Why I Love Low Back Pain
When I was at university, I did a number of hospital based placements as part of my physiotherapy degree. When I was doing my musculoskeletal placement, I worked in an outpatient rehab ward, where we saw patients who had recently been discharged from hospital, or people who had an injury but could not afford to see a private physio so they would go through the public health system. One thing that both private and public physio had in common was the large amount of people who had back pain, most commonly low back pain.
Now I have to be honest here and say that the education for the different types of back pain that I received at Uni was underwhelming to say the least. So I was really hopeful that whilst on my placement I would learn much more about back pain from actual practising physios, those who were essentially on the ‘front line’ of back pain. Unfortunately this was not my experience. What I saw was that most patients with acute back pain were treated with a one size fits all approach and those with long standing back pain were essentially treated as though the pain was all in their head. You see, there is this unfounded belief within the industry that all back pain should resolve within 3 months, so if you’re still in pain after that, it’s your fault because you’re too focused on your pain and now you’re catastrophizing… unfortunately it just doesn’t work like that.
I’ll never forget the mismanagement of so many low back pain patients that I witnessed while doing my placements at Uni. I kept thinking to myself that there HAS to be a better way to manage back pain, I NEEDED to know more! This sparked a thirst for knowledge on this topic which continues to this day. Fortunately there are many very well educated individuals who are what I would call specialists in this area, from whom I have read, watched, listened to, and absorbed as much information as possible.
A one size fits all approach to back pain just doesn’t work. The way we move has such a massive effect on back pain, such that all those with low back pain will have a movement-directional preference that does not cause pain. That is, some will find spinal flexion painful (think bending forward) but find spinal extension is pain free (think leaning backwards). Yet others will be present with the exact opposite painful and pain free directions. When you consider this, it’s easy to see why it is so important to have an extensive back assessment and understanding of the injury mechanism, so that we can design a rehabilitation program that is not going to reproduce the same mechanism that caused the injury in the first place.
One thing that I find so interesting when I see patients with low back pain is some of the beliefs they have and ‘common sense’ recommendations that they have or have been told. I like to call them ‘back pain myths’ and I’ll discuss some of them here.
*disclaimer – I’m going to challenge some of the most common back pain beliefs here;
1.Stretching the back and increasing the range of motion is beneficial, and reduces back problems. Without fail whenever I ask someone with back pain if they do any stretches, they all say “yes… but not as much as I should”. Most are shocked when I tell them to stop stretching their backs. To be clear, there is ZERO evidence that stretching reduces back problems. In fact, what the evidence does show is that, on average, those who have more range of motion have a GREATER risk of future back problems.
2. If I get my back stronger, it’ll be more resilient to injury. I know this is going to shock a few people, but training strength for your back does NOT reduce your risk of injury. Strength has little association with back health, in fact many hurt their backs trying to increase strength. On the other hand, muscle endurance, as opposed to strength, has been shown to be protective for future back troubles. Nooooow… I know what some of you are thinking…how could I say that strength is not important. Well, I never said that, but the reality is that strength is one of the final stages of rehab, and for most people with back pain, they will never need to get to this high of a level. However for those who participate in a sport or have a job that is very physical or laborious, strength training will be required, but it is only trained after a thorough foundation of back endurance has been established.
3.Your back pain is because you have delayed activation of your TA (transverse abdominus). Ahhh, I could talk about this one all day. Occasionally in physiotherapy there will be a study that comes out that has such a profound influence on the direction of treatment. In the early 1990’s, physiotherapy was all about ultrasound. We used it to treat everything because apparently it reduced inflammation and reduced pain blaaah. Turns out actually it does nothing, and now it’s not used at all anymore. This is how I view TA activation training, and the sooner it’s removed from practice like ultrasound was, the better.
It all started in the late 1990’s when a study came out of Queensland that showed that people with low back pain had delayed activation of their TA with rapid arm movements, and so this began the generation of ‘core stability’ where TA activation exercises, and pilates were king. Pull your belly in gently and activate your TA and this will fix your back pain… If only it was that simple. The paradox to this is that pulling your belly in to engage your core is actually DESTABILISING, and here’s why:
- In the study that started the whole TA movement, delayed onset of TA was 10 to 30 milliseconds. This is irrelevant during a normal movement in which these muscle are continually contracted to ensure stability;
- The major stabilisers of the spine have different activation patterns for different tasks. That is, core stability is task specific – it does not start exclusively with TA activation;
- Drawing the abdominals inwards actually DECREASES core stability. In biomechanical terms, it reduces the moment arm. Smaller moment arm equals less power… less power equals less strength which equals less stability;
- People are unable to activate this muscle in isolation beyond very low levels of contraction because it is designed to activate with the internal obliques; and
- There are now multiple studies that show that there is NO delay in TA activation in those with back pain.
I’ll leave it there on TA… suffice to say if you see a physio who says you need to activate your TA, probably best to seek out another physio.
You’re probably now thinking that I don’t believe in core stability, but actually quite the opposite is true. I’m a huge advocate for core stability in treating low back pain. If you think about any injury that occurs in the body, it creates laxity. Think an ankle sprain, now your ankle is a bit looser and you’re more susceptible to spraining it again. So you need to strengthen the muscles around it to make it more stable. Back pain is no different. The most common type of low back injury is an injury to the intervertebral disc. This is essentially a ligament, so when we injure it, we get laxity around the area. Many people suffer from painful micro-movements that occur in the spine following and injury. For those of you with back pain, think about that sharp sudden pain you sometimes get that takes your breath away. It might be when you’re reaching out to grab something, bending over, or maybe when you’re sneezing or coughing. If this sounds like you, then you’ve probably got some instability in your spine. The only way to increase the stability in your spine is to increase the strength of the muscles that stabilise your spine. For your information there is about 10 different muscles that I target when I’m training core stability, and all of them are just as important as the other, there is not a single most important muscle.
Back pain is a complex issue that requires a comprehensive assessment so that an individual rehab program can be written and perfected for each person. My treatment approach follows a simple methodology.
- Remove the movements that are causing pain
- Teach the person about motor control and corrective movement strategies
- Train core stability focusing on endurance
- (Many people will not get to this stage or beyond) Train strength
- Train speed and sport specific tasks
If you’re experiencing back pain, book in with me for a free initial assessment. I’d love to have the chance to help you resolve your pain and get back to doing what you love.
Thanks for reading, have a great day.
Trent Shannon
Back In Motion Rowville
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