In
Part
1 of this series I discussed how I assess people with Low Back Pain (LBP).
In this article I get down to the treatment side of things. I want to thank
everyone who took the time to read the article & provide such useful
feedback. Hence this article is out later than desired as I wanted to reformat
it & do it right.
Disclaimers: As I said in Part 1 this is not intended to
be medical advice. Plus I don’t expect that everyone’s going to agree with
every single point that I make – that’s fine. Also this is going to be a long
article and is very context and assessment dependent. It’s not a recipe.
My approach comes down to 4 basic tenets
1) Minimize what
exacerbates the issue
I didn’t say “take away” or “remove” as for some people,
such as patients with chronic pain and central sensitization, that may not be
realistically doable. But I still believe in modifying and reducing (and if
possible eliminating) what exacerbates the issue. These can be
-
Specific movements, postures, loads, behaviours,
activities (or volumes of activities) or repeated movements OR
-
General health factors such as poor sleep,
stress, depression, or being overweight
Going step by step through these…
Movement/Posture: My movement recommendations depend a
lot on the mechanism.
If someone is aggravated by very specific directions or
postures (i.e. what some would consider flexion intolerant or extension
intolerant) than yes I get people to move in a way that’s not provocative (or
is at least less provocative). This may involve using a neutral spine/hip hinge
technique (I teach a modified sumo lift technique for people with sciatica and
for tall people), emphasis on using the gluteal muscles more (they are never
turned off short of a neurological injury) and bracing … or conversely relaxing
the core musculature and breathing deeply as some patients are very tense &
guarded and need to relax.
For posture – oddly enough (and there’s a bit of
research and
anecdotal support on this) that some people tend to sit or stand in the same
posture that provokes their symptoms and some are very rigid &
overprotective!!! For these people I will have them adjust their lordotic curve
to find a position that’s comfortable for them. I’m more of a fan of teaching
people how to find movements & postures that are comfortable for them rather
than trying to find an ideal.
One of the reasons why I look at movements and repeated
movements is to give people ways to do their day to day tasks that (hopefully)
don’t aggravate their symptoms. While I’m not a fan of telling people to avoid
movements forever it doesn’t make sense to force people through movements that
can aggravate and worsen their symptoms with repetition. Sometimes you need to
take a break from the exacerbating issues to facilitate recovery. How long
movements are avoided is a contentious topic that depends on a variety of
different factors.
For people who have more of a central sensitization (CS)
pattern it may be that everything (including hip hinging) hurts to some degree.
In these populations I’m not as concerned about movement technique as I am
about other variables (more on that below) but I will still teach some
biomechanical principles (i.e. keeping loads to the body, avoiding excessive
muscle tensing or bracing) to make things easier in theory.
General health:
In terms of other risk factors and contributors to LBP
-
Sleep: I educate patients on simple sleep
hygiene (which I will write about in another article) and on the importance of
sleep. Past that if there are other issues I will refer to sleep specialists
especially if I have bigger clientele who may have sleep apnea or people who
may have major psychosocial issues.
-
Stress, Anxiety, Depression and other
psychosocial factors: I’m gonna get some heat for saying this but I don’t
believe; unless it’s related to movement, injury, pain or activity; that
physios should be trying to treat psychosocial factors other than educating
patients about their importance, giving them some exercise to do (which can
help with psychosocial factors) and again referring out.
-
Body weight management: Same principles apply –
educate the patient about the importance of it, get them moving, and if need be
refer out to other health professionals who can help fill in the blanks with
diet and hormone management.
The 2nd key principle of my approach to back
pain is that
2) Well tolerated
movement & exercise are good
A lot of research has shown that general exercise and
“core stability” exercises
are equally
effective for LBP management. While I don’t disagree with the research I’ve
found (anecdotally) that some people with LBP may not tolerate certain
exercises well – be it core training, walking, cycling, general strength
training, or directional exercises.
For home exercises my first go to are generally repeated
movement/McKenzie style assessments based on the directional preference of the
person I’m working with. If a client I’m working with doesn’t have a
directional preference my home exercises are generally
-
For more nociceptive/neuropathic cases: usually
exercises that address “painless dysfunctions” (I hate the term but that’s what
people understand) that may limit an individual’s ability to move in
non-painful (or less painful) patterns such a lack of hip, ankle or shoulder
mobility and/or a lack of hip/core strength or endurance
-
For people with more of a CS presentation: some
people I work with who have CS are insanely deconditioned and have some MAJOR
mobility or strength limitations. In those situations I give people 1-2 low
dose exercises (ie sets of 2-5 2-4x/day working into a bit of pain but not
blowing through it) to either address these limitations or maintain the
mobility that’s already there
In the clinic I am also a fan of core, glute, and general
cardiovascular exercise for most people with LBP who tolerate them. Some may
criticize me – but given the
poor adherence of patients
to home exercise programs I’d rather see them do a few exercises in the clinic
rather than f*cking around with a TENS machine or ultrasound. For people who
tend to have more of a CS presentation I spend more time talking and a lot less
time with exercise & manual therapy.
