Lower Back Pain

Lower back pain is the most common reasons for someone to seek care from a chiropractor. In fact, worldwide lower back pain relief has become one of the leading causes for seeking care from doctors and allied health professionals.  The Lancet (a highly reputable academic source) recently published updated guidelines and a call to action regarding the need to understand and manage lower back pain better on a global scale. The paper revealed some very interesting facts about our current beliefs about back pain and the best treatment for lower back pain. 

This article will cover some of the most common questions about lower back pain;

  • What is lower back pain?
  • What are lower back pain red flags?
  • What causes lower back pain?
  • Best treatments for lower back pain
  • How to prevent lower back pain
  • Best exercises for lower back pain

What is lower back pain?

Lower back pain is a generalized term describing discomfort at any location between the lower ribs and top of the pelvis. It can be associated with sciatica (pain radiating down the leg) or other symptoms such as loss of range of motion and loss of strength. The pain intensity may vary between individuals and may be dependent on the cause of the pain. There are many causes for lower back pain, most of which are not emergency scenarios, however there are certain signs and symptoms to be aware of (discussed below). 

What are lower back pain red flags (medical emergencies)?

Although only a very small percentage of people with back pain are medical emergencies, it is important to recognise some of the signs and symptoms associated with serious cases. Medical emergencies for lower back pain may include, but are not limited as infection, malignancy or spinal fractures. The associated signs and symptoms from these causes may be back pain associated with a fever, unexplained weight loss or night sweats. Prior history of malignancy or other serious health conditions should also be considered.

What are the causes of lower back pain?

Before we discuss the current understanding of lower back pain, we need to discuss the causes of pain in general. This area of pain science is hotly debated and there are many differing opinions on the mechanisms of the pain experience. For the purpose of this article we will quickly discuss the Bio-Pyscho-Social (BPS) model, which is a modern understanding of pain. 

The BPS essentially states that the  pain experience is driven by many different factors. The ‘Bio’ describes the mechanical structure (muscle, tendons, bones etc) which may sense stress and movement. The ‘Pyscho’ is the mental aspects of pain including beliefs, expectations and prior experiences. The ‘Social’ aspects defines the social influences of pain, including environmental, family and friends influence and socio-economical status. All pain experiences are formed by a combination of all of this. Essentially, pain has many contributing factors all of which will play a role on the pain experience. 

Lower Back Pain Brisbane. The biopyschosocial model.

It is important to recognise that pain is extremely individual and context specific. No person can compare their pain experience to anyone else. Pain is also contextual to the persons environment, for example, a person with lower back pain is probably going to notice it more when sitting at a desk versus when enjoying themselves at a concert or exercising. 

Non Specific Lower Back Pain

According to the Lancet study, most back pain is described as ‘Non-Specific Lower Back Pain’. This essentially means that most back pain cannot be attributed to a singular cause. For example, disc herniations, sacro-iliac joint pain or muscle spasm. The reason most back pain (and other regions of the body) cannot be attributed to a singular structure or cause is because the tests we use (orthopaedic tests, imaging etc) cannot be correlated very strongly to pain. For example, many people with back pain will be referred for an image (MRI, Xray or CT scan most commonly) and will often be diagnosed off the findings of that image and an assumption is made that what we saw on the image is causing the pain. This approach has been shown to not truly represent the causes of the lower back pain, because when we image people without back pain we can often find similar findings. 

With the above in mind, there are several other causes of lower back pain that may be diagnosed through a combination of a good history, physical examination and possible imaging. 

Disc injuries.

These injuries are relatively common but are often over diagnosed. Discogenic pain (pain originating from the spinal disc, commonly known as slipped disc, disc bulge, drisc protrusion or disc herniation) may or may not be associated with nerve symptoms (commonly sciatica and symptoms in the leg). Similar to any other injury, these will heel and resort back to normal when treated and managed appropriately and are not a lifelong sentence. They typically present as

  • A deep ache or sharp stabbing sensation
  • May have associated leg pain, numbness, tingling
  • Worse when sitting and/or bending forward
  • Stiff and painful in the mornings.

Sacro-iliac joint pain (SIJ)

SIJ pain is also a common diagnosis, however, this also may be over diagnosed. True SIJ pain is relatively rare and is associated with significant disability as the SIJ is a major weight bearing joint. Below are the common milder presentations that may indicate the pain has some origin at the SIJ

  • Pain located on one side usually below the PSIS (the ‘dimple’ area either side of the tailbone)
  • Worse when walking and standing from a seated position
  • May have associated sciatica 
  • May be painful to bear weight on the side of pain.

Facet Joint Pain

The facet joints are the joints on either side of the spine. They are associated with general movement and also play a role in weight bearing. These joints can get injured and may be more problematic in older populations. Typically they present as;

  • Usually one-sided pain
  • Worse when leaning back or twisting side to side
  • Aggravated by prolonged sitting or standing.

It is important to remember what has been stated above, that pain is always multifactorial and we need to look at all aspects of our health, not just the mechanical parts to truly resolve symptoms.

