Back pain? Here's what you should do.
If you have experienced low back pain at some point in your life, then you are not alone. Low back pain is the most common musculoskeletal condition and has recently been dubbed the “common cold” of musculoskeletal injuries. A recent study by Ferguson et. al. has shown that 1 in 4 people will experience low back pain for >1 week in duration over the next year alone, not to mention over the course of their lives.
In fact, not only is low back pain extremely common to experience, but it is also one of the most common reasons for disability in work loss. According to Guo et. al., low back pain is the most common work-related injury and one of the highest contributors to losing time from work.
Perhaps the most impactful of all is the uncertainty and fear that can often come as a result of low back pain. Common concerns include “will I need surgery?”, “is there severe structural damage?”, “is my spine unstable?”, “have I been using bad form or posture?”, and “will this ever get better?”.
To help decrease some of these concerns and provide clarity on what to do when experiencing low back pain, I have put together a generalized decision-making guideline for the different types and stages of low back pain. While optimal treatment involves seeking a provider who will treat your individual and nuanced needs, this guideline should serve to point you in the appropriate general direction and change your recovery trajectory for the better. To make the most effective use of this guideline, pick the category or categories that best suit your particular situation and follow those recommendations accordingly.
Acute Low back pain (0-4 weeks)
Acute low back pain refers to a more fresh painful episode that has been present for less than 4-6 weeks. These situations are more common after an injury or unorthodox movement and the pain typically occurs immediately or soon after one of these events, (although this is not always the case). This can also appear in the form of a “flare up” in somebody who has historically had on-and-off again low back pain. The acute stage is often the most painful and will usually result in the most significant impairments in function.
What to do: the acute stage of low back pain is the time to take it easy and give your body some much-needed TLC. That will look different for different individuals, but should generally include gentle mobility drills, very light exercise and activity modification to reduce pain aggravation, and possibly some manual therapy and/or modalities such as a hot bath to help take the edge off. Prioritize sleep, nutrition, and minimizing stress to create an internal ecosystem that supports your recovery and allows mother nature to do her job. Focus on what you CAN do so that you don’t lose too much progress. This multimodal strategy will set you up for success and decrease the likelihood that this episode of back pain will become a long-term issue.
What NOT to do: do not panic. The vast majority of low back pain episodes will resolve within a few weeks to a couple of months; trust the process and do what you can do to stay relatively active without reaggravating the pain. The worst thing you can do is catastrophize about all the various things that might be structurally wrong with your spine; even if something is damaged anatomically, the body is resilient and it is highly likely that it will heal just like an ankle sprain or muscular strain.
Do not rely on the passive route. Yes, you will probably have to taper back on your activity levels somewhat. Yes, manual therapy and spa days can be helpful in reducing symptoms and stress. What is NOT helpful is when people go too far in this direction and become overly reliant on passive modalities. Too much of the passive route can lead to deconditioning, decreased mental and physical resilience, and can even lead to long-term movement intolerances that will make returning to your prior activity level that much more difficult. Plus, many of these passive modalities (I’m looking at you e-stim and ultrasound) have been shown in the research to have very little value in the treatment of low back pain.
Subacute Low Back Pain (4-12 weeks)
Subacute low back pain is the phase after the initial storm of pain. Oftentimes, the pain has reduced somewhat but is still present enough to impact activity level. Many times, people can start to do more during this stage but are not yet able to return to their prior level of function because some degree of pain is still present.
What to do: during this stage it is important to start easing back into some of your previous activities using pain as a guide, whether that be doing some modified exercise at the gym or simply returning to light gardening. While you may not be able to do a full depth or high intensity squat or deadlift (for example), gradually exposing yourself to your problematic movements while keeping your pain at a minimum is a crucial step in A) progressing back to your prior level of function and B) making sure your pain doesn’t stick around in the long-term. Manual therapy can still help manage pain at this stage, although it is not essential.
What NOT to do: in addition to the above “no-no’s” for acute pain, this is the most common stage where people will get confident and overdo things. Don’t overdo it. This stage is where you really want to find the sweet spot between doing too much and doing too little.
Don’t be too quick to seek out an MRI. Conversely, this is the stage where people may start to get impatient with their recovery if they have not seen significant improvements; they expect it to go away within a month and get concerned when it is not completely resolved after that. Back pain is complex and can take some time to get back to 100%. Like Dr. Paulina wrote about in her previous blog, MRI’s are becoming a last-ditch effort for people with low back pain. Too often do they lead to false positives, resulting in Docs putting too much significance on certain findings that are actually extremely common, even in nonpainful individuals (I’m looking at you bulging discs, arthrosis, and stenosis). This can result in unnecessary surgeries, needless panic, and overly-anatomical thinking when it comes to the origin of pain. In reality, pain is multifactorial and more than what is just going on anatomically with your spine and discs. Your MRI only tells one tiny part of the story. Be patient and only go the MRI route if your physician thinks it is essential.
