals during sexual intercourse.
There are other rare cases in which back pain can signal a serious medical problem. Seek immediate care if your back pain:
Is accompanied by fever
Follows a fall, blow to your back or other injury
You a pulsating feeling in the abdomen
We must also be aware if your back pain:
Is severe, unremitting and doesn't improve with rest
Causes weakness, numbness or tingling in one or both legs
Is accompanied by unexplained weight loss
Also, see your doctor if you start having back pain for the first time after age 55, or if you have a history of cancer, osteoporosis, steroid use, or excessive drug or alcohol use.
The reality about Back pain!
Most back pain is not due to any serious disease and will improve within a few days or a few weeks.
Being mobile will help your back to get better quicker, the long-term outlook is good.
Even if some aches last for a bit longer, it doesn’t mean that anything serious is wrong. You can still be active even if there is some pain.
Flare ups of pain are common but again it does not mean that there is anything seriously wrong. Between flare ups stay active and you’ll be back to normal soon.
The back needs to move to remain healthy. The sooner you get moving the sooner you will feel better.
The people who cope the best with back pain are those whose stay active and get on with life.
The old-fashioned approach for low back pain was to rest in bed waiting for the pain to go. We now know that this is the worst thing to do as it:
Prolongs the pain.
Muscles and bones get weak
You get stiff
Your physical fitness is reduced
You get depressed
The pain feels worse
It is harder to get back to normal.
What Causes Low Back Pain?
Your back is one of the strongest parts of the body. It is made up of compact bony blocks joined by discs to provide flexibility and strength. It is then reinforced by strong ligaments and surrounded by large and powerful muscles that protect it. Most simple back strains do not cause any lasting damage. ‘Slipped discs’ or ‘trapped nerves’ are uncommon and in fact these often get better on their own anyway.
Back pain can often occur as a result of prolonged poor posture or overload to a specific area; it is rarely due to a serious disease. Although it can be frustrating not to know the exact reason for your pain, in another way it is good news, as it means there is no serious disease or damage in your back.
Most back pain comes from the muscles, ligaments and joints in your back not moving and working as they should. Therefore the best approach to returning to normal is to get moving and working as soon as possible.
Related factors – The Biopsychosocial Approach.
The latest research has shown us that rather focusing on individual aspects of back pain we need to address external factors such as biological, psychological and social factors, which can all influence the severity and level of your pain.
Cardiovascular health
There is a close association between poor cardiovascular fitness, low levels of physical activity and low back pain. Regular physical activity and improved cardiovascular fitness are important for general health and helps you to carry out daily tasks and leisure activities. The healthier you feel the better your ability to deal with the stress and strains of normal life.
Emotional wellbeing
When living with pain it is normal to notice changes in your mood. Research has shown that they are closely linked. It is common for people to report that it not only impacts on their ability to manage but may also influence pain itself.
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Your pain is a real physical experience that can also be affected by anxiety and stress. For example, being worried, anxious or stressed can cause physical changes to your body like your heart beating faster and clammy palms. It can also increase the level of pain.
Attitude and beliefs
Your past experiences can influence your body’s interpretation of pain and the way you respond to pain. Understanding of pain can help you make positive steps in your recovery.
Sleep Quality
Sleep is an essential part of feeling well and happy. Poor sleep quality and sleep disruption can deprive you of needed rest and recuperation, which can make managing your pain more difficult.
Strength
Reduced muscle strength can make moving challenging and contribute towards low back pain. It is important to improve the strength of muscles throughout the whole body. There is no one form of exercise that is proven to be better than another and the strength you need will depend on what you want to do.
Comorbidities (other health issues)
There is a relationship between medical conditions (such as diabetes, hypertension, respiratory and cardiovascular disease) and low back pain. Improving the management of your overall health can have a positive impact on your back pain.
Weight
There is a strong association between being overweight and low back pain. Excess weight can increase the physical demand on the body and contribute towards low grade inflammation.
Smoking
Smoking increases the risk of developing over 50 serious health conditions including cancer, heart disease and stroke. Research has also identified smoking has an association with low back pain.
Flexibility and stiffness
Everyone is built differently and there is no ideal amount of flexibility. Being able to tolerate what you want to do in life may require more mobility and flexibility.
