- Is my back pain something more serious?
- Will a MRI show me all I need to know?
- My MRI showed there was something wrong
- How much of my pain is from the injury and how much is caused by my back being so sensitive because of the injury?
- What can your therapist do?
- What should your therapist be telling you and not telling you
This blog is a review of the paper: Acute low back pain. Beyond drug therapies. Peter O’Sullivan & Ivan Lin.
This paper collated a review of the recent evidence on acute low back pain that was non-surgical. It is not intended to give personal advice to each individual patient as different people need different management and treatment plans.
A quarter of all adults in Australia have low back pain. Between 10% and 40% find their low back pain becomes persistent and disabling.
Low back pain can also be associated with other pain disorders such as other joint and muscle pains, headaches, migraines, pelvic girdle pain and irritable bowel syndrome (IBS), as well as other health disorders such as depression and anxiety.
Is my back pain something more serious?
Only 1 to 2% of people with low back pain have a serious disorder, such as systemic inflammatory disorder (e.g. particular types of arthritis or polymyalgia rheumatica), infection, spinal malignancy (cancer) or spinal fracture (broken bone).
Some of these symptoms are indicative of a serious illness causing low back pain. However they can also be indicative of a non-serious cause of low back pain. If you have any of the following consult with your GP for a second opinion.
- Pain that comes on for no apparent cause.
- Constant pain not obviously provoked by postures and movement.
- Night pain.
- Morning stiffness.
- Past history of malignancy (cancer).
- Age over 65 years and/or declining general health.
- History of using corticosteroids (e.g. steroid tablets/inhalers).
- History of repeated trauma to an area.
A number of systemic, abdominal and pelvic illnesses may also cause spinal pain.
Will a MRI show me all I need to know?
If you’re the patient that needs them MRI’s are fantastic. They show any number of serious illnesses that can cause low back pain. However they don’t show everything and the things they don’t show are what most commonly cause low back pain.
This is why most people (90% in some studies) get diagnosed as having no serious illness or condition causing their back pain. These people get labelled as having ‘nonspecific’ or ‘mechanical’ low back pain.
In these patients studies have shown imaging their spine unnecessarily when they don’t need it makes them worse. It can lead to poorer health outcomes, greater disability and work absenteeism.
My MRI showed there was something wrong
MRI’s always show something wrong. Sometimes these things are important and an appropriate referral and immediate attention should be followed.
However this is only in 8 to 15% of patients. The rest of the time MRI shows something wrong but it’s irrelevant. You will even find things wrong in people with no pain.
If we put a section of the population with NO back pain in a MRI scanner we would find:
- Disc degeneration in 91% of people
- Disc bulges in 56% of people
- Disc protrusion in 32% of people
- Annular tears in 38% of people
When any of these conditions are severe then obviously they can, in some cases, be a problem in their own right. But as a general rule of thumb, even if you had no pain, it would be more strange not to have some of these things on MRI than to have them.
How much of my pain is from the injury and how much is caused by my back being so sensitive because of the injury?
If so many people have low back pain and so many people can’t be diagnosed by MRI there must be any number of things that can cause low back pain not picked up by MRI.
These physical injuries not picked up by MRI, to name just a few muscle spasm or a strain, will cause low back pain. However they will also cause your spine to become sensitive to pain, which intern, causes further pain.
There is no way of knowing what exact percentage of pain is caused by an injury and what percentage is caused by how sensitive your spine becomes because of an injury. However there is a growing body of evidence that shows that negative beliefs about low back pain can predict how sensitive someones spine becomes to pain.
In the absence of serious illness negative beliefs has been shown to predict pain intensity, disability levels and work absenteeism as well as how long the pain lasts. This has been shown to be more accurate than MRI.
These negative beliefs usually come from patients being mismanaged with their condition. This may take the form of the wrong diagnosis, inappropriate treatment or inappropriate lifestyle advice. This results in the patients adopting beliefs such as ‘I know it will just get worse’ ‘hurt equals harm’ ‘movements that hurt should be avoided’ because of fear of pain and/or harm.
Additionally this negative belief about low back pain can also relate to how we compensate for pain. If you sprain your ankle it hurts, you grimace and you take more weight on the other side. However when you overly or disproportionately compensate for pain, be it ankle pain or back pain, there is evidence to suggest you adopt a catastrophic way thinking (e.g. ‘my back is damaged’, ‘I am never going to get better’ and ‘I am going to end up in a wheel chair’). This results in fear and distress leaving the patient feeling helpless and disabled. Ironically by overly compensating you also physically put strain on the injured area and other areas too.
