Low Back pain affects a large number of people and it can be difficult to find clear information on how to manage it. This post aims to provide some clear ways of managing low back pain and details the thinking behind some of the chosen treatment pathways.
Low back pain affects many people in the UK and the North West Commissioning Support Unit (NWCSU) estimates that 80% of the population will suffer low back pain at some point in their lifetime . Further more, the National Institute for Health and Care Excellence (NICE) reporting that one third of adults in the UK will suffer back pain each year . What is often confusing is the wide variety of types of back pain and numerous causes. It can be difficult to accurately identify the source of pain, let alone the cause, even with medical imaging like MRI or x-ray. With the cause difficult to identify, the question of how to progress and improve the pain can also be hard to answer. In truth no two presentations of back pain are identical, and what works well for one person may not be effective for another. Because managing and improving a back pain complaint can be complicated, I (Alexander Pouros at the Spine and Sports Injury Clinic) have found people can become frustrated with the process they go through, even though the treatment that has been prescribed is completely in the interests of improving the pain complaint.
Due to the high incidence of low back pain and the cost to the NHS as a result (not to mention the cost to businesses due to sick leave) there have been a number of studies to try to identify the most effective way of managing back pain. From a review of these NICE has developed guidelines that identify pathways of treatment from evidence-based practice to help guide the practitioners’ choices. There have been many times in my clinic (The Spine and Sports Injury Clinic) when patients have been frustrated with the NHS’s treatment of their pain, but in fact I have had to agree with the pathway the GP has selected. This is because it is the evidence-based approach that has shown to work in a majority of cases. Once the reasons are explained as to why a particular pathway has been chosen, patients are often reassured and feel more confident in the way the complaint is being progressed. So what type of treatment should you expect if you suffer a back pain complaint? The answer will depend on the type of back pain you suffer with:
-Acute non-Specific Low Back Pain
-Persistent Non-Specific Low Back Pain
-Chronic Non-Specific Low Back Pain
-Non-Specific Low Back Pain with Sciatica
First lets deal with acute non-specific low back pain.
Acute Non-Specific Low Back Pain
Non-specific low back pain is defined by NICE as “tension, soreness and/or stiffness in the lower back region for which it is not possible to identify a specific cause of the pain. Several structures in the back, including the joints, discs and connective tissues, may contribute to symptoms.” . This term is used for back pain when infection, cancer, fracture or inflammatory diseases have been ruled out as a cause . Acute pain is defined as pain that’s less than 3 months old; once you’ve had pain beyond 3 months it is classed as chronic. However, many of the acute and persistent pain pathways treat pain up to 1 year. Once you have been diagnosed with chronic pain this is managed in a different way.
In the initial stages of acute pain I would advise that the priority is to settle the reactive nature of the complaint. There are a number of methods to do this, including: rest, ice, heat, combined ice and heat, gentle exercise / mobility [4, 5]. This list may sound conflicting, but the aim is to find the right mix of approaches that best work for you. As previously mentioned, this is likely to be different from person to person. First assess the physical strain of your environment, that is review any lifting or carrying you may need to perform, as well as any repetitive postures or activities such as desk bound work or gardening. In the first instance you would look to reduce this to a level where the pain is not provoked. In some more severe cases you may need to stop these activities altogether so the complaint can begin to settle. In addition to reducing the physical load you can make use of ice or heat (see our information sheet on how this might be used) to help settle the reactive nature and improve the speed of your recovery. Finally, keeping some form of exercise is essential, in fact many treatment pathways advise you to maintain activity as part of the management of your pain [1, 2, 3, 4, 5]. This is because unnecessary excessive rest can prolong your recovery and increase the chances of developing chronic pain. As your pain reduces, the aim is to increase your activity at the earliest opportunity and to return to normal day to day actions as soon as possible. Often this is best done under the guidance of a health professional such as an Osteopath, Physiotherapist or GP. Use of pain medication to help the management of pain is recommended [1, 2, 3, 4, 5,] and often allows people to start the process of getting active at an earlier opportunity [2, 3, 5]. The NHS will usually prescribe analgesic medication for low back pain as an initial treatment pathway. This is because many people will experience significant improvement without treatment in the first 6 weeks of pain . Once 6 weeks has passed it is accepted that manual therapy (including Osteopathy, Physiotherapy, Chiropractic, Sports Therapy) can be an aid in improving people’s recovery and allowing them to return to normal function [1, 2, 3, 4, 5, 6]. Manipulation of the spine (a technique that’s provided by osteopaths and practiced at the Spine and Sports Injury Clinic) is also advised to assist in the recovery from low back pain [1, 2, 3, 4, 5, 6]. However, if you want guidance on how to manage your pain earlier than 6 weeks from its onset, then you can always seek treatment and advice soon after your pain has started. At the Spine and Sports Injury clinic I see some people seeking treatment at an early stage in their pain to help improve their management, whilst others would prefer to modify their activities, use pain medication, and observe it over the first few weeks. If the pain resolves then they carry on, if it remains then they attend the clinic to see what can be done to help it improve.