Posture
There is no perfect posture. Having a particular posture does not cause low back pain. However, consistently being in the same position without regularly changing position can contribute towards your pain.
Do I need an X-ray or MRI scan?
X-rays are not required in the assessment of low back pain (unless a fracture is suspected through a traumatic incident).
MRI scans give a very detailed picture of the spine and may form part of the assessment process, but they are not as important as a good clinical history and a physical examination.
In the vast majority of patients with low back pain, MRI scans are unable to identify the cause of pain. MRI scans do not reflect the degree of pain that people experience. It is common to see age-related changes (to discs and joints) in people with back pain, as well as people without back pain. Therefore, in the most cases, MRI scans are not helpful as it rarely leads to a change in management or improved outcomes.Often with low back pain MRI scans can be misleading and in fact research has shown us that in many cases the findings on scans do not necessarily specify what the problem is. MRI scans are only indicated if surgery is indicated or something more sinister is suspected.
How to manage Pain:
There are many ways in which you can help reduce low back pain. Although they may not remove the pain completely they should reduce it so that you can make yourself better by moving and increasing your activity. This is what the latest research says.
Pain Medication
It may surprise you, but simple over the counter painkillers such as paracetamol and ibuprofen are the most effective pain medication. If you feel you need them – use them. You should only take the recommended daily dose but do not wait until your pain is out of control to take them.Consult with your GP if you have any concerns and do not take ibuprofen or aspirin if you are pregnant or have asthma, an ulcer or indigestion.
Hot/Cold.
An Ice/cold pack in the first 0 – 72 hours can be used to help reduce back pain. Only use for 10 – 15 minutes on protected skin. After this period heat; such as a hot water bottle, a bath or a shower can be an excellent effective way to reduce pain.
Massage.
We all feel good after a massage and many people do find that it can reduce low back pain as it relaxes the muscles and soft tissues, reducing some spasms. This treatment can be used, however it must be used in conjunction with exercise to maintain any benefits obtained and ensure you are able to return to normal activities as soon as possible.
Manual Therapies.
Manual therapies are an excellent way to reduce pain and increase movement in stiff areas of your spine. You should feel some improvements within a few sessions and like massage the optimal results are found when used in conjunction with exercise and should NOT be used as an isolated treatment.
Other.
There are many other treatments such as; acupuncture, electrotherapy or alternative medicines that are used to treat low back pain. However, you need to be realistic, in fact, these treatments rarely provide a quick or permanent fix. If there is no change in your symptoms after a few sessions there may be no value in it.
The main treatment is to get active!!!
How to manage persisting pain
It is important with conditions like back pain that we are aware of practical approaches which can help us in their management and treatment. Obviously, in this case the exercise is the main tool and gradually being able to increase the amount or resistance (load) has positive effects on what we are able to do and the amounts of pain we feel.
As individuals, we are all different, and we are also aware that we can sometimes fall into habits or patterns due to the pain that may not always be useful to our recovery. It is useful to investigate for these patterns. When identifying ways to manage your back pain you should look at ways to recognise these patterns and address them. We call this pacing. Try to breakdown tasks in to manageable chunks, given yourself a rest period between activity. Try to then gradually build activity up overtime.
We also advise to plan for Flare ups. These are events when symptoms increase temporally, but can sometimes put a halt to progress. Flare ups are normal and are expected, and if we plan for these, it should limit their impact. It is important that we try to restart the things that we enjoy. Setting Goal’s and maintaining these through your Long term plan can help you returning to normal activities sooner.
What Now?
As we have mentioned the best form of treatment for back pain is to get moving. But how? Try to strike a balance between doing activity and pacing so that it does not put too much strain on your back. The simple rules are:
Keep moving
Move a little further and faster each day
Do not stay in one position for too long
Move before you stiffen up
Don’t stop doing things, just adapt the way you do them
SITTING: experiment – choose a position that is comfortable for you, get up and stretch regularly.
SLEEPING: some people find different mattresses suit them better than others. A lot of people finder a firmer mattress helps. You may need to experiment. Try taking your painkillers an hour before you go to bed.
LIFTING/CARRYING: Think before you lift/carry. Don’t lift more than you need to, keep the load close to your body, use your big leg muscles to do the movement and don’t twist whilst lifting/carrying.
