Watch this video of Katie Gill Senior MSK Physiotherapist presenting on ‘Low Back Pain: facts, fallacies & self-management.’
This video was recorded as part of SSC’s Online Public Information Meeting, focusing on Back pain & the Spine.
Firstly, a little bit about my background I qualified as a physio from UCD in 2011, and I worked in a lovely private practice for several years in Dublin before moving to London to undertake my Master’s in advanced practice MSK, I worked in the NHS for a couple of years in a mixture of acute persistent or acute and chronic Services, and I moved back in 2018 to under to start my current role in sports Surgery Clinic. About the hospital itself, so that you can see the top picture, there is the main hospital, and that’s where all the orthopaedic surgeons work out and where all the operations take place. The picture below is where I work, so the building is just around the corner but still part of the hospital, and in that building is this team, so we have a good mix of services here, so we’ve got physios, strength and conditioning coaches, nursing admin and Sports Medicine Consultants. You’ll hear from Dr Matthew Cosgrave this evening, and I’m one of eight physios, in essence, who are doing research alongside our clinical practice. The reason is that we can get our patients to better quicker, contribute to the body of knowledge, and provide excellence in our clinical care.
Aims of this Presentation
The aims of the presentation this evening, so what will we go through? First, we will look at the background of low back pain and the categories. We’re going to look at treatment guidelines, management, and advice from a Physio’s perspective, and then Matt will come at this from a medical perspective this evening. We’re going to look at some myth-busting and look at some sign postings for some resources, and there’ll be time for questions at the end. Just as a note that the presentation shouldn’t be used for individual advice for your specific queries or back pain, and we’re kind of generally talking about low back pain this evening, so if you have any specific questions or concerns and I’d advise you to seek the advice of your physio or Healthcare professional.
What to Expect from a Physio?
Firstly, what to expect from a physio consult I’m sure some of you are listening might be frequent flyers into physio and know what it’s all about; others might be listening to this evening thinking, I have no idea what to expect back pain is. The first thing, and we’ll expand on why getting a good history is essential, we need to have a good conversation at the beginning and have a talk about how long the back pain has been going on and the history of the things that make it works and make it better and having to the in-depth conversation first. Then there’ll be a physio, and there’ll be a physical exam this would look at how the back moves and how your hip moves and take some strong measures. At the end of the session, there should be some time for questions and going through some parts from the treatment section, so physio sessions are usually divided into three, the history, the exam, and the treatment. I wanted to share with you what evidence-based or evidence-informed medicine is. Healthcare professionals and physios must work within an evidence-based or evidence road treatment. It just means that we have to offer and be up to date with all the evidence and research coming in through our field. If you’re going to see a physio, you should make sure that they are core registered, and they should be. I’ll give you a link where you can look up the register yourself, and you know that if you’re a Physio core registered, they’re keeping up with evidence and standards.
So the first thing is back pain can be terrifying. Still, it doesn’t need to be, and I’m hoping that this presentation will help alleviate some of those fears I find with my patients that often the concern is not knowing and not knowing what this pain means and what it is all about. As Chartered physiotherapists, physios are trained to do what we would term as red flags, which means something serious that isn’t appropriate for physio. The first thing we do with our patients ensures they’re appropriate for physio. They don’t need to be sent on; you know we’re doing that anyway but what I would say, as you can see in the bubble, is if there’s something that’s explicitly worrying you, do you bring it up in your consult, say look I’m apprehensive about my back in terms of you know there a fracture there is there something wrong? Whatever it might be that’s worrying you, do bring it up if you haven’t been explicitly asked.
Now we’ll keep returning to this notion of the fingerprint. Because back pain can be very straightforward to treat, it can also be complex if some of you might know and think about your back pain as like your fingerprinted but only yours and it’s particular to you and also thinking about that there’s a person attached to that back pain you’re not just your back pain either so. We’ll develop this idea later on in the presentation but remember that your treatment needs to be tailored obviously to the evidence base there. Still, it needs to be tailored to you and your specific needs.