Once you have had the pain for more than 6 weeks and standard pain medication has failed to improve your injury then it is considered to be persistent non-specific low back pain ….
Persistent Non-Specific Low Back Pain
This is the point that many sources will advise a course of exercise and manual therapy, including manipulative therapy [1, 2, 3, 4, 5, 6]. The most suitable approach will change from case to case but generally I (Alexander Pouros) promote a mixture of both. At the Spine and Sports Injury Clinic we mix exercise therapy and hands on treatment to suit the individual’s pain and will alter the approach in light of how things respond. As for what type of exercise is best, this will also vary from case to case. The first important thing to establish is that the activity does not increase the pain either during or in the hours after. It is worth noting that you may experience some discomfort during activity even though this is not damaging. If the pain remains at a tolerable level then it is generally accepted that the exercise can continue [4,5], if it increases as you progress through the exercise then it is best to look for an alternative. Furthermore, it is possible for people to experience no pain at all during an activity and then see a significant increase of pain by that evening or the next morning, this is known as a delayed response. Because of the potential for a delayed response, I advise people sample exercise cautiously – performing a low intensity short version of the exercise on the first occasion then review the response. If it’s positive then you may start to steadily progress the intensity and duration. If you see an aggravation of pain then it is best to look for something different. Be aware that although you may experience an aggravation of your pain from an activity it doesn’t mean that the exercise has caused more damage. Simply that it has agitated the sensitive tissue and this will calm again with suitable management. Because the increase of pain is not a reflection of damage, it is always worthwhile to keep sampling different forms of exercise to find as many different types of suitable activity as possible. Types of activity can include general walking, cycling, swimming, yoga , GYM based exercise, pool based exercise, pilates, tia chi, etc. Almost any form of exercise (provided it doesn’t increase your pain) is suitable to help people improve a back complaint. By keeping active with your pain you allow the area to keep mobile, can improve your general fitness, benefit from the feel good endorphins that are released when you exercise , and all of this helps to reduce the sensitivity of your pain and improve your rate of recovery . Due to this, it is essential to keep experimenting with activity to find an exercise that helps. Once identified I find recovery often begins to improve at a significantly increased rate.
The type of manual therapy applied can vary also and can include manipulative therapy (techniques that produce a click or pop noise from the joints), soft tissue manipulation (massage), and gentle mobility techniques. The mixture will change depending on what the patient is responding to and also inline with the individual’s preference (for example not everyone is comfortable with receiving manipulative therapy). When this is combined with a plan for activity, I (Alexander Pouros at the Spine and Sports Injury Clinic) find that people often achieve very good results.
Be aware that, at this stage, further imaging like x-rays and MRIs are not advised [1,2,3,6] or helpful unless your pain is the result of a more serious pathology. It has been found that people can show disc injury or degenerative changes on MRI scans despite not having suffered any low back pain at all . Because of this, early scanning of low back pain is likely to raise more questions than it answers. Just because a disc bulge is identified doesn’t mean it is the reason for your pain – it may simply be there as a coincidence. Even if the pain is a result of some degenerative change or disc damage, the recovery plan is much the same. To progress steadily through an exercise and manual therapy programme before considering any other form of treatment.
If the pain has been on going past 12 months then is it considered chronic non-specific low back pain:
Chronic Non-Specific Low Back Pain
Once your pain has been on going over a 12-month period the treatment for it becomes more complicated. This is because your pain is no longer a true reflection of the extent of injury you have suffered; meaning it is possible to be experiencing significant pain even though there is no longer any damage to the affected area. When I, Alexander Pouros, discuss this with people they often find it difficult to grasp the concept of pain without injury. Firstly, view pain not as a response to damage but instead as a warning system to potential damage. In chronic pain this warning system becomes so sensitive that you are bombarded with pain signals in scenarios that normally wouldn’t produce pain. In order to change this sensitivity treatment needs to consider a wide range of contributing factors and also, most importantly, the role the brain has in increasing and reducing sensitivity. If you suffer long-term pain then you’ll be very aware of the large impact it has on a person’s daily activity, mood state, relationships, and even employment status . As well as the effect pain has on you, it is now understood that an individuals emotional, cognitive, and social functioning will also influence the pain that is being experienced, with the person’s mental health having an impact on their response to treatment . Because pain can be influenced by a person’s mood and state of mind, it is important to consider psychotherapy along side any manual or exercise therapy. The need for this will differ depending on the pattern and nature of your pain but it is important to consider the role a pain psychologist can play in changing your pain. This video describes the numerous factors that influence chronic pain and goes some way to explain why it is so involved . This may be why the Scottish Intercollegiate Guidelines Network (SIGN) found that brief patient education on chronic pain can improve pain and dysfunction better than other active interventions alone, including surgery . This isn’t to suggest that other interventions are not worthwhile in improving a person’s pain, but that it is vital for the individual to understand the process of their pain and how to take control of it. When this is combined with other methods of treatment (including manual therapy, exercise therapy, psychotherapy, etc) people are able to make a significant difference to how the pain affects their life.
