Exercise for low back pain
I see lots of patients who ask me what exercises to do for back pain. My reply is as formulaic as the exercises are. I generally reply firstly with,
"Will you do them?"because it is my experience both personal and professional that folks just don't. And therefore I argue to myself why go through a very specific well thought out exercise regime with people who, with the best will in the world, are not going carry them out in any therapeutic fashion.
It is better in my book to get the message over that any exercise is better than none. It may be that the 55 year old slightly cuddly lady whose idea of exercise is to wind her own watch may well respond to the suggestion that a Salsa class can be as helpful as a leotarded aerobics body-pimp session. Or that a brisk walk to the shopping centre is as valuable as getting on the lounge floor and creating work for the Hernia surgeon.
I am always keen to provide pointers to those of my patients who want more information and also are serious about working through a regime of exercise (see the Big 3) but I consider it as helpful as anything physical I do in the consulting room to guide people through the principles of self management of back pain.
There are loads of interesting and (probably) helpful exercise regimes out there from core stability to hyperextensions and none of them demonstrate a body of evidence that says they are exclusively therapeutic. The fact is that activity in whatever guise is generally helpful and whilst there are always caveats (mogul skiing, cage fighting, international rugby) keeping going is demonstrably and evidentially beneficial.
I was intrigued to see a campaign launched in Wales to help with treatment of acute low back pain. Or perhaps the word should be management rather than treatment as they don't seem to mention any treatment for folks who have acute low back pain at all. Quite correctly they (and they are "a joint initiative developed in response to Health Challenge Wales") point out that the medicalisation of back pain is a bad thing and therefore "treatment' can be unhelpful in the resolution of the back pain symptoms.
Quite correctly they talk about keeping active, keeping positive and understanding that pain does not equal damage. There is even a section on better breathing. There is some helpful advice for both patients and GPs alike about the likely outcomes and what is useful in terms of diagnosis.
The glaring omission from this worthy initiative is that there is a place for manual therapy and spinal manipulation in the management of acute back pain. People with back pain need advice and some demystification of the problems associated with back pain sure enough but many of them would also benefit from manipulation or acupuncture/dry needling. The only mention of spinal manipulation is in a short piece by Jonathan Pryce, the actor, who says that he seeks the care of a qualified chiropractor when he has pain. Sensible chap.
The NICE guidelines for nonspecific back pain mention keeping active, manual therapy and acupuncture. I would have thought that the website ought at least give a little advice about how to seek help and who from and what to expect.
I hope the good folk of Wales are happy doing breathing exercises when their backs are killing them. I, for one, would rather see my local quack.
Hard or Soft bed?
There is nothing like a comfy bed when you are not feeling 100% especially if your back is painful but as most back sufferers know the last place you want to be is lying down. Getting horizontal for even a short period of time is often excruciating for those with certain types of back conditions and waking up in the morning and trying to move is positively dreadful.
For some the natural conclusion to be drawn by the early morning nightmare is that the bed needs replacing but with what? By common assent one should lie on a hard bed if you suffer with your back. Preferably an old door, so the story goes. And there one should stay until mended. But is this true?
Hard beds often aggravate bad backs and although the reason is not absolutely clear it would seem that the arch formed by the lumbar spine when lying on your back seems to be accentuated by a hard surface. When that happens the back stiffens and becomes painful. There is probably a role for the fact that intervertebral discs ( IVD) swell over night acting like sponges as they absorb local tissue fluid complete with its nutrients ( the IVD has very little blood supply.) Whatever the reason the harder the bed the worse the stiffness and pain in the morning in most cases.
I often advise patients who have this problem to try lying on a folded quilt as a bottom sheet for a few nights, or if they have a softer bed in the house try that. They can then tell if the bed is making a big difference to their back condition. Many are under the illusion that their beds are too soft!
Having said all that, I think that beds are rarely the whole cause of pain in the back; they may contribute to the discomfort but spending £1000 on a new bed might get you a great lay but will rarely completely rid you of all your morning aches. If you feel like getting a new bed, experiment with the beds and quilts in your house to alter the hardness or otherwise of the surface you lie on so that you can be sure when you order that new bed that it’s going to be comfortable.
The General Chiropractic Council
It's of limited interest to those outside the profession but for those inside a real sea change occurred last week when the General Chiropractic Council finally put to bed an old chiropractic tenant that manipulation on a regular basis improves health. This defunct idea has been called the subluxation theory.
