VITRUVIAN EXERCISE PHYSIOLOGY
News & Information
LOW BACK PAIN,CARE GUIDELINES & THE ROLE OF EXERCISE
Low back pain (LBP) is the number 1 musculoskeletal complaint globally, with up to 90% of us experiencing at least one episode in our lifetime. LBP has a favourable natural history, meaning for most people it will improve and/or resolve on its own within days to weeks without the need for specific interventions.
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A quick recovery, however, is not always the case, and some individuals still experience symptoms 3+ months later
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This page will focus on non-specific low back pain (NSLBP), which accounts for 90-95% of all back pain. The term ‘non-specific’ does not imply it is not important, or that it doesn’t have the potential to impact your life, or that it’s ‘all in your head’. It refers to the fact that it is not the result of serious pathology and that we cannot precisely identify the exact cause or structures involved, even with the use of scans/imaging. This is not a problem as this doesn’t change how we manage it. Imaging is not required for NSLBP, and in fact, care guidelines advise against its use.
5-10% of back pain arises from specific, identifiable causes. Radicular pain (sciatica) is an example of this, as are certain inflammatory conditions of the spine. Often, these conditions can be diagnosed clinically but imaging may be used as results may influence management.
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Serious pathology as a cause of back pain is rare. Serious pathologies include fracture, cancer, infection, and cauda equina syndrome. These conditions require specific treatment and specialised care. Accumulatively, these conditions account for approximately 1% of back pain cases (meaning individually they are very rare). Your healthcare professional will remain vigilant, monitoring signs, symptoms, and relevant history (red flags), that may suggest your back pain is caused by one of these.
What causes non-specific low back pain (NSLBP)?
The short answer is, we can’t be 100% sure. We don’t have clinical diagnostic tests that can accurately identify the exact source of the pain, and the same goes for imaging. We do know, however, that low back pain (pain in general) is a complex phenomenon that involves many variables.
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Tissue changes (disc degeneration, disc bulges etc) and biomechanics (how we move) certainly play a role. However, alone, they cannot completely explain the onset and persistence of LBP.
''Mechanical dysfunction has been rightly called into doubt as a single explanatory variable for LBP, and the view that a biological approach alone is inadequate is indisputable.''
This does not mean that tissue changes and biomechanics are to be discounted. It means that many other factors, including unhelpful beliefs around pain, fear, anxiety, depression, poor general health, previous injury and medical history, work satisfaction, sleep quality, and stress, can all act to sensitise our nervous system and increase our chance of experiencing pain.
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The current consensus is that LBP is a multifactorial problem, where any individual risk factor or mechanism plays a small role in the overall condition. It is now standard practice to view back pain from a biopsychosocial perspective (biological, psychological, and social factors).
The contributing factors for LBP arise from a range of domains including:
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Biomechanical
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Tissue injury / pathology
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Psychological
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Central nervous system processing
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Behaviour / lifestyle
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Social / work context
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General health / family history
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There is a lot going on in this picture. The idea of showing it isn’t for you to memorise all the inputs, or even to try and read them all, it is to demonstrate the complexity of low back pain, and how attempting to single out one exact cause may be too simplistic to explain a complex interaction.
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Initially, this may seem daunting, but we prefer to look at it through a positive lens. If there are many factors contributing to LBP, then it stands to reason there are many things we can do to influence it.
Clinical care guidelines for non-specific low back pain (NSLBP)
First line care
Because a majority of NSLBP will resolve on its own given time and a sensible approach, first line care guidelines are based around:
Advice, education,
& reasurance
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Most people will see improvement in symptoms in days to weeks
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Imaging is not required and will not change treatment / management
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Pain does not equal harm. Your back is not damaged, it is most likely just temporarily sensitive to certain movements and positions, and this sensitivity will settle down
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No movements or postures are inherently bad for your back
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Addressing unhelpful beliefs around back pain (we will look at this shortly)
Self-management
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Temporarily avoid and/or modify aggravating activities until your symptoms begin to settle, then gradually reintroduce them
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Superficial heat (heat packs, hot water bottles etc)
Physical activity
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Continue daily activities, including exercise if you normally participate
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Stay at work or return as soon as possible
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Avoid bed/prolonged rest
Second line care
Guidelines identify two approaches to stratify individuals in an attempt to direct them towards best care.
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One approach is to stratify according to symptom duration (acute <6 weeks / subacute <12 weeks / persistent >12 weeks). Treatment then begins with more simple therapies and only progresses to more complex treatments if there is insufficient improvement.
A second approach aims to identify individuals who exhibit signs and characteristics that suggest they may be at an increased risk of poorer outcomes.
​Your symptom severity, irritability & duration are part of this picture, as are:
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Unhelpful beliefs (such as ‘I have back pain due to a weak core’, or ‘bending my back is bad for me’, or ‘it must be because I have bad posture’, or ‘my back is damaged and therefore I shouldn’t use it’)
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Focusing on pain or catastrophising
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Fear avoidance (being fearful to move due to a belief you will damage your back)
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Disengagement from activities that are meaningful to you and make you happy
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Poor expectations of recovery
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Passive coping behaviours (expecting someone else to ‘fix’ you without taking a proactive approach).