I often find that patients who attend the Spine and Sports Injury clinic complaining of chronic pain will undertake a journey to better understand their pain, adapt their approaches to it, and begin to progress forwards in reducing the severity of it. It is always important to have a health professional guide you through the process of progressing chronic pain so that reassurance and guidance can be given where it’s needed, and further referral for scanning or Orthopaedic opinion made where necessary. When I provide treatment for a chronic pain patient I use a mixture of different manual therapy approaches, combined with exercise therapy, and spend a lot of time educating about the nature and process of pain. In short it is a varied approach that is tailored to the individuals pain and their response.
So far we have looked at low back pain that remains local to the low back. When you have leg pain accompanying back pain then it is considered to be Non-Specific Low Back Pain with Sciatica.
Non-Specific Low Back Pain with Sciatica
Sciatica is the term used to describe pain, tingling or numbness that travels down the back of the leg, calf and foot. Around 90% of cases of sciatica are caused by a bulging low back disc that then compresses the nerve as it leaves the spine . Although this can mean there is a more specific cause to the pain (although not in all cases), the treatment approach is similar to the previous types of pain already discussed. Pain medication should be used in the early stages to help allow people to become more mobile, lifestyle should be reviewed with a view to reducing aggravating factors and allow the reactive nature to settle, general activity should be maintained (at a level that doesn’t provoke pain) as much as possible, and you should aim to return to normal day to day activities as soon as the pain allows . It is worth noting, however, there are some additional complications with sciatica that may require more urgent scanning and onward referral. For this reason I, Alexander Pouros, advise people with sciatic symptoms to always seek advice from a health professional (such as a GP, Osteopath, Physiotherapist, Chiropractor) at an early stage to ensure they are progressing the injury correctly, and to screen for the possible need of further referral. As was mentioned in the persistent non-specific back pain section, an MRI may not be helpful in the early stages unless the cause of the sciatica is considered to be a severe disc injury. Be aware, however, that the severity of pain is not a reflection of the severity of injury. I have seen people suffer severe pain and then when MRI scanned only show minor disc damage. Once a health professional is satisfied the cause is not severe then you are better to progress through the manual and exercise therapy approaches before considering any other intervention. When it is looking like an MRI scan may be necessary the decision should be made from the advice of your health professional (GP, Osteopath, Physiotherapist, Chiropractor).
Back Pain Due to Infection / Fracture / Cancer / Inflammatory Disease
This is a specific type of back pain and should only be treated and advised on by an appropriate specialist. When you visit a health professional for a back pain complaint they will be looking for certain signs that may imply this type of back pain. Should they identify any cause for concern they will refer you back to your GP for more investigations and then an onward referral to the appropriate specialist. If you suspect your back pain is due to this type of cause then you should visit your GP who will review the nature of pain and accompanying symptoms, and refer for suitable investigations if they are required.
In summary, with any type of back complaint it is important to understand the nature of the pain. With that understanding the focus is to maintain as much activity and normal day to day function as possible whilst avoiding any aggravation of the pain. Because an aggravation of pain is not a reflection of increased injury, you should experiment with different activities to find the ones that best help you, often starting with a low intensity short version to review the response. You may return to work or normal day to day activities with some pain remaining but, as long as there is no further aggravation, this is fine and can often help in the recovery of the complaint. See a health professional (GP, Osteopath, Physiotherapist, Chiropractor) to ensure you are employing effective management of your pain and for guidance on how to progress and improve things further. If you would like more information on how to manage your pain complaint please contact Alexander Pouros at the Spine and Sports Injury Clinic (Covering Margate, Broadstairs, Ramsgate and surrounding areas). Contact details are on our website (www.SpineSportsInjury.com).
 Greater Manchester EUR Policy Statement, Persistent Non-Specific Low Back Pain; The North West Commissioning Support Unit (NWCSU); November 2014
 Early Management of Persistent Non-Specific Low Back Pain, NICE Clinical Guideline 88; National Institute For Health and Care Excellence (NICE); May 2009
 Information For The Public, Early Management of Persistent Non-Specific Low Back Pain; National Institute For Health and Care Excellence (NICE); May 2009
 NHS.CO.UK; Back Pain – Treatment – NHS Choices; Last Reviewed February 2015; Accessed June 2015
 The Back Book Eighth Impression; Stanley Bigus, Martin Roland, Gordon Waddell et al.; 2011
 Commissioning Guide: Low Back Pain Broad Principles of The Patient Pathway; British Orthopaedic Association; 2013
 Systematic Literature Review of Imaging Features of Spinal Degeneration in Asymptomatic Populations; Brinjikji et al.; American Journal of Neuroradiology 36.4 (2014): 811-816
 Management of Chronic Pain: A National Clinical Guideline; Scottish Intercollegiate Guidelines Network (SIGN); December 2013
 Understanding Pain in Less Than 5 Minutes; https://youtu.be/5KrUL8tOaQs; October 2014; Accessed June 2015
 The National Pain Audit Final Report; The National Pain Audit; 2010-2012
 CKS.NICE.ORG.UK; Sciatica – Lumbar – Radiculopathy; Last Revised April 2015; Accessed August 2015