Back Pain

 

back pain

The back is a general term covering a large area of the trunk behind an imaginary line dividing the front and back halves of the body (frontal or coronal plane). The upper back is so closely related to the neck in terms of the conditions that affect it that this section will only be referring to mid & lower back pain (with or without leg pain). Low back pain with radiating leg pain is often referred to as sciatica. This can be misleading however as sciatica really refers to a specific set of nerves in the low back running down the back of each leg to the feet called the sciatic nerve. Many people use the term for any leg pain and sometimes even just pain in the buttock with no leg pain. Remember not all low back & leg pain is due to sciatic nerve irritation!

There are 3 main types of musculoskeletal injury affecting the mid and low back (excluding fractures) – muscle pain (myalgia), joint pain (arthralgia or arthritis) and nerve pain (neuralgia). Below is a discussion of each with links to the latest evidence based guidelines on treating these injuries along with what our clinic has to offer. At the bottom is a series of home exercises which are often helpful for these types of injury. Please bear in mind that without an assessment it is impossible to say if these exercises will be the correct ones for a specific case so if you have any doubts please consult your chiropractor first.

Muscle Pain – If the muscle is not torn/strained then this arises from “active” muscle trigger points, tight knots of muscle thought to occur due to fatigue either from overuse or poor conditioning. This means they can affect the very fit and the most sedentary. Generally described as a dull achy pain that gets worse towards the end of the day and possibly other symptoms such as numbness, tingling, pins & needles or weakness. If they persist for a long time such as with a repetitive strain injury (RSI) they can become inflamed leading to more pain and referred pains around the ribs, into the buttocks, legs or feet depending on the location of the muscle trigger points.

Range of motion may also be affected leading to a feeling of stiffness and this may cause a person to alter the way in which they move in order to compensate for the discomfort, this can lead to other injuries or trigger points developing. Muscle trigger points are always associated with at least one stiff joint and vice versa joint pain/stiffness will always be associated with at least one muscle trigger point so for management of muscle pain see the information at the end of the next section on joint pain.

Joint Pain – Joints may be sprained or similar to muscle trigger points they can develop pain and stiffness over time from things like; poor posture, overuse, lack of use, injury, poor movement patterns or age related changes such as osteoarthritis. It is important to note that even though osteoarthritis is age related it does not mean that all 50 year olds are equal and when they are 70 they will show the same age related joint changes over a 20 year period.

Your joints, just like the rest of your body, respond to the stresses you put on them in combination with your inherited natural potential (genetics – blame or thank your parents!). Everybody shows some signs of osteoarthritis on x-ray over the age of about 20 this does not mean that your pain is due to osteoarthritis or your age and often there is more that can be done about it than just popping painkillers.

Joint pain will tend to be sharper than muscle pain and often feels as if something is “catching” on certain movements. It can also be a dull achy pain though and is often difficult to distinguish from muscle trigger points hence the need to look at and treat both. Many people will find changes in the weather affect their joint pains. Often holidays in hot countries will reduce or even completely relieve joint pain which quickly builds up again upon returning to the UK.

It is not clear why weather changes arthritic symptoms, it may just simply be the heat loosening up the muscles around the joints (and increasing blood flow) similar to warming up before physical activity or there may be other environmental factors such as pressure changes within the joint fluid or changes in vitamin D levels affecting the immune system (which controls inflammation). Current advice to help manage this kind of arthritic pain is to bugger off to Spain for the rest of your life…..if only that were true!

In all seriousness exercise and a healthy diet are the obvious ones but other dietary advice can be misleading. The latest cochrane reviews on dietary aids for osteoarthritis suggest arnica may be as effective as NSAID’s such as ibuprofen but surprisingly arnica may be more harmful. It is unclear if capsicum is effective but comfrey extract gel probably does improve pain so I would currently recommend trying that first if you are looking for non-pharmaceutical alternatives. Chondroitin, alone or incombination with glucosamine, may also be beneficial in the short term at least.

What can we do for you? A short course (usually 4-8 treatments) of manipulation or mobilisation combined with some form of soft tissue therapy like trigger point therapy or instrument adjusted soft tissue mobilisation (IASTM – basically graston without the trademark!) will relieve pain and restore mobility in most cases of joint or muscle pain. We also offer dry needling (a more specific form of acupuncture) and rocktape which is a brand of kinesiotaping that is commonly seen on sports people to help keep their muscles flexible and reduce swelling. Also whilst it cannot cure osteoarthritis manual therapy is one of the most effective ways of managing the symptoms along with exercise which we will also advise on.

