Medical Musings, Health Hypotheses & Therapeutic Thoughts
Exercises for Low Back Pain
As with the last blog, we will assume that your low back pain is mechanical, and that it has been screened by a suitably-trained healthcare professional.
So, what are some specific exercises that might help with your low back pain?
Again, please do not perform any of these exercises if they are actively painful (some discomfort is ok).
Some general tips about stretching and mobilisation
Stretching, particularly when done for rehabilitation or healing (as opposed to mere flexibility for e.g. dancing or martial arts), should always be in pain-free range of movement.
The human hand is such a sensitive and specialised structure; anatomically complex and strategically engineered by time and nature, having the ability to create such varied and precise movements.
Our hands contain so many weird and wonderfully specialised sensory cells that function to collect information via touch, position, pressure or temperature in relation to our current surroundings.
The information is continuously relayed to our brain where the appropriate networks of neurons pass precise instructions via the spinal cord, neural networks and down the nerves in our arms to the muscles responsible for generating the gestures we require.
This intricate sensory/motor control system is continuously checking itself and making small adjustments. We could be typing away in an attempt to conquer the monstrous, multi-headed hydra-like inexhaustible queue of office emails, operating an electric sander to remove tired paint in an effort to restore an antique to its former glory or just the general lifting and carrying as we go about our everyday activities.
With all these moving parts and capabilities made possible with our hands, we can create works of art and express ourselves. .
When we’re limber and feeling good, we barely notice how much we rely on and require that normal baseline level of ease.
However, when things don’t go as planned and if an injury occurs, whether caused by simple tasks or other health conditions, the loss of our normal function is very apparent.
One possible common condition responsible for hand pain is Carpal Tunnel Syndrome (CTS).
It affects 4-5% of the population (1) and can be quite disruptive, affecting a variety of people, from pregnant women, office workers and the elderly, to tradesman and others who work directly with their hands.
It seems to be caused by multiple factors, which could include (2);
Many of the structures that operate the hand are sandwiched together and must pass through a channel at the wrist (the carpal tunnel) bordered by sturdy carpal (or wrist) bones and ligaments, particularly the transverse carpal ligament as the ‘unyielding ceiling’.
Most of the space in this channel is occupied by rigid tendons that control finger movements, leaving only a small potential space for the squishy median nerve, which can be easily compressed here (1, 2).
Being the main sensory and motor supply for the palm of the hand, a squished median nerve can result in the frustrating and restrictive experience that Carpal Tunnel Syndrome is known for.
If you are experiencing signs and symptoms such as those described, the best course of action is to consult your GP or manual therapist as early as possible.
This could limit the impact on your everyday life activities and the need for any interventions in future.
If CTS is left to progress, a cortisone injection may be beneficial. It was reported that approximately 75% of patients experience improvement following this procedure (4, 5).
Failing that, a small surgical procedure can be recommended. It involves releasing the transverse carpal ligament (the mentioned ‘ceiling’ of the carpal tunnel), creating more space for the muscle tendons to glide together at the wrist, alleviating the direct pressure placed on the median nerve.
Luckily surgical intervention for CTS has a very high success rate, with over 90% of patients reporting alleviation of symptoms (6, 7, 8),
However, it is important to remember that as far as your body is concerned, there is no such thing as 'minor' surgery! Even in the best case scenario, the carpal tunnel now has (even more rigid and unyielding) scar tissue around it, which can cause other issues.
So the best thing to do is avoid any intrusive interventions.
And it’s entirely possible!
Along with osteopathic techniques for treatment, there are some simple and inexpensive things to try, some examples include (2, 3);
Developing an understanding of how and why this is happening; knowledge alone can alter the experience and help settle the worry.
Being informed is a powerful position to be in as you can select the best course of action and knowing what the possible benefits or disadvantages of the available options are.
CTS can be debilitating and impact negatively on your health and wellbeing and day-to-day activities. That’s why getting treated as soon as possible is so important.
By finding the right combination of strategies that are best for you, your osteopath can get you moving and back into your daily routines, whether it be gardening, writing, creating a masterpiece, or tackling a home renovation.
Not to mention going back into battle with inexhaustible email queues – the multi-headed hydras!
NOTE: This blog post is essentially a copypasta of the page on the same topic; but it is so important a subject I wanted to make the information was available to all of our blog subscribers as well...
When we talk about 'chronic pain', we're not just talking about pain that has been going on for a long time; although that it is part of the definition. Chronic pain, in this sense, involves changes to the way that information is carried and processed in our bodies.
To understand this a little better, we will have to consider (briefly!) the nature of pain and what it means.
Pain is an output
What this means is that all pain is produced by your central nervous system; that is, pain is the label your brain applies to information it really wants you to pay attention to.
When you injure yourself, like burning your hand on a hotplate, your nerves send signals up to your spinal cord and brain. We call this nociception, or something like 'detection of something harmful or noxious'. Your brain then decides whether or not to call those signals 'pain'.
