Low Back Pain Info - Part 1

SOME GENERAL GUIDELINES FOR BACK PAIN

Back Pain can be undaunting - no doubt about it! 

If you suffer with back pain, you probably already know there is no one way or even any standard way for that matter, to fix it. Strep infections have penicillin. There is no “penicillin” for back pain.  Finding a clinician who can help relieve some of your symptoms is certainly a trial itself. Many, if not most of us, have been there.

In Part, I will provide some standard and recognized guidelines from the medical community to know and think about if you suffer from back pain.

In Part 2, I will provide some of my thoughts and opinions from my many, many years of experience in treating back pain symptoms (including my own,) and from changing my approach to treating back pain umpteen times.

1.      GENERAL CLINICAL PRACTICE GUIDELINES FOR LOW BACK  PAIN

While there are many things that clinicians and physicians disagree about in the care of back pain, here is the somewhat official list of what is agreed upon for back pain in the medical community:

·      Rule out specific spinal pathology or other pathology that can cause back pain

·      No routine use of imaging for non-specific pain -  (see # 2 below for more info on imaging guidelines and reasoning behind it.)

·      High quality patient education – including pain science education

·      Physical Exercise – Movement or activity should be based on patient preference or what patient will actually do. Active motion is better than passive.

·      Manual Therapy combined with exercise is best, better than exercise alone.

·      Early return to activity

·      Caution with Opioids

·      Promote Self-Management   - (Freda agrees strongly with this one, once what works for your pain is figured out.)

·      Assess and manage psychosocial factors – refer for psychological or cognitive therapy when indicated

2.      IMAGING

WHEN IMAGING IS NOT RECOMMENDED

In the absence of red flags, imaging is no longer recommended for:

·      Acute pain within the first 30-45 days - (“Imaging for low back pain in the first six weeks after pain begins should be avoided in the absence of specific clinical indications (e.g., history of cancer with potential metastases, known aortic aneurysm, progressive neurological deficit, etc.). Most low back pain does not need imaging and doing so may reveal incidental findings that divert attention and increase the risk of having unhelpful surgery.”)   American Society of Anesthesiologists – Pain Medicine January 21, 2014.  * SEE CHART BELOW *

·      Low back pain with referred pain (as in some hip or butt pain) especially in people over age 65. (Referred pain often increases with walking and decreases with rest.)

·      Chronic low back pain related to generalized pain

CHART *

The following chart shows image findings in people who have NO back pain. Various degrees of spinal degeneration are present in high proportion without symptoms. Thus, what might be found in imaging may not be causing the problem and can divert attention away from the problem or increase a patient’s anxiety about their back pain.

WHEN IMAGING  IS RECOMMENDED

Imaging is recommended for:

·      Low back pain with radiating pin

·      In progressive neurological conditions

·      When surgery ss potentially indicated

·      When one is a candidate for epidural injections

·      With other clinical findings such as central canal stenosis with bowel and bladder changes, root compression with muscle weakness that does not change with movement or position changes

3.      ACUTE PAIN vs CHRONIC PAIN

Back pain is considered to be acute if you have had pain for 3 months or less.

Back pain is considered chronic if it has occurred for 3 months or more.  Chronic pain may be more associated with other generalized pain or psychosocial issues.

Intermittent, “on and off” pain is not particularly noted in the literature, but Freda has seen this a lot and will address in part 2.

STAY TUNED FOR PART 2 WHERE TOPICS WILL INCLUDE INFO ON EXAMINATION, TREATMENT AND FREDA’S THOUGHTS ON LOW BACK PAIN THROUGH EXPERIENCE

LESS IS MORE!!!

Are you getting enough exercise? Am I getting enough exercise?  Probably not. Most of us are inherently lazy. And besides, we all know “life gets in the way.”  Right?

But perhaps, if you are getting and paying for physical therapy for an injury, fall or need to work on general strengthening and mobility, the question should be, “are you getting the proper exercise?” Are you getting a therapeutic dose of exercise that will actually help you improve? The answer to this question is also “probably not.”

In my many years of practice, I have worked in various settings and in most of them I would venture to say the proper amount of exercise to facilitate improvement is not being given. Especially in outpatient practices, I have too often seen a patient initially get evaluated by a therapist and put on a program. In subsequent visits the patient is either working on their own or with an aide or assistant following the initial directions that were given. Six weeks later the patient is still using the same 2 lbs. weight they started with.

Does your therapist or trainer tell you to do 3 sets of 10 repetitions of something or to do 50 repetitions? Where did they come up with that number? Do they tell you to do this every day? 

If you can do 50 repetitions of an exercise, even 20, 25 or 30 repetitions, especially if you are trying to increase your strength, you are more than likely wasting a lot of your time.

Research and evidence based data show that to improve your strength or endurance you have to work at a moderate or high intensity level. To work at moderate intensity, you have to work at 60 to 80 percent of your capacity.  This actually translates into doing less exercise and spending less time exercising! This is GOOD NEWS! You can be more efficient and effective with your exercise and see more improvement.

To increase your strength, in simple, practical terms, you only need enough weight to be able to perform a strengthening exercise for one or two sets of 8-12 repetitions, done  once or twice a week.  If you are able to do more repetitions than that, you need to make the exercise harder – not do more of it - to improve.  For both endurance and strengthening the perception of moderate intensity exercise should be “hard” to “very hard” or a perceived exertion of 5 to 8 on a scale of 1 to 10.  Your scale of perception.

The therapeutic dose of moderate intensity exercise to improve endurance or aerobic capacity is 5 days a week for 30 minutes in the perceived 5 to 8 difficulty range.  Studies have also shown that doing the 30 minutes in three 10 minute increments is as effective as doing 30 minutes at one time, so breaking up the 30 minutes is an option if that works better for you.

If whatever you are doing feels “easy” it most likely is not helping you improve.  It is still good for you and helping you maintain your current level of functioning, but you are not moving onward.

To recap - less repetitions and less time exercising with harder exercises is the ticket to helping you improve. Also working those exercises into your daily activities/routine rather than taking specific time out of your day to do them will also help you to spend less time doing what you need to do but don’t feel like doing.

(There are different parameters for high intensity exercise but let’s leave that to the athletes for now or email me and ask for that info if you want it.)

Bottom line. Work harder. Work smarter. Spend less time exercising and improve more than you did before.