Most chiropractors who have considered the evidence have realized this for decades however there are chiropractors who to this day promulgate the subluxation theory and practice accordingly.
Still the shift that this most official of chiropractic bodies has described is welcome and cannot be overstated. Chiropractic should involve itself in the practice of musculoskeletal (MSK) medicine, expanding the evidence base as we are well placed with our daily exposure to the primary care presentation of back pain and other MSK conditions to learn more about what helps and what doesn’t.
Most sensible chiropractors junked the so called “subluxation theory” years ago – it’s good to see it in black and white from the GCC.
I often tell some of my more anxious back pain patients that "backs get better". And for the most part this is perfectly true; of course there are people for whom back pain will be ever present and for these people we can only have the greatest sympathy. Long term pain of any kind is a truly awful thing.
Even so, for many, backs do get better and this little nugget of information is often a complete surprise. Back pain is so incredibly common that should I grab the first 100 adults emerging from my local Tescos, 20 of them would be suffering low back pain at that very moment. How many of them would be sneezing with a common cold? It is estimated that over 60% of us have at least one major episode of back pain at some stage during our lives. If we look at it in the light of all this suffering it is self evident that most back trouble does resolve or the majority would be bent double for most of the time.
But perhaps we should be a little more cautious. Patients do not continue to consult their GP, Chiropractor, Physio etc if they feel that the problem has not resolved despite treatment. A study for the BMJ by Croft et al in 1998 about the outcome of GP management for low back pain concluded that,
"The results are consistent with the interpretation that 90% of patients with low back pain in primary care will have stopped consulting with symptoms within three months. However most will still be experiencing low back pain and related disability one year after consultation."
Many appear to just simply put up with the discomfort and alter their lives to accommodate it, disillusioned with the care they have received and not confident to seek any more until perhaps their problems are intractable and they become a self fulfilling prophesy.
Maybe then it is not that backs get better - perhaps it is patients who simply stay away.
Core stability is a buzz phrase in rehabilitation circles and part of the core stability programme for the abdominal muscles often involves doing sit-ups or modified sit-ups (Crunches).
Professor Stuart McGill, a leading biomechanics researcher established that the compressive load on the lumbar spine when doing a sit-up or a crunch is in excess of 3300N (about 730lbs). The USA's National Institute of Occupational Safety and Health has set the action limit for low back compression at 3400N. It has been found that repetitive lifting loads that generate this sort of compressive force on the lumbar spine is linked to higher injury rates in workers.
So should we do abdominal exercises at all? Well, yes probably but it is a case of doing a safe exercise that doesn't potentially do us more harm than good. An example of a safe abdominal raise is demonstrated by the excellent Dr Phillip Snell in the YouTube video below.
The jury is still out on what type of exercise helps back pain, however it is probably true that keeping active is better than not. Most people would be very surprised at the lack of evidence for any type of exercise as a therapy for back pain.
From experience exercises help as long as they don't compress their spine considerably as so called flexion exercises do or indeed the traditional extension exercises do. Just keep active without doing any chores - delegation, that's the key!
For more on exercise see my Advice page.
For the National Institute of Occupational Safety and Health click here http://www.cdc.gov/NIOSH/
The General Chiropractic Council has commissioned a document called the UK Evidence Report. Written by a number of the top chiropractic scientists in the world this report attempts to gather together a definitive round-up of the evidence for manual therapies for the treatment of musculoskeletal conditions and some non-musculoskeletal conditions.
The document has been generally well received within the chiropractic community who recognise that this is an exercise that is well overdue and provides a real solid footing for those who look to evidence to inform their everyday practice. I have yet to see much in the way of response from more mainstream medical backgrounds; it will be interesting to see what they have to say.
One thing is clear though; manual therapy, ie manipulation and various soft tissue techniques, is one of most evidenced based approaches for the treatment for non-specific mechanical low back pain. Quick delivery could save cost, absenteeism, side effects from long term drug therapy, hospital consultation and imaging resources and lastly but not least patient discomfort.
The Musculoskeletal Services Framework and the NICE guidelines both demand manual therapies as a treatment for back pain and yet it is questionable that the average patient who sees their GP is given that choice.
Click for the UK Evidence Report, NICE Guidelines and the Musculoskeletal Services Framework
Keith Walker is a chiropractor and manual therapist . He provides evidenced based care for his patients in Plymouth, Devon.
www.chiropractorslocally.co.uk- We are listed on Chiropractors locally