For individuals with symptoms lasting less than 12 weeks and/or those deemed to be at low risk of poor outcomes, second line care includes:
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Continuation of regular physical activities including general exercise if normal for you
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Use of superficial heat
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Spinal manipulation / massage (not all guidelines recommend manual therapy, but those that do recommend its use in conjunction with exercise)
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Some international guidelines recommend acupuncture, UK guidelines do not
​For those with symptoms lasting over 12 weeks and/or identified as medium to high risk of poor outcomes, guidelines recommend:
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Structured exercise therapy (therapeutic exercise)
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Psychological therapies (eg, cognitive behavioural therapy or mindfulness)
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Spinal manipulation (combined with exercise)
Pharmacological interventions
Medications are discouraged in first line care and should only be considered for individuals who have not adequately responded to non-pharmacological interventions.
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Paracetamol is no longer recommended in updated guidelines for either acute or chronic LBP. Non-steroidal anti-inflammatory drugs (NSAIDs) are endorsed.
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UK guidelines support the use of weak opioids only for cases of acute LBP where NSAIDs are contraindicated, not tolerated or ineffective.
Invasive non-surgical treatment
Recent guidelines continue to discourage the use of any type of spinal injection for non-specific LBP.
Surgical treatments
Surgical interventions for NSLBP are discouraged
What type of exercise & how does it help?
Exercise is consistently included in care guidelines for the management of back pain.
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Given that biomechanics and tissue changes alone cannot explain low back pain, only attempting to address these factors in rehab is unlikely to result in optimal outcomes. The current research base suggests that improvements in pain cannot be explained solely by local (muscle, joint etc) changes, but involve more central effects, including the brain, central nervous system, and threat perception.
This is why exercise is helpful – it has the potential to positively impact many of the contributing factors from the various domains mentioned previously. So, yes, exercise can improve tissue health and resilience, and this is absolutely something we want to achieve. But also:
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Exercise accesses the ‘medicine cabinet’ in our brains by affecting the release of chemical messengers (neurotransmitters) responsible for having an analgesic effect (reduction of pain).
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Exercise can decrease the sensitivity to pain of our central nervous system through a mechanism called ‘descending inhibition’. This mechanism results in the brain dialling down the amount of unhelpful sensory information it is receiving. It’s much like turning down the volume on your radio.
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Exercise results in reduced levels of systemic inflammation, again, reducing levels of central nervous system sensitivity.
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Exercise promotes increased movement variability and can remove fear for individuals with unhelpful beliefs around what is safe movement. Sometimes, simply being given the ‘permission’ to move freely again can begin the road to recovery.
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Exercise can improve anxiety and depression symptoms, which have been shown to physiologically feed pain.
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Exercise improves general health. There is an association between increased number of comorbidities and LBP.
On a population level, no one type of exercise is better than others. Lots of different types of exercise and movement can help, but of course, not all exercise types will help all people all of the time. The decisions made will be determined by your unique circumstances, including symptom severity and irritability, your beliefs around your pain, your expectations, tolerances, preferences, exercise history, and end goals.
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Options include:
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Heavy load resistance training
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Low load motor control exercises – may be better in the short term but are no better mid to long term than other forms of exercise
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Pilates
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Tai chi
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Aerobic exercise
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This is not an exhaustive list, but it highlights the fact that we have options.
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There is no ‘one size fits all’ answer to LBP, and the approach taken is influenced by a myriad of factors unique to you. Our role at Vitruvian is to try and help you understand your pain and work alongside you to find ways to improve it and return to the activities that you enjoy most.
The Vitruvian Team.
International Framework for Red Flags for Potential Serious Spinal Pathologies
Finucane et al. Journal of Orthopaedic & Sports Physical Therapy. 2020
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Can Biomechanics Research Lead to More Effective Treatment of Low Back Pain? A Point-Counterpoint Debate
Cholewicki et al. Journal of Orthopaedic & Sports Physical Therapy. 2019
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Primary care management of non-specific low back pain: key messages from recent clinical guidelines’
Almeida et al. Medical Journal of Australia. 2018
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Clinical practice guidelines for the management of non-specific low back pain in primary care: an updated overview
Oliveira et al. European Spine Journal. 2018
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Trajectories and predictors of the long-term course of low back pain: cohort study with 5-year follow-up.
Chen et al. Pain. 2018
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Prevention and treatment of low back pain: evidence, challenges, and promising directions.
Foster et al. The Lancet. 2018
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Is a positive clinical outcome after exercise therapy for chronic non-specific low back pain contingent upon a corresponding improvement in the targeted aspect(s) of performance? A systematic review
Steiger et al. European Spine Journal. 2012