From this point of view, the pain itself is just as real in something like phantom limb pain (when you (e.g.) have an arm amputated but can still feel pain in the hand) as when you accidentally stab yourself in the thigh while cutting a recipe out of a magazine (just a random example that sprang to mind).
So pain is not something you feel in your body, it is something that is created and projected out by your brain. Put simply, it is an output, not an input.
Pain is an evolutionary strategy
In the case of touching your hand to a hot stove, you have already started moving your hand away by the time you feel the pain.
What the pain is intended to do is to point out to you that your unprotected hand is not the best way to turn that pancake, and that maybe next time you should use a spatula!
So the memory of pain makes us less likely to try and use our digits as kitchen utensils in the future as well as making us stop the behaviour causing the pain in the first place.
It also makes you take care of an area while it is healing, so serves a protective function.
So pain is just a warning signal, and in normal circumstances, it is a good thing. Another way of saying this is that it is a adaptive strategy, or one that makes you more likely to stay alive.
People who can't feel pain for one reason or another run a very real risk of ignoring a seemingly small injury that then becomes infected, and possibly life-threatening.
Pain is normal!
Leading on from the above two points, it should be clear that pain is a normal function of our bodies when everything is working as it should, albeit one most of us don't really want! It is meant to be unpleasant, otherwise it wouldn't work the way it does.
Pain is what we experience when our brains have decided we are threatened or in danger, and wants us to do something about it.
In the case of chronic pain, where the pain has persisted long past the point where we might have expected any injury to heal, the key is to identify why the brain feels threatened.
'Pain' is, tellingly, also used with respect to grief or loss, or loneliness. This emotionally-laden 'pain' is crucial in understanding chronic pain - indeed, all pain! - as it reinforces the idea that these sensations are the result of many different inputs, and our emotions, thoughts, beliefs and behaviours are all important contributors to how we experience pain.
Pain and damage are not necessarily related
This starts to explain the idea that pain is an output, where trauma or tissue damage is not the only factor (as mentioned over on the page on age-related conditions like arthritis.)
We know from decades of medical imaging that people can have the most spectacular structural failures, like compression of the spinal cord or broken bones, and experience little to no pain or dysfunction.
Sheehan (2010) for example, found that among asymptomatic (i.e. not having any symptoms) 60 year-olds, over 90% had degenerative or bulging discs. 21% had spinal stenosis, narrowing of the hollow middle bit of the spinal column, where your spinal cord sits. One might imagine that squishing your spinal cord would result in some sort of symptoms, but not necessarily!
See the image on the left for a truly mindboggling scan of a compressed spinal cord that did not result in any pain at all (they had the scan done for other reasons).
Anecdotal reports from wounded in wartime often describe bullet wounds and even severe trauma as an impact, like being bumped or knocked in a crowd.
At the other end of the spectrum, consider a paper cut.
If pain is just an evolutionary mechanism to warn you about damage, why does the bloody thing hurt so much!
It is not deep, or (under normal circumstances) anything close to a serious danger to the body, but we react as if it was the next thing to losing a limb.
So how can osteopathy help?
An analogy I often use with my patients is to think about your central nervous system (or CNS, consisting of your brain and spinal cord) as a genius four year-old.
It is incredibly discriminating and intelligent in some ways, and unsophisticated and stupid in others.
Like a four year-old, it also has a tendency to throw tantrums (overreact with pain, for example).
And also like a four year-old, the best way of getting through to it is repetition.
By repeatedly moving and stretching areas where the body perceives pain, we can increase the 'positive feedback' coming from that area.
"Look, we are moving this painful shoulder in all these different ways, and the arm has not fallen off! Maybe it's OK to decrease the number of pain labels we are attaching to this area. Maybe it's OK to relax a little!"
This makes the CNS feel a little safer.
We can also help you with some of the other facets of your pain.
The folks over at NOI (the neuro-orthopaedic institute) have come up with this wonderful concept of DIMs ("Dangers In Me") and SIMs (Safeties in me) that can help identify unhelpful and helpful factors in your life that influence whether or not you feel pain.
The more factors we can identify, the more chance we have of helping you get your CNS to a place where it feels safe, and where you do not feel pain.
Eliott, JM, Fleming, H & K Tucker (2010) "Asymptomatic spondylolisthesis and pregnancy" J Ortho Sports Phys Ther 40:324
Gifford, LS (1998) "Pain, the tissues, and the nervous system: a conceptual model" Physiotherapy 84(1):27-36
Sheehan, NJ (2010) "Magnetic resonance imaging for low back pain: indications and limitations" Ann Rheum Dis 2010; 69:7-11
Special mentions to The Sensitive Nervous System (Butler et al, 2000) and Explain Pain Supercharged (Butler et al, 2017), which are great resources around explaining both central and peripheral nueropathic pain and have informed my whole approach to chronic pain management.
Low back pain (LBP) can be due to any one of a number of different causes.