DESK WORK: Adjust the height of your chair so the screen is directly in your eye line, most places will offer an ergonomic assessment so you don’t feel strained and everyone is different. Get up and move regularly.
DRIVING: adjust your seat so it is comfortable and safe for you. Stop regularly for a break and get out of the car and move around.
DAILY ACTIVITIES: variation is key. Do all the things you want but not for too long and keep changing activities.
SPORTS: Continue with your normal sports but you may need to reduce the intensity. Gradually build it back up. Swimming is particularly good in the first instance as it is low load but encourages whole body movement.
SEX: continue. See what works for you, you may need to experiment with different positions.
Exercise and Physiotherapy.
Research shows that a graded exercise program is the best management plan for patients with back pain. The initial aim of exercise is to increase the range of movement in the back, which we know the back needs to get better. This will in turn reduce pain and improve your general function. Due to the importance of movement, at the end of the exercises there is a full range of stretches to help increase your flexibility and reduce any stiffness.
When carrying out the exercises there may be a slight increased ache but this is normal. However, the level of pain should not exceed 3-4/10 on a pain score.
As your range of movement increases and the pain reduces we aim to provide stability to the trunk, through core and Pilates based exercises. Our focus then moves onto normal movement patterns, when we introduce general exercises to not only develop muscle strength but also improve your confidence to return to normal, keep active and reduce the risk of flare ups.
Participating in an exercise program carries a certain element of risk for some people. You should consult with your healthcare professional before initiating this program if you have any concerns, to ensure your safety.
If you have any issues please do not hesitate to contact the physiotherapy department. If you feel light headed, dizzy or have issues with your breathing please contact your general practitioner (GP) immediately.
Level one: Range of movement
Repeat each exercise 10 to 15 times and do 3 sets 1: Lower back extensions (the Cobra)
Begin lying on your front then prop yourself up on your elbows, extending from your lower back. Hold this position for 2 - 5 seconds and relax downwards to the starting position. As this becomes more comfortable you can progress to pushing up from your hands with straight arms. Keep your breathing relaxed throughout.
https://www.youtube.com/watch?v=DQrcVGBSjYo&list=PLDhTyibwWirwQP55X0sSI7JXYy3GOFh_92: Knee rolls.
In a lying position, on your back, with your knees bent and together. Keep your upper body relaxed and chin gently tucked in. Slowly roll your knees to one side, keeping both shoulders on the floor. Hold for 2 – 5 seconds and go to the opposite side.
https://www.youtube.com/watch?v=WuE0xD-Xw9Y3: Pelvic tilts.
Lie with your back on the floor in a neutral position with your legs bent and toes facing forward. Pull your belly button in toward your spine, pushing your pelvis up toward the ceiling. Tighten your bottom muscles as you tilt your pelvis forward. Hold for 2 - 5 seconds and then go as far the opposite way and do the same. If you have a Swiss ball you can progress this exercise to doing it on this.
https://www.youtube.com/watch?v=FRdDwbUkCSc4: Knee hugs.
In a lying position, on your back, with your knees bent and relaxed. Pull one knee up to your chest and hold for 2 -5 seconds, repeat on the other side. As this gets easier change the starting position to lying with your legs straight. The next progression is to pull both knees up at the same time.
https://www.youtube.com/watch?v=f2atKYDrh6A
Level two: Core activation
Repeat each exercise 10 – 15 times and do 3 sets.1: Bridge
START POSITION: Lie on your back with your knees bent and your feet flat on the floor, approximately hip distance apart. You should have equal amount of weight through all parts of your feet. Push your back into the floor whilst engaging your core.
ACTION: keeping your torso in one flat piece, press your feet into the floor and squeeze your buttocks as you lift your hips up. Come up to a point that makes a straight line between your shoulders to your knees. Hold this position for 10 seconds and return to the starting position.
https://www.youtube.com/watch?v=PXUtxHAddeI2: Heels slides in neutral spine.
STARTING POSITION: lying on your back, knees bent and core engaged (Same starting position as exercise 1).