Long term management of any back injury will depend on how much you avoid or reduce the aggravating factors and how often you practise the beneficial exercises. Another good way of managing the symptoms is to have periodic treatment every few months instead of letting the problems build back up again, chiropractors call this “maintenance” treatment and it is similar to what dentists offer to look after your teeth or having your car serviced before breakdown occurs.

What does the evidence say? The main clinical guidelines in the UK are produced by NICE and they are updated every few years with the next update for low back pain due towards the end of 2016. Currently NICE recommends manual therapies such as manipulation in combination with exercise advice and soft tissue therapies for up to 9 treatments over a 12 week period.

Nerve Pain – This is where things get a little more complicated because the real problem is identifying what is causing the nerve to be irritated. It may actually be tight muscles which would then follow the muscle pain section above. Nerves can be compressed due to degeneration of the spine over time reducing the size of the holes that nerves exit the spine. In the early stages this can easily be treated similar to the way described in the joint pain section above.

In later stages this may become a condition known as stenosis and the pain will increase the further you walk, stopping and resting will quickly relieve and particularly if you flex your spine so people often describe relief when bent over a shopping trolley for example. Depending on the type of nerve compression causing the stenosis it may respond to manual therapy and exercise but some cases will require surgery, your chiropractor will be able to advise you when this is necessary.

The other common cause of stenosis as well as “sciatica” and other nerve related low back and leg pain is disc bulges. The discs are specialised forms of connective tissue found between the surfaces of each spinal vertebral complex (between each pair of bones). They degenerate naturally over time but also as with the rest of the body the speed of degeneration depends on what you do….things like prolonged sitting or standing have been associated with greater disc degeneration as has smoking, being overweight and poor bending patterns when lifting etc.

Most disc bulges occur posteriorly and laterally (poking out backwards and to one side) and may trap or inflame the nerve root that exits at that level of the spine leading to nerve pain that radiates along the course of that nerve (radiculopathy). The most common vertebral levels affected are between L4/5 and L5/S1 both of which have nerve roots that form the sciatic nerve hence why most cases of low back pain and leg pain are called sciatica. If a different level of the spine is involved then a different nerve may be affected and this would not be called sciatica even though there may be leg pain.

The greater the level of nerve compression the more severe the neurological symptoms will be (not necessarily pain). Pain can be just inflammatory and does not mean the nerve is being compressed. Sensory symptoms such as numbness, tingling and pins & needles will occur with mild nerve compression. With greater nerve compression the muscles will start to lose nerve supply leading to muscle weakness. This is a more serious sign as prolonged or rapidly increasing muscle weakness may lead to permanent deficit. The worst of these cases will require surgery.

It is very important to look out for signs of spinal cord compression when you are suffering from low back pain. In the lumbar spine the spinal cord splits into smaller bundles of nerves that look like a horses tail hence the term equina when referring to spinal cord compression in the low back (cauda equina). In severe cases it is a surgical emergency and this can be identified by loss of control of the legs and/or bladder/bowel including saddle anaesthesia which is a loss of sensation around the anal area.

What can we do for you? Well in most cases the same treatments that help with muscle and joint pain also help with nerve pain. This is most likely because improving your mobility and posture will reduce the stress on the disc/nerve and those treatments also have a pain relieving affect. The main difference is these injuries take longer and usually require more treatment (8-12 treatments).

Acupuncture can also help with pain relief. There are specific exercises that often help too, see below for a list of the commonly helpful ones but remember if it is making the leg pain worse and travel further down the leg then it is probably not helping. Things that help to localise the pain closer to its origin in the low back or buttocks (centralisation) are likely helping. Things that increase the pain further away from the origin of pain are likely hindering recovery (peripheralisation).

What can you do for yourself? A key part of managing nerve radiculopathies like sciatica is reducing the daily irritation to the nerve so the inflammation can heal any tissue damage and then settle down. Therefore reducing inflammation (but not stopping it altogether) will help control pain (ice for 10 mins 3-4xday) and avoiding or reducing any aggravating postures will stop inflammation building up. For example try taking regular breaks from sitting if you have a sedentary job and if you have a job involving lots of bending/lifting then make sure you do it with good technique and limit how much of it you have to do.

Nerve inflammation can be very painful and can take 2-6 months to recover so it may also be advisable to seek pain relief from your GP or pharmacist. For more self help see exercises below under the disc bulge section as general low back exercises may not always be beneficial for disc bulges.

What does the evidence say? The NICE guidelines do not have a separate guidance for nerve pain compared to muscle or joint pain so currently they also recommend trying a course of manual therapy along with pain medications.

