Watch this video of Katie Gill, Senior MSK Physiotherapist, at UPMC Sports Surgery Clinic in Santry, 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 bit about my background I qualified as a physio from UCD in 2011. I worked in 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 to Santry in 2018 to start my current role with UPMC Sports Surgery Clinic.
You can see in the top picture that this is the main hospital where all the orthopaedic surgeons work and where all the operations occur. The picture below is Sports Medicine, where I work; it’s located around the corner but still part of the hospital. Our Sports Medicine Team covers a good mix of services in this building. We have Physiotherapists, Strength and Conditioning Coaches, Nursing Administration and Sports Medicine Consultants.
I am one of eight Physiotherapists and S&C Coaches doing research alongside clinical practice. By doing this, we can better our patients quicker, contribute to the overall medical body of knowledge and ensure excellence in our clinical care.
The aim of the presentation this evening is to discuss Back Pain. First, we will look at the background of low back pain and then at treatment guidelines, management, and advice from a Physio’s perspective. In the next presentation, Dr Matthew Cosgrave will give his views on the same from a physician’s perspective.
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.
I’m sure some of you who are listening might be frequent flyers into physio and know what it’s all about; others might be listening to this thinking, I have no idea what to expect when I have back pain and attend a physiotherapist.
Firstly, your Physiotherapist will ask you to provide them with a history of your back pain. When did it start, how long has it been ongoing, and are there movements that make it worse or better?
Then a physical exam will examine how your back and hips move, and some strength measurements will be taken.
At the end of the session, there will be a conversation where you can ask questions, and we will go through some advice on treatments.
So physiotherapy sessions are usually divided into three sections, the history, the exam, and the treatment.
As healthcare professionals, physios are obliged to work within evidence-based treatment guidelines. This 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 ensure that they are CORU registered to ensure they are keeping up with evidence and standards.
So the first thing is back pain can be really scary, but it doesn’t need to be. I hope this presentation will help alleviate some of the fears associated with low back pain.
I find with patients that their fear often comes from not understanding the source of their pain.
If you find yourself in this situation, I recommend you tell your Physiotherapist what is worrying you at the beginning of your consultation.
Now we will keep returning to this notion of the fingerprint. While back pain can be very straightforward to treat, it can also be complex. Think about your back pain as you would think of your fingerprint.
It is very specific to you as an individual. We will develop this idea later in the presentation but remember that your treatment needs to be tailored to 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 highlighting how common and 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 it at any one time, which is vast. Most people will experience it during their lifetime at some point.
I hope talks like this will help put the correct information out there and that people learn that low back pain isn’t necessarily something to be frightened of. It is unpleasant, but it is very treatable, and people should know what to do and not do when they suffer back pain.
The biggest thing to take from this slide is that if you’re playing a numbers game, most cases of back pain must settle within six weeks. Somewhere between 80% and 90% of episodes will settle within six weeks if you do nothing without any treatment from your GP or Physio. That’s an empowering statistic because your back is always working behind the scenes to settle that pain.
Another thing to remember is that serious causes of back pain are extremely rare. Less than 1% of patients have something that is serious or requires ongoing management or investigations or has a serious underlying cause. So it is very rare.
But why do so many people feel there’s something seriously wrong?
When I talk to my patients, they believe something is seriously wrong with their backs, as their pain is excruciating. Back pain can be really sore. In the best cases, you are uncomfortable, unable to do the things you want to do. In worst-case scenarios, people experience excruciating pain so naturally, believe something to be seriously wrong.
I would like to reassure you that the pain and damage aren’t the same and that you can be sore but safe.
We break back pain into two categories. Specific and non-specific.
Specific back pain relates to 5% to 10% of cases depending on which research you read. Specific means you can point to something or know the cause of your 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.
Everything else is called non-specific. So 80% to 90% of people fall into this category, and it’s unsatisfactory. It’s extensive, and I will explain why it’s so broad, but most people are in that non-specific low back pain category.
Timeline is another way to categorise back pain. Acute backpain refers to the first six weeks and persistent back pain for six weeks and onwards.
Why are so many people in that non-specific low back pain category and why can’t we tell exactly what’s causing their back pain?
Part of the reason is due to the anatomy of the lower back.
if you look at my finger here you can localise my anatomy around my finger, But if you look at the picture on the left the yellow bits are the spinal nerves and in between are joints. Two joints might be a centimetre apart on the left and a centimetre apart on the right and there’s a lot of anatomy within the same area. All of these body parts have a nerve supply so your skin, your muscles, your ligaments even the nerves of your discs have a nerve supply and they’re all very close together.
So if you’re lifting, carrying, moving or bending forward you’re going to be moving all of them so it’s very hard to say well look it’s absolutely one or the other causing the pain.
If you look at the picture on the right in terms of your lower back you will see the anatomy is very complex. There are a lot of muscles covering this area so we used to think we were able to diagnose precisely the cause of it every time – it’s just that the anatomy is too complicated to let us do that.
Discs have a nerve supply, so some problems can be very painful, and some discs can have degenerative changes. It’s just 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.
Think about how your body adapts to that. If your discs change slowly over time, your body doesn’t see that as a problem. But if somebody has a sudden injury, they fell down the stairs, and there was too much pressure or force, causing a sudden change, that disc can be painful.