Looking at the background of low back pain, the picture at the top is from a paper published in the Lancer, a very well-respected Journal in 2018; they did a vast series of documents and just highlighted how common and how prevalent low back pain is. It is the leading cause of disability globally, and at any point in time, about 550 million people are experiencing any one time, which is vast. Most people will experience it during their lifetime at some point. I think it’s because it’s so common and because most people will experience it. I hope talks like this Are going to put the correct information out there and that people know that low back pain isn’t necessarily something to be frightened of. It’s absolutely unpleasant but very treatable, and people should know what to do and not do with their back pain. The biggest thing to decide is that if you’re playing a numbers game, most cases of backing must settle within six weeks, so somewhere between 80 and 90 per cent will settle within six weeks, and that’s if you dodo nothing if you’re not seeing your GP or Physio and or having any treatment. I think that’s an empowering statistic because your back there is working away behind the scenes to settle that pain. I often tell my patients that their back is like it’s in a hospital; their back is trying to source that pain.
Another thing to remember is a severe case of back pain are extremely rare. Hence, less than one per cent of patients have something severe or would require ongoing management, ongoing investigations, and a series of underlying causes, so it is scarce. But why do so many people feel there’s something wrong I’ll ask all of my patients if they’re worried about their back and if there is anything seriously wrong because it’s excruciating; back pain really can be so sore at the very best case scenario if you’re uncomfortable and you can’t do the things that you want to do worst case scenario it can be excruciating so naturally I think if your back is sore, it’d be natural to suppose well God there must be something seriously wrong. I hope that can reassure you that the pain and damage aren’t the same and that you can be sore but safe. Now looking at the categories of low back pain, how do we categorize this into two categories? The first is specific, so specific back pain makes up roughly between five to ten per cent of cases depending on the research that you read; specific means I can point to something, and I know that’s the cause of my back pain it might be an infection because say you’ve had surgery. If there’s an infection in the back that’s a specific cause, or you’ve had a fracture in your back that’s a specific cause, we know exactly what’s causing it. Everyone else is in what’s called non-specific, so 80 to 90 per cent of people are in that and in that category, and it’s unsatisfactory. It’s extensive, and I will go into why it’s so broad, but most people are in that non-specific low back pain. The other way we categorize is by a timeline, so acute mapping in the first six weeks of persistent back pain is categorized from six or twelve weeks onwards. Why are so many people in that specific low back pain or a case and why can’t we tell you know exactly what’s causing the low back pain and the majority of patients and the reason is because of the anatomy of the lower back if you imagine say my finger here and vocalize my anatomy around my finger but if you look at the picture on the left so the yellow bits are the spinal nerves and in between them are joints they’re all like the two joints might be a centimetre apart and even on the right centimetre part on the left and there’s a lot of anatomy within the same area and all of those things have a nerve Supply so your skin your muscles your ligaments even your nerve their nerves the nerves of your discs have a nerve Supply and they’re all very close together so if you’re lifting, carrying, moving and bending forward you’re going to be moving all of them so it’s very hard to say well look at absolutely one or the other and if you look at the picture on the right in terms of your lower back Anatomy it is very complex there’s a lot of muscles covering that area so we used to think we were able to diagnose precisely the cause of it every time and it’s just the anatomy is too complicated to let us do that and I know some of you will be thinking what about discs ?
The answer is that it depends, and Matthew will speak about this a little later. Some of you will be told well, I’ve bulging discs because I was told I’ve problems with my discs and the discs have a nerve Supply. Hence, they are they can be very painful, and I would say that some discs can have degenerative changes, which are like getting arthritis in our knees, arthritis of our hips or growing hair and wrinkles; it’s part of our ageing process and doesn’t necessarily cause any pain and think about what how your body adapts to that if it’s slow to change slowly over time your body doesn’t see that as a problem but if you say had somebody who had you know significantly a sudden injury. Hence, they fell down the stairs, and there was, you know, too much pressure, too much force, and there’s a sudden change then that can be painful, so you have to read the distance it sometimes depends it is, and sometimes it doesn’t.