3) Address
negative beliefs about movement, the body, pain and activity
As I said above I’m not a fan of physios trying to be
psychiatrists. Just as you wouldn’t want a personal trainer trying to treat a
client’s broken arm … I don’t believe a physio should be trying to treat a
client’s PTSD from combat or trying to grief counsel a mother who’s lost her
kid.
But anything related to movement, activity, pain, injury
or the body is within our ballpark IMO.
Therapists such as Peter O’Sullivan have written about
the importance of beliefs as they relate to LBP. While pain science education
is important sometimes patient education has to take different paths based
on
the individual.
In my experience some people respond quite well to pain
science education and others have a hard time changing their view of pain.
Behaviour change and belief change is a long, time consuming process for some
people and some may never change their beliefs. We as a society have become so
engrained in the idea that pain is always due to “issues in the tissues” that
some patients may never change their beliefs. We as therapists have to accept
that we can’t change everyone.
In more “non-specific” cases I point out how a patient’s
pain is due to changes in their nervous system and body that make them more
sensitive and more likely to experience pain. This allows me to put a “feeler”
out there to determine if the patient is interested in more pain science
education. If they are – great. If not, no harm no foul. If they want to learn more than I will draw a
bubble diagram outlining all the factors contributing to the situation and will
go into more detail about pain science in coming appointments.
In patients where there is a legit tissue injury, or in
cases where a patient is dead-set that their MRI findings are the cause of the
problem, I point out how a lot of back injuries
can heal given proper
management.
A big component of my work is positive coaching and
cueing. Some health and fitness professionals freak patients out by pointing
out numerous dysfunctions that either can’t be reliably assessed and/or don’t
correlate well with pain. I don’t coach certain people to do certain movements
or exercises by saying “do this or your back will explode.” I coach movement
and positional strategies in a way that empowers patients to move in ways that
are comfortable for them. Sometimes showing people ways to move and exercise
that are comfortable for them alleviates a lot of the anxiety and enables
people to trust in their bodies a lot more.
I also believe that getting people to do things they
never thought they could do (within reason of course) and progressively working
them towards the activities they want to do also helps build confidence &
change beliefs.
4) Build people
back to the activities that they want to do
This is where we tackle the first elephant in the room …
spinal flexion
Yes – most of my patients that I see on Day 1 (arguably
over 97%) don’t tolerate much spinal flexion. As such I try to minimize that in
the early stages. However, while I’m still reluctant to have people flex 100
million times a day or to do it under heavy load, I do believe we should be
able to move our spines as needed.
When patients are getting closer to full recovery I start
to ease them back into spinal movements through low-load exercises such as cat
camels & prayer stretches and progress them to being able to move fully in
standing. There are however situations where I will stick to the “minimize
spinal movement” approach such as….
-
People with a recurrent flexion or extension or
motion intolerant low back pain that is more nociceptive and/or neuropathic in
nature
-
Athletes who require a great degree of spinal
stiffness in their sports such as powerlifters
In these three populations I often encourage people to
hip hinge as much as possible. I don’t say “don’t bend your back or your spine
will blow out” but I do believe that hip hinging is a better option to achieve
their goals.
If a certain exercise or activity is a goal of the
individual (e.g. returning to walking) than the activity itself (or some close
derivative) is part of the exercise program and is progressed based on the
individual’s activity tolerance in increments of 5-20% per week based on how
the patient responds. As Tim Gabbett has said (yes his research is in athletes
but I believe it applies here too) people respond
differently
to
different increases in activity and as such you have to be flexible to
adjust the rate of progression to your clients tolerance.
For people with nociceptive or neuropathic pain I prefer having
people do activities in shorter bursts, stopping just before their pain would
increase, and repeating those bursts through the day. I find anecdotally that
many of my patients who use this technique for walking or activities experience
a huge increase in their pain free walking tolerance within a couple weeks.
For people who have more CS with walking (or any
activity) I just advise that it’s OK to work into a little bit of pain, not to
blow aggressively blow through pain, and work with them to slowly increase the
amount that’s done.
What about the
other elephant in the room – manual therapy?
I’ll confess that I use manual therapy less than most
therapists do. If it’s a patient that’s had chronic back pain for years and has
already sought out a bunch of passive treatment modalities than manual therapy
isn’t going to be the first thing that I’ll do with them. In addition I find
manual therapy, no matter how gently its done, just makes some people really
sore.
By the same token if I have a case that’s so irritable
that they can barely tolerate any activity, someone who’s overdone it, or
someone who is limited in ability to exercise due to deconditioning or medical
comorbidities, than manual therapy (or even modalities) can play a role but in
my opinion it’s not as important for overall treatment as many therapists
think.
When doing manual therapy for the back (or for other
joints) I try to direct it towards painless limitations (I hate the word
dysfunctions) first and then afterwards painful areas. Since manual therapy’s
effects are non-specific, if I can reduce pain and improve function in another
of the body that kills 2 birds with 1 stone.
So that is basically how I go about treating people
with LBP. As always, thanks for reading.