Ten years ago, a significant study was conducted on 3000 people on this subject. A cohort of people between the ages of 20 to 80 who were not suffering from back pain was given an MRI.
MRI showed that 30 % of people in their 20s had disc bulges but no back pain. The figure was 50% for those aged 50 and over which is a significant amount of disc bulge with no symptoms of back pain.
So the MRI findings need to fit in with your own personal history and with your clinical patterns. You are subjective, and I think getting advice from your Physio or Healthcare practitioner around that is essential in order to interpret them 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.
I like to focus on evidence-based exercises and treatments for low back pain. You may have heard of NICE or The National Institute for Health and Care Excellence.
They are a huge research body that provides guidelines for rehabilitating things like low back pain or obesity, and smoking. The same applies to Cochrane.
The following guidelines have been approved by these two bodies.
They are 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 advising during the first six weeks?
The first advice is to remain active, but look at and pacing yourself, and manage what you need to do. For example, if you have an irritated back in the first six weeks, this is not the time to try and run a personal best or do a big clear out in the house or swing the grandchildren around. It’s about doing what you can, pacing yourself, and maybe keeping yourself moving without overdoing it.
The interesting part here is exercise therapy has limited use in 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 needed. It’s more like telling people they’re sore but still safe, and I 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. However, it still needs to come with advice and education as well.
To recap, here are the dos 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 and gentle mobility exercises to encourage normal movement. It is really important to stay at work where possible and don’t panic. Back Pain can be very sore but we want to try to get the body out of this fight or flight mode and back into a more relaxed state.
The advice 20-30 years ago was to stay in bed. Try not to stay in bed. Get up and move around every 20 minutes to half an hour. If you’re sitting, resting, standing up, sitting down, walking to the kitchen and back, and just trying to keep yourself moving.
I would say to patients at this time that they are sore, but they are safe.
Can pain be a good thing?
I’m sure everyone thinks that there’s no way pain can be a good thing and that I am actually like Pinocchio and that I’m telling lies, but I promise you I’m not especially in the acute phase of back pain.
Imagine your pain is your body trying to talk to you asking you to change your behaviour. There are a group of people with this genetic mutation who cannot feel pain. This sounds wonderful but their bodies don’t have a way to 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 tell us what we need to pay attention to. It’s you’re body letting you know that we’re not going to go to the gym today and that we will do more gentle exercise. So our pain system must be there because it keeps that warning system in place, which is good.
Persistent Back Pain.
Persistent low back pain is when the pain is there longer than six to twelve weeks. If you are suffering for this amount of time I would recommend you visit your GP or Physiotherapist because you’ve suffered for long enough and there are lots of treatments available so there is no need to suffer.
The advice or evidence here is slightly different, so the advice is still to remain active and educated is still essential. However, exercise therapy now becomes the first treatment. It’s as crucial that its used in conjunction with manual therapy, and actual hands-on treatment which is secondary. Exercise advice and education are all the first things that need to be part of your physio program, and some hands-on 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?
We are going to remember that this is like your fingerprint and pain has a context so the best example I can give for that is imagine that you’re having a really good day that you fall up the stairs 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.
The same thing has happened but the context is different so our thoughts, our feelings and our beliefs can shape the way we shape our pain experience remember that if we have an irritated or grumpy back that back is attached to a person in their lived experience so and all of our lived experiences are completely different. I will expand on this in a minute.
The paper I referenced earlier shows different factors can be at play in terms of feeding into low back pain. Things like genetic factors and biophysical factors. So there is strong evidence that people with low back pain have some changes in their strength and coordination. There are other comorbidities like anxiety, depression, social factors and things like stress that can add to the causes of low back pain while not necessarily being the root cause.
Remember that our pain and why low back pain has been persistent and more complex to treat 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. For other people, the strengthening is not a big factor we need to focus on pacing and management so it really just depends.
Why is exercise important for treating back pain, and why is it recommended?
The American College of Sports Medicine has published guidelines on physical activity for adults. This is what we all should be doing anyway as healthy adults. Ideally, everybody needs 150 minutes of moderate-intensity exercise or 75 minutes of vigorous-intensity a week. In addition, we should be building our strength on two days or episodes a week.
This is quite a high amount of exercise, but it’s what we should be doing not just to be fit but to maintain a baseline level of health. So sometimes, patients with low back pain can miss out on the benefits of general exercise because they’re sore.
Why do we recommend our patients undergo strength or resistance training at SSC?
We encourage our patients to do some strength or resistance training here in Sports Medicine for several reasons. In this slide, the bottom left is a picture of a cross-section of the human back.
The two dark circles at the very bottom are the back muscles. Resistance training can improve the amount of fat within a muscle. Another reason 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. It is excellent for building bone strength as well as building muscle strength.
Our lives require us to have a level of strength so if you think of pushing a shopping trolley, opening a heavy door, lifting grandchildren or walking to work, all of those things require us to have a certain level of strength, so it’s being able to meet the demands of your day-to-day tasks as well as the positive impact it has on our mental health.
Our Physiotherapy Department at UPMC Sports Surgery Clinic takes self-referrals. You can phone us on 01 5262040 or email firstname.lastname@example.org for further inf
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.