Home Exercises: The level one exercises are for beginners who want to reduce their current low back pain from muscle and/or joint pain and also reduce the chances of it returning in the future. The best results will likely be obtained at levels 2 and 3 but you should not progress levels unless you have really mastered the previous level. The final section is on specific exercises for disc injuries as these often require a more conservative approach.

Level 1 – Start with improving breathing patterns & mobility of the hips, calves, quads, hamstrings and back. Also at this level try and learn the basics of glute strength and “core” stability:

Breathing patterns: Who knew you could breathe wrong?! Using your diaphragm to control your breathing as opposed to the smaller muscles around your neck (scalenes in particular) will help stabilise your spine thereby reducing the work the lower back muscles have to do so they don’t get as fatigued as when you have poor breathing patterns and no core stability. Since this is also important to reduce neck muscle tension the exercises for it are in the neck pain section.

Calf stretch:

Drop heel towards floor and hold stretch for 30 seconds.
Drop heel towards floor and hold stretch for 30 seconds.

Hamstring stretch:

Hold for 30 seconds, concentrate on tilting your pelvis as far forward as possible before reaching towards toe.
Hold for 30 seconds, concentrate on tilting your pelvis as far forward as possible before reaching towards toe.

Quad/hip/back stretch:

Start on all fours, sit back onto heels and reach hands out in front, hold for 30 seconds.
Start on all fours, sit back onto heels and reach hands out in front, hold for 30 seconds.

Glute bridge:

Lift hips off the floor using your buttock (glute) muscles not your low back or hamstrings. Repeat 10 times.
Lift hips off the floor using your buttock (glute) muscles not your low back or hamstrings. Repeat 10 times.

Rolling patterns: Rolling patterns on youtube with Dr Perry Nickelston. Start with the upper body soft rolls for level 1. The aim is to become aware of your abdominal area and use contraction of all the muscles in that area (your “core”) to roll you over rather than your legs (which will twist and irritate your low back). If you are feeling confident and they do not irritate your low back pain then feel free to try the progressions in the second half of the video.

Level 2 – So hopefully your lower limbs and low back are more supple and you have discovered your glutes and abs! If so then you are ready to start increasing their strength and incorporate the contractions into more complicated movement patterns. The glute bridges are essentially how you should initiate getting up from a chair, getting up from a chair is one half of a squat. So you should be capable of a basic squat and at the very least try and do it whenever you get into or out of a chair and you will be squatting multiple times per day without going near a gym!

Squat: Start from a high chair with your butt near the edge of the seat, feet shoulder width apart, heels under the edge of the seat. Next sit upright slightly sticking your chest out and keeping your head facing forwards not down. Tense your abdominal muscles (like in the rolling patterns) and keeping your knees shoulder width apart focus on pushing your heels into the ground so your glute and hamstring muscles heavily contribute to pushing your torso upright without letting your knees move forward. If you are struggling with this put a chair in front of your knees to stop them moving forward.

squat technique

To make this a squat instead of a sit-to-stand simply reverse the process back down to the seat and repeat a few times without letting your weight fully rest on the seat until you have finished several repetitions. This exercise requires good calf and hip mobility as well as glute and core strength so hopefully you can see why it is important to master the level 1 exercises first.

All bending and lifting tasks should be as close to proper squats (as described above) or lunges (see below). Unfortunately many manual handling courses teach incorrect lifting technique. Most will tell you to keep your back straight & upright whereas you should actually lean forward from the hips up to around a 45 degree angle if necessary. With your back completely upright they will then tell you to bend through your knees which will lead to you raising onto your toes and significantly overloading your knees and being off balance, not a recipe for good/safe lifting!

Plank: One of the easiest core exercises technique wise which means your less likely to do it wrong. Basically you just have to hold as straight a body shape as you can for anywhere from 10 seconds to a maximum of 1 minute. The key point is too feel the effort mostly in your stomach muscles, if you feel it in your low back you have likely dropped your pelvis too close to the floor, if you feel it more in your legs/shoulders you are likely to far from the floor with your pelvis.

plank

You can hold for longer if you want but the gains from holding longer are minimal and the risk of losing your technique and injuring something increase significantly so I would look for a different exercise if you can easily plank for at least 30 seconds.