Chronic Low Back Pain (>12 weeks)
Admittedly, chronic low back pain can be the trickiest to deal with, especially without seeking help. In this stage, pain might not be as consistently disabling as it can be right after an injury, but it may result in long-term functional impairments and even correlate with mental health and wellness issues. This can be the most frustrating type of low back pain, considering by this point many people feel they have tried every option under the sun but their pain remains, and they begin to believe that they are structurally flawed and their pain will never go away.
This could not be further from the truth. While finding the right treatment at this stage can be more difficult, it is important to approach chronic pain holistically in order to tackle the various potential contributors to pain, such as musculoskeletal factors, stress and anxiety, nutrition, sleep, etc.
What to do: during this stage it is actually the safest and most important time to resume a CONSISTENT exercise routine while keeping pain at reasonable levels. Not only can strength training and mobility work be appropriate at this stage in the game, but performing regular steady-state cardiovascular exercise has also been shown to help significantly with chronic low back pain. At this stage, don’t allow yourself to be sidelined by your pain. Modify your exercises or activities if needed to reduce pain, but ensure that you are living your life as normally as possible to avoid the mental and physical ramifications of becoming a sedentary individual.
Use this time as an opportunity to address your stress, anxiety, sleep habits, and nutrition. Pain is multifactorial, and the presence of chronic stress, anxiety, and sleep deprivation will put the body in a constant state of fight or flight. Similar to a car alarm that has become too sensitive, living with frequent fight or flight will cause your body to send out pain signals too quickly and easily as a protective mechanism from any possible threats that may appear to be present, whether those be specific movements, positions, or even emotional states.
What NOT to do: do not allow yourself to become sedentary. Not only will this result in deconditioning and worsening mental health; it can also reinforce to your nervous system that movement is indeed dangerous, ultimately decreasing your tolerance to movement in general and leading to more frequent pain. Additionally, by becoming sedentary people rob themselves of the positive, pain-reducing endorphins that are naturally produced with movement and exercise, which can ultimately have negative repercussions from a physical and mental perspective.
Do not fall into the mental trappings of thinking your pain will never go away or you may need surgery. The overwhelming majority of back pain gets better with physical therapy, chiropractic, massage, and/or time. Sometimes it simply requires people to find the right provider(s) for them while simultaneously fine-tuning other aspects of their wellness behaviors to create an environment that supports recovery. The worst thing that you can do for your recovery is be overcome by negative self-talk, doubt, and fear.
This guideline should help to steer the majority of people with low back pain in the appropriate general direction. That being said, every individual is different and may require slightly or even vastly different approaches. When it comes to the human body, there is an exception to every rule.
Additionally, if your pain is unrelenting and is not impacted by movement, if it worsens and wakes you up at night consistently and prevents you from going back to bed, or if it is accompanied by the onset of other symptoms such as significant changes in appetite, unexplained weight loss or gain, nausea, unusual extreme fatigue, changes in bowel or bladder function, sudden onset of balance loss, or anything else that feels “off”, seek out a medical provider immediately prior to attempting to self-diagnose and treat.
Back pain is endemic in this nation and impacts people of all demographics and athletic ability. By knowing what route to take based on what stage of pain you are in, you will increase your likelihood of recovery and reduce the impact that back pain has on your life.
Dr. Brooks Kenderdine PT, DPT, CSCS, USAW-1
Co-owner
The PATH Rehab & Performance
Resources
Ferguson, S.A., Merryweather, A., Thiese, M.S. et al. Prevalence of low back pain, seeking medical care, and lost time due to low back pain among manual material handling workers in the United States. BMC Musculoskelet Disord 20, 243 (2019). https://doi.org/10.1186/s12891-019-2594-0
Guo HR, Tanaka S, Halperin WE, Cameron LL. Back pain prevalence in US industry and estimates of lost workdays. Am J Public Health. 1999;89(7):1029-1035. doi:10.2105/ajph.89.7.1029
Interventions for the Management of Acute and Chronic Low Back Pain: Revision 2021 Steven Z. George, Julie M. Fritz, Sheri P. Silfies, Michael J. Schneider, Jason M. Beneciuk, Trevor A. Lentz, John R. Gilliam, Stephanie Hendren, and Katherine S. Norman Journal of Orthopaedic & Sports Physical Therapy 2021 51:11, CPG1-CPG60
