Lower back pain – To bend or not to bend?

Posted on: May 6th, 2017 by The Physio Movement | Categories: Sports Medicine & Nutrition

Have you had back pain at some point in your life? The answer, most likely is yes. Back pain is common with about 80% of people experiencing back pain within their lifetime. However, it is rarely due to serious cause. For 10-30% of people, back pain can be very distressing, interfering with activities of daily living, the ability to remain active and can negatively impact their quality of life.

There are many common and unhelpful myths about back pain like: back pain is caused by wear and tear, damage or the joint ‘being out’, we can ‘slip discs’, the back wears out from lifting, we shouldn’t exercise or lift with back pain and that back pain gets worse as we get older.

Firstly, to understand low back pain (LBP), and understanding of categories of pain is essential. Acute pain is that initial pain felt when either tissue structures have been damaged and may result in inflammation and dysfunction. This pain is important and serves as a protective function for humans. It tells us something has happened, and we need to rest and heal. However, if this pain remains longer then 3 months it is known as persistent or chronic pain. By this point in time, whatever soft tissue damage occurred to discs, joints, ligaments or muscles has healed. Therefore, this pain serves no purpose to us and tends to create fear that tissue damage is still occurring. Chronic pain can be debilitating, as is currently the highest costing condition in Australian healthcare, costing billions of dollars annually.

As a society, we generally have negative thoughts towards pain in general. When it comes to LBP, we tend to have increased fear and negative attitudes about it. We tend not to stress too much about a sprained ankle, as we know it will get better over time, but if we sprain or injure our backs we can have panic set in very fast. LBP can either be categorized as specific or non-specific LBP.

Specific LBP is rare, less then 1% of people have it related to cancer, infection, fracture or an inflammatory process. Further, only 5% of people have back and leg pain associated with nerve compression. This means that the majority of people with LBP DO NOT have a ‘specific’ pathology. The good news for 90-95% of people is that their LBP is not related to specific pathology, but more due to a simple strain of the back usually at a time where we are more vulnerable (run down, tired, stressed, tense, sad, inactive or over-active).

Often with LBP, we are quick to seek medical imaging such as CT scans and MRI’s. Scans are not indicated for the majority of back pain unless specific pathologies are suspected. What people with pain are generally unaware of is that everyone over the age of 20 will have some form of degenerative changes to discs (80%) including disc bulges (50%) that may not be causing any pain at all. There are times when scans can be helpful, but usually can make things worse as we start to worry more and more about our backs in an unhelpful way and try to protect them.

Evidence in recent years is driving the medical industries (physiotherapy included) to change their beliefs about the spine. There is generally a lot of fear with the structure of the spine. People are told to be careful with their backs and have the fear to do harm. When disc related pathology is suspected, people are told to avoid bending forward and avoid loading the spine. Whilst in some instances this is needed (acute injury etc.) the spine is a strong and robust structure, which we can trust. Spines are made to move and bend!

The role of the brain and the nervous system in pain is an area of focus gaining more and more attention. We now know that pain is a very subjective sensation completely generated in the brain. Often with disabling back pain, the motor systems are overactive or hypersensitive. This means the muscles that affect the spine are guarding the back too much. In chronic LBP, neural pathways that send messages to the brain can become hypersensitive, meaning messages that may be interpreted as pain are fired increasingly easily, almost to the extent that all information from the back is perceived as pain. Stress, anxiety and fear are all large contributors to a heightened nervous system, meaning the person is constantly on edge about their pain.

So, what is the importance of continuing to bend in chronic and acute pain? It is especially important in acute cases of lower back pain, to encourage gaining flexion range back as early as possible. By encouraging normal movement patterns and allowing the patient to trust their backs again, the effects this would have on development of neural sensitization, depression/ anxiety, fear, negative thoughts, illness behaviors and over protection/muscle protection will be huge.

Once you’ve been cleared of serious pathologies and your physiotherapist is happy for you to start moving again, do it!

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