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A brief overview of the research surrounding the management of non-specific lower back pain (CNSLBP) – An evidence-based model and what to do about it.

“The boundaries between health and disease, between well and sick, are far from clear and never will be clear, for they are diffused by cultural, social and psychological considerations.” – George Engel

You most likely have experienced some form of lower back pain during your lifetime and you are not alone, as this is the most common musculoskeletal complaint. The question must be asked: if lower back pain prevalence is still so high, with such a significant cost to the medical system how effective have we really been at managing this condition?

It is fair to say that the management of non-specific chronic lower back pain remains a challenge.

Most cases of lower back pain will fall in a category known as “non-specific”, which refers to an unknown cause. This represents the idea of lower back pain involving a number of factors, assuming that red flags have been ruled out of the equation (i.e. serious factors such as fractures or tumours). NB: It is important to screen for red flags as this requires targeted and specific treatment from a medical professional, however, such pathologies are extremely rare. These rare cases are accompanied by other symptoms, such as unexplained weight loss, fever and loss of bowel control.

So, what is it that we should do to manage chronic lower back pain?

Well, it depends…

Move more and often general exercise is recommended. This goes against the traditional treatment suggestion of “bed rest” for lower back pain and for very good reasons. A review highlighted that exercise decreased pain, disability, secondary physical deconditioning, or time off work in patients with chronic lower back pain. This emphasises the importance of a gradual introduction of exercise to reduce disability, increase physical capacity and in turn help return the individual to their meaningful activities.

What type of exercise?

Aerobic exercise can play a role in managing it. Think of it as your typical cardio-based exercise such as walking, dancing, swimming, running and rowing that is performed for a prolonged period. Aerobic exercise has shown to increase the body’s production of “feel good” chemicals which have a role in decreasing the perception of pain. They act in a very similar fashion to pain-reducing drugs (i.e. morphine), however, it is natural and may assist people from relying on pain medication.

Did you want to know the plus side to this? The positive side effects are endless, and can include improved mood, sleep, confidence, strength, cardiovascular health, bone mineral density and cognitive function. A 6-week walking program was shown to be just as effective as specific lower back exercises in improving function, pain and avoiding activities due to fear. This finding could give people with back pain the option of participating in a preferred mode of exercise, which is important in exercise commitment in the long-term.

Strengthening exercises are also very important

  • Exercises that strengthen the muscle groups of the back and trunk have shown to reduce pain and disability. Intervention of specific exercises such as the bird dog, side plank and slow curl ups were effective in reducing pain and disability.
  • Specific exercises, such as a side plank, single leg balance, upper body rotation and a squat can play a role in reducing low back pain.

 

As is flexibility training

  • Flexibility training of the lower back and lower limbs also showed some improvement in pain reduction for people with CNSLBP. However, it doesn’t necessarily mean that “tight muscles” (which is generally just a sensation) causes lower back pain.
  • The benefit can be attributed to improved range of motion which may allow the individual to mobilise the spine, partake in activities of daily living and assist in tasks such as lifting and bending.

“How do I keep on moving and exercising if I am experiencing lower back pain?”

It is very normal to hold this thought and to have some fear around exercising with a sore back. A pacing strategy can be utilised in these situations to help build your confidence and reassure you that you aren’t as broken as you think. If you enjoy walking but the sound of a 20-minute walk sounds out of your reach at the moment, then it is perfectly okay to begin with a 5-minute walk and slowly increase from there. It is still okay to move with some symptoms. In the series to follow, I will discuss how shifting your attention towards more function-based goals may help you have more control of your health outcomes.

In summary, moderate quality evidence supports the idea that exercise alone, or in combination with education, is effective for the prevention and management low back pain

This type of intervention is more supported by evidence compared to other widely used modalities, such as education alone, no-lift policies, ergonomic furniture, mattresses, back belts, lifting devices.

It is recommended to do something that you enjoy. Being involved in an activity that we find joy in will help with exercise commitment in the long-term and will make exercise feel less of a chore. Before partaking in an exercise program, it is important to reflect and ask yourself, “do I see myself doing it in a few months’ time?”.

Guidelines also suggest exploring psychological interventions, however a discussion of these modes are outside the scope of this blog.

My take-home point is to try to find ways to move more, do activities that you enjoy. If you are unsure of how to start your journey of improving your quality of life, it is recommended to seek the advice of an evidence-based exercise professional.

 

References:

Chatzitheodorou, D., Mavromoustakos, S., & Milioti, S. (2008). The effect of exercise on adrenocortical responsiveness of patients with chronic low back pain, controlled for psychological strain. Clinical Rehabilitation, 22(4), 319-328. doi: 10.1177/0269215507079858

Chen, S., Alexander, R., Lo, S., & Cook, J. (2012). Effects of Functional Fascial Taping on pain and function in patients with non-specific low back pain: a pilot randomised controlled trial. Clinical Rehabilitation, 26(10), 924-933. Doi: 10.1177/0269215512441484

Foster, N., Anema, J., Cherkin, D., Chou, R., Cohen, S., & Gross, D. et al. (2018). Prevention and treatment of low back pain: evidence, challenges, and promising directions. The Lancet, 391(10137), 2368-2383. doi: 10.1016/s0140-6736(18)30489-6

Gordon, R., & Bloxham, S. (2016). A Systematic Review of the Effects of Exercise and Physical Activity on Non-Specific Chronic Low Back Pain. Healthcare, 4(2), 22. Doi:10.3390/healthcare4020022

Harris, R. (2006). Embracing your Demons: An Overview of Acceptance and Commitment Therapy. Psychology in Australia. 12(4).

Henchoz, Y., & Kai-Lik So, A. (2008). Exercise and nonspecific low back pain: A literature review. Joint Bone Spine, 75(5), 533-539. Doi: 10.1016/j.jbspin.2008.03.003

Inani, S., & Selkar, S. (2013). Effect of core stabilization exercises versus conventional exercises on pain and functional status in patients with non-specific low back pain: A randomized clinical trial. Journal of Back and Musculoskeletal Rehabilitation, 26(1), 37-43. doi: 10.3233/bmr-2012-0348

National Health Service (NHS) Back Pain. (2020).

Premkumar, A., Godfrey, W., Gottschalk, M., & Boden, S. (2018). Red flags for Low Back Pain are not always really red. The Journal of Bone and Joint Surgery, 100(5), 368-374. Doi: 10.2106/jbjs.17.00134

Shanyderman, I., & Katz-Leurer, M. (2012). An aerobic walking programme versus muscle strengthening programme for chronic low back pain: a randomised controlled trial. Clinical Rehabilitation, 27(3), 207-214, doi: 10.1177/0269215512453353

Suni, J., Rinne, M., Natri, A., Statistisian, M., Parkkari, J., & Alaranta, H. (2006). Control of the Lumbar Neutral Zone Decreases Low Back Pain and Improves Self-Evaluated Work Ability. Spine, 31(18), E611-E620. doi: 10.1097/01.brs.0000231701.76452.05