What treatments are best for lower back pain?

There are a multitude of different treatments for lower back pain, all with varying degrees of efficacy. For the sake of this article we will talk about conservative treatments for lower back pain. Conservative treatments are non-invasive treatments such as exercise, rehabilitation, manipulation, massage, dry needling etc. The good news with conservative care is that it is the first line of treatment for almost all lower back pain issues. There is strong evidence that early conservative management may in fact help prevent more invasive procedures in the future.

Exercise for lower back pain

Exercise has consistently been shown to be a beneficial treatment for lower back pain. While the research hasn’t been able to show which type of exercise is best, the most common approaches are resistance training, motor control/stability exercises and aerobic exercises. There is also some research to suggest that the intensity of the exercise is quite important as well, with moderate to higher intensity showing better outcomes. 

Manipulation for lower back pain

Manipulation is a common technique amongst Chiropractors, Physiotherapists and Osteopaths. Manipulation has been shown to be effective for both acute and chronic lower back pain. Like any intervention, it is even more beneficial when combined with exercise interventions, education and addressing pyscho-social factors to pain. 

Massage for lower back pain

Massage is a form of treatment utilized by many practitioners. The overall effectiveness of massage varies depending on the type of massage and the lower back diagnosis. Relaxation is often the goal of massage and may in itself reduce pain and help for short term pain relief. 

Dry needling for lower back pain

Dry needling is another commonly used treatment amongst allied health professionals. Dry needling is different to traditional Chinese acupuncture from both a practical and theoretic sense. Typically, dry needling is performed by inserting an acupuncture needle into a muscle and manipulating the needle to result in a muscle twitch response. This has various affects on the muscle and nervous system that may result in short term pain reduction, increase range of motion and improved blood flow to the area. 

Education and lifestyle modification

Education and lifestyle modification for lower back pain have been shown to have a significant impact on lower back pain. According to the Lancet study, this is an essential component to long term pain relief. Education and lifestyle modification should be individualized, practical and correlated to the individuals symptoms provocations. Generally, education and lifestyle modification alone may not fully resolve an individuals pain, but in conjunction with rehabilitation and treatment is highly effective. 

Best exercises for lower back pain

As mentioned above, there are no ‘best’ exercises for lower back pain. The best exercises for back pain are dependant on the individual, their current circumstances, their goals and ability. Generally speaking, an exercise is more likely to help someone in pain when;

  1. They are engaged with the exercise and believe that it will help
  2. They are consistent with the exercise
  3. The exercise can be progressed to become harder as the individual gets better at it.
  4. The exercise is done in conjunction with other lifestyle changes (eg improving sleep habits, addressing psychological factors etc) and providing accurate and practical education

Conclusion

The majority of lower back pain can be resolved with appropriate treatment, education, management and advice. It is very rare for lower back pain to be a serious health risk regardless of the intensity and duration of pain. Most pain is non-specific in nature, meaning that it is not due to a singular cause. Rather it should be viewed as a general health issue and addressing other aspects of the individual’s lifestyle should be considered. Ultimately, 

If you are experiencing lower back pain and want to get back to doing the things you love, pain free book an appointment at Scope Chiropractic Brisbane or Scope Chiropractic Ipswich by clicking the link below.

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References

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  2. Verbrugghe, J., Agten, A., Stevens, S., Hansen, D., Demoulin, C., Vandenabeele, F., & Timmermans, A. (2019). Exercise Intensity Matters in Chronic Nonspecific Low Back Pain Rehabilitation. Medicine and science in sports and exercise51(12), 2434-2442.
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  6. Furlan, A. D., van Tulder, M., Cherkin, D., Tsukayama, H., Lao, L., Koes, B., & Berman, B. (2005). Acupuncture and dry-needling for low back pain: an updated systematic review within the framework of the cochrane collaboration. Spine30(8), 944-963.
  7. Furlan, A. D., Imamura, M., Dryden, T., & Irvin, E. (2009). Massage for low back pain: an updated systematic review within the framework of the Cochrane Back Review Group. Spine34(16), 1669-1684.
  8. Brox, J. I., Storheim, K., Grotle, M., Tveito, T. H., Indahl, A., & Eriksen, H. R. (2008). Systematic review of back schools, brief education, and fear-avoidance training for chronic low back pain. The spine journal8(6), 948-958.
  9. Traeger, A. C., Huebscher, M., Henschke, N., Moseley, G. L., Lee, H., & McAuley, J. H. (2015). Effect of primary care–based education on reassurance in patients with acute low back pain: systematic review and meta-analysis. JAMA internal medicine175(5), 733-743.
  10. Choi, B. K., Verbeek, J. H., Wai‐San Tam, W., & Jiang, J. Y. (2010). Exercises for prevention of recurrences of low‐back pain. Cochrane Database of Systematic Reviews, (1).

Daniel Rothenberg

Daniel Rothenberg is a Sports Chiropractor with a Masters of Chiropractic and Masters of Exercise Science majoring in Strength & Conditioning. He works closely with a range of athletes in Brisbane and Ipswich.