But what I would like to share with you, if you are still not believing me that can be this source of pain, is that this table and there’s a massive study done about ten years ago and they did an MRI scan on 3000 people so a considerable amount of people and from and the age of 20 up to 80. These are all people who didn’t have back pain, so even if we’re looking at disc bulge, 30 per cent of people in their 20s have the Discord on MRI that has no pain and looking at them from looking across those 60 for 50 years over so it’s a considerable amount and these people don’t have symptoms. Hence, it is it’s possible to have changes on the MRI and for them not to be painful, so in red there at the bottom, it’s the MRI findings that need to fit in with your history and with your clinical patterns so that it needs to fit in with them with your exam. You are subjective, and I think getting advice from your physio or Healthcare practitioner around that is essential as having them interpreted correctly. I spend a lot of time with people who are just given reports and understandably have a long list of things that come up from an MRI, and a lot of it is like grey hair and wrinkles; it’s part of how the body ages and not something to be worried about.
Challenges in treating low back pain
Guidelines for treatment Matt will speak about some specific things we can do. I’m going to focus on more of the advice towards exercise again, as we spoke about earlier. There are what we want to be evidence-based or evident foreign practitioners, and there’s you might have heard of the National Institute for Health and clinic Care Excellence; they’re a vast research body that provides guidelines for things like low back pain or obesity and smoking and I’m saying for Cochrane the following guidelines have been approved by these two bodies, so they’re divided into acute low back pain and persistent low back pain. As a reminder, acute low back pain is what we have from zero to six weeks, and this table is taken from the paper I referenced earlier on, and I have the reference for you at the very end of this presentation.
What is the evidence? What should we do we be doing in the first six weeks? Their first advice is to remain active and educate what can be included that will be specific to each person. Still, it will be things like staying active and looking at and pacing yourself and managing the things that you need to do so if you have an irritated back in the first six weeks, is the time to do a personal best on your run or you know do a big clear out or swing the grandchildren around and throw them around no, probably not. It’s about doing what you can, pacing yourself, and maybe keeping yourself moving without overdoing it.
The exciting part here is exercise therapy has limited use and selected patients, so from a physio point of view, I tell people to do the movement things that they enjoy. I try to give them some basic exercises if they need them, but it’s more like telling people they’re sore. Still, they’re safe and try to get them back into things they need to do. You’ll know they’re at the very bottom for things like manual therapy, spinal manipulation massage and Hands-On work should be in conjunction with the education and remaining active, so it shouldn’t be done by itself it’s if you’re seeing a Physio and they’re doing some Hands-On that’s fine. Still, it needs to come with advice and education as well.
To recap on the do’s and don’ts for low back pain, if you want to take a picture of this slide, I don’t mind. So do keep moving you could talk to your pharmacist about pain relief, you can use hot water bottles gentle Mobility exercises to encourage normal movement really important to stay in work where possible Don’t Panic and again coming back pain is totally understandable and it’s very sore but we want to try to get the body out of this Fight or flight mode and back into kind of a more relaxed State and don’t the advice 20-30 years ago was stay in bed try not to stay in bed and try to be up and moving around every 20 minutes to half an hour if you’re sitting, resting, even standing up sitting down, walk to the kitchen and back and just trying to keep yourself moving I would say to patients in this time is that they’re sore but they’re safe so if you’ve irritated your back in the first six weeks you’re putting your shoes on absolutely fine moving around the place is absolutely is absolutely fine now can pain be a good thing I’m sure everyone is thinking that um there’s no way pain can be a good thing and that actually like Pinocchio there that I’m telling lies but I promise you I’m not primarily in the acute phase think about that your pain is trying to talk to you to tell you to change your behaviour. So a group of people with this genetic mutation cannot feel pain, which sounds wonderful. Their bodies don’t tell them if they have an infection or have broken a bone. Their mortality rate is relatively high, so we need our pain system to work, and it’s telling you that you know what you need to pay attention to; it’s trying to let you know that we’re not going to go to the gym today. We’ll do a more gentle exercise, so our pain system must be there because it keeps that warning system in place, which is a good thing.