Side Plank: Guess what….its like a plank but done on your side! So for this one you should feel the main effort in the sides of your stomach muscles (obliques & QL muscles) that are closest to the floor. Then repeat the hold on the other side. This is harder than the front plank so expect to hold for around half the time of the front plank.

sideplank

Bird-dog: This sometimes gets incorrectly called supermans. You should start on all fours and try to raise one arm at a time up in front of you without the rest of your body moving. This will require you to tense your stomach & buttock muscles hard. If the rest of your body moves then it doesn’t count as a rep. When you can do 10 reps with each arm try just straightening one leg at a time. Once again reps only count if the rest of your body barely moves.

bird dog leg

If you get to the stage of being able to do 10 good reps with arms or legs then try moving one arm at a time with the opposite leg straightening at the same time. This is very tough and is definitely moving onto level 3 or above, most people who do this in gyms move their trunk so they are wasting their time! If you ever get to the level of 10 good reps of opposite arm/leg it is possible to do same arm/leg and for this you are allowed to shift your weight slightly to opposite side in order to keep your balance. A significant shift in weight is a failed rep, this level is really only for athletes I have tested professional footballers with this and none of them could do a good rep at this final level. And if your asking after lots of practise over the years yes I can do this exercise so its not impossible!

Level 3 – Well if you’ve mastered levels 1 & 2 you should be reasonably flexible with good core stability. Now you are ready to do some more complicated movement patterns. If you apply the core stability and glute control from exercises like the squat, plank & bird dog to any lower body/core stability exercise you should have the basic fitness and coordination to do any gym exercise or sporting movement. All you need to do is learn the specifics of that particular technique. Below are a couple of more advanced movements that will help with everyday life.

Step ups: Unless you live in a bungalow you probably go upstairs several times a day. Just as squats help you with getting in/out of chairs and lifting things step ups will help you go upstairs or hills. The key point as with squats is to get your glutes involved. Focus on pushing the heel into the ground and preventing the knee from moving inwards. Also use your glutes to stop your hips kicking out to the side. So when you get to the top of the stairs/hill your butt muscles (not your quads as is normally the case) should be feeling at least a little tired and like they have done as much if not more than any other muscle in your body.

stepups

Lunges: This is just an exaggeration of walking and running so if you can do this well you should be well prepared for those activities. Just like the step ups the front leg should be getting a heavy dose of glute work not just quad. The aim is to drop your trunk STRAIGHT down towards the floor controlling the descent with the glute muscles of your front leg rather than the quad muscles of either leg. Then push back up through the heel of your front leg and toes of the back leg.

lunges

Exercises for lumbar disc injuries – Hopefully at some point you can start going through the progressions at level 1 above as these will be beneficial as preventative exercise for the future. However in the first 1-2 months of a disc injury you may find them too irritating to the disc and need to just keep things simple until the inflammation has eased. It is vital though to keep moving the spine during a disc injury as this helps the injury heal, the key is to not do too much.

Mackensie exercises: There are five basic exercises in the Mackensie protocol. Standing still and bending to touch the toes, standing still and bending backwards, standing still and shifting your trunk from side to side, laying on your back and hugging the knees to the chest (exercise 5 below) and laying on your front and propping yourself up on your forearms. The aim with disc injuries is to find the exercises that hurt the least and more importantly reduce the radiating leg pain the most.

mackensie

Usually this is the prone extension exercise (exercise 1 & 2 above) but in some cases it may be one of the other four. The prone extension can be done whilst your watching TV. Simply lay flat on the floor, face down. And for 30 seconds at a time prop yourself up onto your forearms. If you are not in a place where you can lay down then try the standing extension exercise (exercise 4 above). Stand tall with feet shoulder width apart and push your pelvis gently forwards with your hands, hold for around 5-10 seconds and repeat. Remember any of these exercise are making your leg pain worse don’t do them, not everyone has the same type of disc injury!

Cat stretch: This is a relatively safe mobilisation of the spine but as always with disc injuries if it is provoking your leg pain don’t do it. Start on all fours and slowly arch you back into the air as far as is comfortable and then slowly arch your back the opposite way so you go a little beyond the original flat back starting position. repeat this at least 10 times to mobilise your lower back.

catcamel

Sky reaches: This is effectively traction of your spine and you could achieve a greater stretch by hanging by your hands from a bar. Just stand upright feet shoulder width apart and reach your arms as high up in the air as you can. Please note that bigger stretches aren’t always better, traction makes logical sense as a treatment for disc bulges but after years of using it as a treatment on the NHS the evidence for its effectiveness is limited and it is not currently recommended by NICE.

skyreaches

And don’t forget to use ice, that and movement are the best ways to reduce the inflammation and therefore the pain of a disc injury. Only use medications if you still have significant pain despite these methods. The best sleeping position particularly if you only have leg pain on one side is to sleep on the pain free side with a pillow between your knees, hips & knees being bent up to around 90 degrees. You could also sleep on your front although bear in mind in the long run this will increase the chances of developing degenerative stenosis of the lumbar spine and will also lead to neck pain & stiffness.