Low Back Pain Truths
11 Reasons Why Your Back Pain Isn't Getting Better
1. You’re not receiving high quality, consistent, guideline-based care
At Sydney Muscle & Joint Clinic our approach is high quality, that is care that is effective, efficient, safe, patient-centred, timely, equitable, and delivered by practitioners who are respectful, communicate clearly, and involve patients in decision-making. High quality is care that is supported by research, is evidence-based, strives to be guideline-based and ultimately results in the better outcomes for patients.
For low back pain this means active interventions whereby you move, perform exercise and avoid rest. Heat, massage, dry needling, stretching, foam rolling and taping are all not supported by the evidence and therefore have proven to be useless for low back pain and shouldn't be used by evidence-based physiotherapists.
2. You’re not receiving impairment-based treatments
Impairment based treatments mean your treatment is not focused on a diagnosis. Low back pain can be the result of many irritated tissues and treatment should not be focused on "disc protrusion". Instead modern day management is now focused on managing and treating impairments, these include pain, radicular pain (nerve pain), joint stiffness, muscle tightness, weakness, poor balance and poor neuromuscular control. Treatment techniques should target pain, stiffness and weakness- not an L4/5 disc bulge.
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3. You haven’t been educated in the directional preference of your spine
When your spine is painful, stiff and irritable it will always have a directional preference- this means it will prefer to move in one direction opposed to the other. In most cases of low back pain when the diagnosis is disc-related the spine does not like to flex, this means it does not like to bend forward, sit for prolonged periods, do hamstring or glut stretches and does not like deadlifts, squats, crunches or sit ups. In this case your back will love to extend back and should be encouraged to do so as often as positive.
If your diagnosis is unilateral or one sided low back pain with sciatica or radicular leg pain down one leg the spine will not like to flex or shift away from the affected side. In this case your back should be desensitised with contralateral lateral shift and when your leg pain has resolved, progressed to back extensions. These directions and movements should be assessed in the initial assessment and be the cornerstone of your treatment plan. Our physiotherapists and exercise physiologists make a good habit of knowing the directional preference of your low back when painful, stiff and irritable.
4. The treatment you have received or the relief strategies you employ are in direction contradiction to the directional preference of your spine
When your spine is painful and irritable and doesn't like flexing or bending, then don't do hamstring stretches, glut stretches or try to strengthen your trunk (abs) with leg lifts, crunches or sit ups. Use directional preferenced movements to reduce pain and irritability.
5. Stretching does not help back pain and possibly makes it worse
The majority of low back pain that our physiotherapists see is mechanical disc-related low back pain and as such 95% of the time these spines or backs don't like to bend or flex or sit. Stretching your leg muscles has no effect on your back pain and if these stretches are bending your back then you'll be making it worse.
6. You receive passive treatments that are proven not to work- stretching, dry needling, foam rolling & massage.
Stretching, dry needling, foam rolling and massage for low back pain is not supported by evidence or is part of any guideline-based management. These may modulate your pain (tricks the brain to send an inhibitory neuron to block pain out), but long term they have no benefit on your back pain, particularly when you have peripheralisation of your pain into the leg/foot. Directional specific movements aim to encourage centralisation, progressive overload in the form of exercise aims to increase resilience and education and advice on how your back is getting aggravated is best practice.
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7. You haven’t received a clear diagnosis like "mechanical joint-related low back pain" or "mechanical disc-related low back pain"
Having a diagnosis like L4/L5 disc protrusion with lateral recess stenosis or a spondylolithesis or L3/4 facet joint arthropathy is generally not helpful. Our physios and exercise physiologists give you a diagnosis that is more helpful at understanding why yo have low back pain. This starts with a simple triage- serious pathology, nerve root involvement or mechanical. More often than not patients have mechanical pain (meaning specific movement can help or hinder) and based on symptoms and directional preference we ascertain whether it is disc or joint related. A muscle strain in the low back is very uncommon and rarely in isolation.
8. You haven’t used imaging to help guide treatment.
Generally imaging isn't required with mechanical back pain, but often if treatment might change then getting an image can help explain and then formulate a plan. An example is a mechanical presentation with differing directional preferences- in one hand you may have a large disc protrusion (therefore flexion intolerant), but imaging might show this disc protrusion to be causing central canal stenosis (narrowing) and therefore you are extension intolerant. This can help explain symptoms and a necessary plan of action.
9. You haven’t been given cutting edge anti-movement trunk strengthening exercises
Our physios and exercise physiologists prescribe anti-movement exercises when treating low back pain. These exercises target muscles that restrict or control movemnt and examples are anti-rotation, anti-lateral flexion and anti-flexion or extension. They target trunk and back muscles and create stability and stiffness all whilst reducing the irritable movement that is contributing to the back pain.
10. You haven't tried nerve flossing movements to help with leg pain symptoms like pins and needles, numbness, burning or nerve pain
If you have nerve root involvement, sciatica, radicular symptoms or a radiculopathy nerve flossing movements may be helpful in modulating or reducing pain in conjunction with a directional preferenced movement. These may look like a hamstring stretch, but specific changes like keeping knee slightly bent and pulling the ankle back and forth is key to targeting the nerve. Nerve extenders, sliders or gliders can be used on the unaffected leg first if highly irritable and then on the affected leg to help with centralisation.
11. You haven’t built resilience to painful movements with graded exposure
At Sydney Muscle & Joint Clinic our philosophy is firmly entrenched in the theories of mechanotransduction- the processes through which cells sense and respond to mechanical stimuli by converting them to biochemical signals that elicit specific cellular responses. If we can add load (exercise) we stimulate cells to regenerate, rejunevate and to grow bigger and stronger. We can not elicit this response with stretching, dry needling, heat packs or therabands. We need good honest load and as heavy as tolerable to encourage resilience, tolerance and build capacity.
Regardless of the injury, condition or complaint our physios and exercise physiologists find a way to settle your low back pain down and then build it back up with exercises that will stimulate the greatest cellular response.
Just like with someone with a running injury, we would slowly return them to running with a progressive return to running program. The same applies to someone with back pain and is intolerant to flexing/bending, we return them to bending with a graded program- exposing the spine to movement to build its resilience to the movement.