Now persistent low back pain is when the pain is more significant than six to twelve weeks and what I would say is that if you’ve had pain for that long, I will have it reviewed either with your GP or with your physio really because you’ve suffered for long enough and that there are lots of treatments available and don’t put yourself through it and to put up with it for any longer than that.
Now the same paper as I referenced earlier on, the advice here or the evidence here is slightly different, so advice to remain active and educated is still essential. However, exercise therapy now becomes the first treatment, so it’s as crucial. That in conjunction the manual therapy, actual Hands-On treatment is secondary. Hence, exercise advice and education are all the first things you need to be part of the physio program, and some have them work can be used, but it needs to be done in conjunction with the above.
What are the challenges in treating persistent low back pain and we’re going to remember that this is like your fingerprint and pain has a context so best example I can give for that is imagine that you’re having a really good day that you fall up the stairs um at work and it’s really funny you think oh my gosh look I’ve landed on my knee and I’ve hurt myself imagine you’re late for work and you’ve got soaked going in from the car you fall off the chair land on your knee and everything is the worst you’re really sore it’s the same thing that happens but the context is different so our thoughts, our feelings and our beliefs can shape the way we shape our pain experience and remember that if we have an irritated or a grumpy back that back is attached to a person in their lived experience so and all of our lived experiences are obviously completely different and I’ll expand on this in a minute so this is pulled from the paper I referenced earlier on and it shows that the different things can be at play in terms of feeding into low back pain and so things like genetic factors bio physical factors so there is very strong evidence that people with low back pain have some changes in their strength and coordination things like other comorbidities like anxiety depression, social factors and things like stresses and if there is difficulties at home or potentially someone’s going through a stressful time at work or a divorce, perhaps that those things do cause low back pain not necessarily but that think of it like a dimmer switch then it can dial it up or dial it down rather than like a light switch that turns it on and turns it off and remember that our pain and why low back pain has been persistent abnormal complexity is because everybody is going to have a different interplay or some people might have absolutely no stresses in life and none of that going on and really all we need to focus on is the muscles and strengthening other people the strengthening is not a big factor we need to focus on pacing and management so it really just depends.
Another way of looking at that is here it’s a busy slide, but here is a list of evidence-based impairments and low back pain, so on one side, you’ve got things that are reduced muscle strength which is muscle endurance, increased fatty infiltrates, I’ll show you a slide in that in a minute it’s basically where there’s fat in and within in a muscle rather than surrounding muscle things like fear of lifting and fear of movement are also prevalent in this group from a research point of view. Also, things like pain, quality of life and poor quality of sleep and this is why having a comprehensive subjective exam with your physiotherapist is essential because they need to figure out how much and where it is if you see that vendor and where in that vendor diagram do you fit are we looking at muscles or are we looking at fear of lifting, are we looking at pain? And then just trying to tailor that appointment to you.
What does exercise do?