What can your therapist do?
Acute low back pain may be associated with high levels of fear and distress, and providing a clear and effective explanation to the patient with an effective management plan is crucial.
Manual therapies – such as osteopathic manipulative treatment - may be more suitable in the acute ‘spasm’ phase when movement is limited to help facilitate return to normal movement.
Activities recommended in this paper are:
- Relaxation: Encourage breathing to the lower chest wall and stomach – diaphragm breathing.
- Facilitate awareness of tension in the muscles of the trunk and encourage mindful relaxation.
- Mobility exercises: Encourage gentle flexibility-based exercises for spine and hips progressing from non-weight bearing to weight bearing (e.g. hip and back stretches lying down, progress to sitting and standing).
- Functional movement training: Encourage relaxed movements and avoidance of guarded movements, and discourage breath holding and propping of the hands with load transfer.
- Encourage patients to incorporate movement training into their usual daily activities (e.g. walking, bending, twisting) and strengthening and conditioning if relevant to the patient (e.g. squatting for someone who is involved in manual work).
- Physical activity: Aim for patients to undertake aerobic exercise for 20 to 30 minutes each day that does not excessively exacerbate pain (e.g. walking, cycling [leg or arm cycling] or swimming based on comfort and preference).
- Explain to patients that they may need to exercise for a shorter duration initially, or exercise for short periods throughout the day to build exercise tolerance. Advise patients to increase activity gradually (e.g. 10% per week).
- Patients experiencing high levels of distress require special attention, directing management to reduce high levels of fear, anxiety, depressed mood, catastrophising and distress.
What should your therapist be telling you and not telling you?
The messages listed in this paper are for patients who have acute low back pain but in the absence of serious illness.
If you’ve had a MRI and you have a serious degenerative condition then that’s what you have and you should be told that and treat accordingly. This treatment though should include a list of the things you should do not just what you shouldn’t do.
However some people get diagnosed with the things listed under ‘My MRI showed something wrong’. In that section we listed the things commonly diagnosed by MRI in patients with NO pain. Therefore if you have any of these ‘conditions’ to a moderate degree they are irrelevant to your back pain.
Messages that can harm in patients with nonspecific low back pain
- Your therapist shouldn’t be promoting myths about the damage to your back such as: ‘You have degeneration/arthritis/disc bulge/disc disease/ a slipped disc’ ‘Your back is damaged’ ‘You have the back of a 70-year-old’ ‘It’s wear and tear’
- Your therapist shouldn’t be promoting fear beyond what’s reasonable when your back is hurting such as: ‘You have to be careful/take it easy from now on’ ‘Your back is weak’ ‘You should avoid bending/lifting’
- Your therapist shouldn’t promote a negative future outlook such as: ‘Your back wears out as you get older’ ‘This will be here for the rest of your life’ ‘I wouldn’t be surprised if you end up in a wheelchair’
Messages that can help patients with nonspecific low back pain:
Your therapist should promote a biopsychosocial approach to pain to inform you of the facts such as:
- ‘Back pain does not mean your back is damaged – it means it is sensitised’. ‘Your back can be sensitised by awkward movements and postures, muscle tension, inactivity, lack of sleep, stress, worry and low mood’
- ‘Most back pain is linked to minor sprains that can be very painful’
- ‘Sleeping well, exercise, a healthy diet and cutting down on your smoking will help your back as well’
- ‘The brain acts as an amplifier – the more you worry and think about your pain the worse it gets’
- Your therapist should promote resilience: ‘Your back is one of the strongest structures of the body’ ‘It’s very rare to do permanent damage to your back’
- Encourage normal activity and movement
- ‘Relaxed movement will help your back pain settle’
- ‘Your back gets stronger with movement’ ‘Motion is lotion’
- ‘Protecting your back and avoiding movement can make you worse’
- Address concerns about imaging results and pain: ‘Your scan changes are normal, like grey hair’ ‘The pain does not mean you are doing damage – your back is sensitive’ ‘Movements will be painful at first – like an ankle sprain – but they will get better as you get active’
- Encourage self-management: ‘Let’s work out a plan to help you help yourself’ ‘Getting back to work as you’re able, even part time at first, will help you recover’