ACTION: Gently draw navel to spine. Maintaining this position and gently slide one heel down until your leg is straight, hold for 5 seconds and return to the start, keeping your pelvis stable and core activated throughout.
https://www.youtube.com/watch?v=StPxbG8skJ43: Table Top.
STARTING POSITION: lying on your back, knees bent and core engaged (Same starting position as exercise 1).
ACTION: Raise one leg until the thigh is straight up with your knee over your hip and your knee is bent so your shins are at 90 degrees, with your ankle slightly higher than your knee. Follow with lifting your other leg into the same position. Inhale and exhale while holding the position for 5 seconds. Exhale and lower your legs one at a time back to the floor. As this becomes comfortable to do you can push onto dead bug exercise, which you can see in the video below. The key feature with this is to ensure you keep your lower back pushed into the floor throughout the movement.
https://www.youtube.com/watch?v=bdzA3VH77iY4: four point kneeling
Starting Position: Start on your hands and knees, with the heel of the hands under shoulder joints keeping the arms long at the elbows without locking, allowing the wrists to flex. Knees directly under hips and feet relaxed.
Action: lift either one arm or leg off the ground (for core control + limb movement) As this gets more comfortable progress to 4 point kneeling lifting opposite and opposite leg (core control + peripheral limb movement). Remember to keep your back flat throughout. Hold each position for 5 seconds.
https://www.youtube.com/watch?v=dgH1lHsQhO0
Level three: Movement patterns.
Repeat each exercise 15 – 25 and do 3 sets. 1: Squat
With a band around your knees. Perform a squat keeping your knees over your second toes, with your back straight and body weight evenly spread over both feet. As this gets easier try to bend your knees further and add a weight to provide further resistance.
https://www.youtube.com/watch?v=P5g1RRV8_cc2: Lunge
Standing tall, take a large step forwards with either leg and bend that knee until the opposite knee is approximately 5cm above the floor. Then extend through the hip and knee to return to the starting position. Remember to keep your back straight throughout the movement. To progress this you can add a weight for resistance or do it on an unstable surface. Repeat on the other side.
https://www.youtube.com/watch?v=bN5KkUPrUyU3: Deadlift (Romanian – RDL)
Stand with your feet hip-distance apart with a slight bend in your knees, a weight placed in front of you.
Hinge forward at the hips, keeping your spine long and straight as your torso reaches toward the floor. Grip the weight with both hands plugging your shoulders back and down to secure your spine and brace your core. Look down and slightly forward to align your neck with the rest of your back and avoid hyperextension.
Tighten your glutes, hamstrings and core and drive your feet into the ground to stand up straight, lifting the weight to about your upper thighs. Squeeze your glutes and lock out your hips at the top.
Repeat the movement by lowering the weight somewhere between your knees and toes (depending on your flexibility), torso parallel to the ground while maintaining a flat back, slight bend in the knees, and core engaged.
https://www.youtube.com/watch?v=eaCt3tckIQI4: Lawnmower.
Begin with your feet hip width apart and step onto a resistance band with one foot and grab the band with the opposite hand. Bend your knees ad rotate your torso to the side that you have stood on the band. With a firm grip of the band, in a slight squat position, stand up rotating your torso whilst pulling the band diagonally across your body and above your head. Return to starting position.
https://www.youtube.com/watch?v=CxL3dFjMu2M
Stretches.
There are many benefits to regular stretching. Not only can stretching help increase your flexibility, which is an important factor of fitness, but it can also improve your posture, reduce stress and body aches, and is an excellent way to help manage low back pain. Some of these exercises are yoga poses, which we know to be a great form of exercise.
For each exercise hold the position for 30 seconds and do 3 sets.
Quadratus Lumborum in standing
https://www.youtube.com/watch?v=D5W9y561ia4
Happy cat/sad cat - Childs Pose
https://www.youtube.com/watch?v=DkGYBOF7kPk
Pidgeon
https://www.youtube.com/watch?v=21yZAnE1egE
Hip flexor
https://www.youtube.com/watch?v=O5Gq-q1I3q8
Piriformis
https://www.youtube.com/watch?v=29_pBvxjF-A
Spinal Rotation
https://www.youtube.com/watch?v=d72f9Ap9hRA
Hamstrings
https://www.youtube.com/watch?v=CzozxmOpyC0