If it’s so important for low back pain, why is it recommended? First and foremost, there’s a group called The American College of sports medicine that takes low back pain away. These are the guidelines that I’d love it if you could take a photo of this slide for reference. This is what we all should be doing anyway as healthy adults, we need to be getting our 150 minutes of modern-intensity exercise a week or 75 minutes of vigorous intensity of exercise and building strength and which should be done on two days or two episodes per week, but it’s something we should be doing anyway which is quite a high amount of exercise really and just for what is it’s not to be fit it’s to be better to have our Baseline level of health so sometimes little patients with low back pain they can miss out on the benefits of exercise generally because they’re sore so really trying to make sure everybody’s meeting recommended guidelines but in terms of low back pain again consider a first line of treatment and why do we recommend? We encourage our patients to do some strength training or resistance training here in sports medicine for a number of reasons so bottom left is a picture of a cross section of the back so that’s if you were chopping yourself through here and the two dark circles at the very bottom are the back muscles and I’ll show you a picture in a second that shows an increase of the fact through those muscles so resistance training can improve the amount of fat within a muscle other reasons for promoting resistance training is it is very good for maintaining joint range of motion in our spine inner hips and all over the body in particular it is excellent for building and Bone strength as well as building muscle strength and the other thing in terms of strength that we need like our lives require us to have a level of strength so if you think um pushing a shopping trolley, opening a heavy door, lifting grandchildren or walking to work all of those things require us to have our level of strength so it’s really being able to meet the demands of your day-to-day tasks whether that be running, whether that be lifting and whether that be walking around your house whatever your tasks are just holding the body upright requires a level of strength the other side of resistance training is this impact on our mental health and there are and we want to make sure our back pain patients are getting all the benefits from exercise and that they can so this is the slider referenced earlier on so these are three different people so on the left if you can blurry image I apologize but you can see the difference between them and that’s the fat within their muscle it’s like imagine if you had a steak and you’ve got fat through the steak if a muscle isn’t being used it doesn’t get replaced with muscle or a fluid it gets your place at the fat and it just means that muscle couldn’t possibly be functioning as well as the muscles around it so what we want it to keep is that our back is nice and strong actually functioning well as a unit and resistance training can play really important part if there is vascular veins on the MRI to reduce them and improve the capacity and improve spine function.
Now some myth busting so some of these things I know are possibly going to be a little bit controversial and if they are what I’d like you to think about is if you don’t agree I want you to think about where have you got the information from or how those beliefs came about and particularly our own posture and we’ll come to that in a moment so there’s a research group that’s International and they published in a very well respected journal and I’ve included which I’ll go through some of these facts we’ve spoken about already and again looking at that it can be scary and the second one I want to look at is getting older is not a cause of a low back pain and sometimes I think it’s very almost lazy to say well you know it’s I’m getting older and that must be why my back is so sore and that’s not necessarily really not necessarily the case and then which I spoke about that that scans can really show the cause of our back pain now sometimes they can there is a time place for an MRI scan and continuing this back pain that was caused by poor posture I’m sure lots of you are thinking I’m not sure about this what we want we try to do now is your best posture is posture and that you’re not doing anything for too long if you have to sit for work every hour you’re getting up and moving around again if you’re sitting forward like this as you can see in the diagram that’s okay just keep moving and if you’re sitting backwards you just need to be at work you need to be comfortable if you’re sitting and that low back pain isn’t caused by poor posture the only person I’ve ever seen that had the most incredible posture she was up straight for hours was a lady around I was on a course with years ago and she was eight-nine hours up straight I remember saying to her that she held herself so Beautiful she said yeah that’s okay but I’ve a really sore back and she was a ballerina she was trained to have this posture she was incredible but again she was sore and it was one example that really stuck out to me saying well you know this what we’re all told is stand up straight pull your shoulders back bad posture I think cut yourselves a little bit of Slack it’s likely not caused by a bad posture.
Physio care at SSC
In terms of Physio and Sports Surgery Clinic our contact information is here and we take self-referrals you’re able to phone us and book in for an appointment or if you’ve got any inquiries you can just take a photo of the slides there and you can email us and here are the resources and if you take nothing away from this presentation I’d just love you to take a photo of this slide or if you have any questions I can share the resources with you the first one is the nice guidelines for low back pain and there are the guidelines that I keep referencing and anybody who likes podcasts the back pain podcast is excellent it’s about clinicians and the problem with low back pain is because it’s so common there’s lots of information out there and a lot of it isn’t accurate It can be really cool but also some confusion so if you’re listening to podcasts they’re the ones I’d recommend and empowered beyond pain is also another excellent podcast the 10 low back pain facts, the one I thought that might be controversial there’s a link to that there it’s in the BJSM paper that says next link and we touched on Pain earlier on in the presentation and there’s a really lovely video on YouTube called explain pain in five minutes and that is wonderful to have a look at and explains the nature of pain finally, anybody who has I couldn’t recommend the chain the Beast website more highly.
Persistent lower back pain is complex. There’s no crutch, there’s no cast you can’t see it, and there are some beneficial resources and lots of my patients saying that there helpful finally, at the Coru register, if you’re seeing a physio, make sure they’re on that register and then finally we’ll take some questions.
Do you have any recommendations for exercise that a person can do to help relieve pain from spinal arthritis in all three parts of the spine?
yeah I think so there’s some um there’s lots of great questions coming in and we’ll try to answer as many as we can but certainly with marks in terms of exercises like we spoke about in in the Talk looking at things that you enjoy so try to sometimes pay people with spinal arthritis they find that extremes of movement so it might be do yoga but maybe avoid an extreme back bend or stream front Bend if that doesn’t feel right to you so what I’d say in terms of guidelines and pain from spinal arthritis is that the odds nip or pinch with pain is okay if an exercise feels like you know you really don’t feel good afterwards it’s really making that pain worse that one isn’t for you so examples of things with spine arthritis there’s no limits you could run you can do yoga you can swim really looking at what trying to meet those recommended guidelines that I spoke about earlier try to get your enjoyment in but there’s no Bible or gold standard of the thing you absolutely have to have to do and that links in with Maureen’s question which that she spoke about having um some fusion due to arthritis so what that will mean if somebody has lots of arthritis down at the bottom of their spine some of the movement around that region isn’t going to be as good which we’d expect but what if you what you want to try to do is maximize the movement that you do have and maximize the areas above where the fusion is or where the arthritis is and below so it might be making sure you’re getting good hip range of motion and making sure you get good Lumbar and thoracic range of motion so from a treatment an excise point of view Mobility work, yoga will be nice and resistance training would be nice, medical questions I’ll leave I’ll leave for Matt, for that but it really is like our guidelines from earlier on is trying to meet recommended guidelines, do something that you enjoy and if something doesn’t feel right or is painful or if you want more specific advice I think I would chat to your own physio or GP.
A patient has been diagnosed with scoliosis-like species in the past year with grade one slippage of the vertebrae onto the L5 S1 nerve, causing severe back pain and groin weakness. He has been going to Physio and a chiropractor with limited results.
okay so I think my guess is follow-up questions to this patient, and we’re trying not to answer this more broadly because I haven’t assessed them myself. Still, certainly, it depends if you’ve been giving us a good go with a physio or a chiropractor treatment. Indeed, if it’s been going on for a while, I think Hands-On work from a physio or a chiropractor probably sounds like it’s not working, so I think a different approach might be worth there going back to the GP and looking for a second opinion. So what all those terms mean for anybody who’s not familiar with them is just that there’s a little bit of movement of one of the vertebrae, which is putting pressure on a nerve. Some injection options and others depend on how severely you’re impacted from a particular exercise point of view, so certainly, I think if it’s not working with a physio or chiropractor, my first question is, what type of things are they doing with you? If it is more Hands-On, I would put a pin in that go back to the GP looking for an opinion and move from there.
I was wondering how long it takes the muscle condition to deteriorate within an activity, especially in the lumber area, okay?
That’s a great question, so I wonder whether that came from seeing the cross-section of the spine in the presentation earlier. I showed pictures of where there were lots of fatty infiltrates that can level of infiltrate for years, so that’s not something that would happen over weeks or a month, so that level of infiltration when someone is very sedentary takes years, so in terms of deconditioning so you can lose some muscle strength within two to three weeks. Still, you can get it back again really quickly, so I don’t want people to worry or necessarily that if they’ve been on holiday or if you’ve been, you know, unwell for a period that you know your muscle strength completely goes it doesn’t and what you want to try to do is to get your muscles in good condition as best you can. So you’ve noticed the difference in, say, if you were in the gym and what you would lift if that’s a good level of muscle strength. It might be well you know I lifted my grandchild before I went to my six week holiday and have come back to I feel they are bit heavier you might notice some impact in your function after several weeks a very significant deterioration where there’s a tremendous amount of fatty infiltrates that takes years. Still, you can notice lower grade changes within a couple of months. I hope that answers that.