Obviously, stressing/straining the local muscles, ligaments, joints etc. will cause pain and discomfort, but as with the shoulder, other structures in the body are also capable of ‘throwing’ pain to a distant location.
The kidneys, small intestine, colon/rectum, stomach, pancreas, spleen, gallbladder etc. are all known to cause low back pain.
Surprising few of the female readers of this blog, the ovaries and uterus (womb) are also more than capable of causing low back discomfort (especially at ‘that time of the month’ or during pregnancy); as are problems with the blood vessels, heart, various types of infection, cancers, and hormone disorders.
Because of this, it is always important to have your back pain screened by an appropriately-trained healthcare professional, especially if you have noticed other changes before or after the onset of the pain.
For the purposes of this blog, we will ignore all of the slightly more esoteric factors, and instead focus on non-specific (or mechanical) low back pain. As mentioned above, this is usually due to irritation of the moving parts of the spinal column, namely muscles, tendons, ligaments, vertebral bodies, intervertebral discs (the ‘shock absorbers’ between the vertebrae), and facet joints (the joints between one level of the spine and another).
Most mechanical low back pain resolves on its own, most often within 2-4 weeks. However, that can feel like a long time when you are in pain! So, what can you do to help speed that process up?
Such as osteopathy can help to alleviate the symptoms of low back pain. This is largely done by influencing the central nervous system (your brain and spinal cord) rather than directly affecting the areas being worked on, but mobilising restricted joints, stretching out tight muscles, and improving blood flow to the affected areas, can all help to mitigate the impact of mechanical LBP.
It might feel like the last thing we want to do when we are in pain, especially when we have not identified which movements trigger pain, but movement is medicine, as many of my patients have heard time and again. The key here is pain-free movement. If it hurts to bend backwards too far, then only go as far as you can without causing yourself undue discomfort! You should nearly always be able to find some positions or movements that do not aggravate your pain too much, even if it is a bit uncomfortable to do so.
The problem with inactivity is that it impairs the blood flow to and from the affected areas, slowing the healing process. The spinal column has up to eight (depending on definition) pump systems that help to support its health, which rely on normal physiological (to do with normal function of living organisms and their systems) movement to drive them. This is, in part, what osteopathic treatment does: to mimic these normal movements and restore some of these pumps. It also helps to ‘show’ the body that nothing catastrophic will happen if it allows a little bit more movement through the area (the influencing of the central nervous system we were talking about earlier), thus promoting further relaxation and decrease of nociception (the nervous system’s response to harmful/potentially harmful stimuli, i.e. the first part of feeling pain).
Having said all of that, exercising when your back is in full spasm (i.e. just after the injury) may be counterproductive, if the body feels like it is under attack, it will try to protect itself (largely by tightening up the muscles further). Make sure you listen to your body, and don’t perform any movements or activities that actually hurt (some discomfort is normal, and to be expected). If you cannot move at all without pain, then consider:
This does not mean weeks of bed-rest, as may have been recommended a few decades ago. That is pretty much the worst thing you can do (see above!). Rest for no more than 48 hours following the injury (or the first time you notice the pain, if there is no traumatic cause). Getting up and at ‘em (with slowly increasing activity levels) once you notice that initial acute phase subsiding will ease pain and stiffness, and speed up the healing process (again, see above!).
Heat & Cold
As a general rule of thumb, cold is good for decreasing inflammation (the first part of the body’s response to injury, and the start – theoretically, at least – of the healing process), so is advised in the first 72 hours or so after injury. Cold also ‘confuses’ the nervous system – it can’t work out whether to focus on the cold or the pain signals, an effect know as pain-gating. It is the same mechanism when a parent rubs on the banged elbow or barked knee of a child: the pressure of the rubbing decreases the amount of attention the brain pays to the pain stimulus. You don’t need an ice-pack, specifically, just wrap a tea-towel or similar around a bag of frozen peas or other vegetables (never put anything too cold into direct contact with the skin).
Heat is very good for helping tight and sore muscles relax, and increasing the blood flow to an area. How good does a nice hot bath (or shower) feel after a long day of working hard?!
However, both have their caveats: Heat will aggravate any inflammation present, and part of the inflammatory process is to increase fluid in the area (swelling), so the last thing you need is more blood flow to the injured part. Cold also has the potential to cause muscles to contract to protect themselves and keep warm. So, the golden rule is: if you put on ice/heat and it makes it feel worse, then stop! Ask your osteopath whether heat or ice would be more appropriate given the nature of your injury.
Pharmacological (drug) management
Over-the-counter (OTC) medications, such as acetaminophen (Panadol) or non-steroidal anti-inflammatories (NSAIDs) such as ibuprofen (e.g. Neurofen) or sodium diclofenac (Voltaren), may help with your back pain. We know that these drugs are not very good at helping with chronic back pain, and are not a good long-term management strategy, but in acute cases they may help to ease a bit of discomfort, which then allows you to move a little more easily, which speeds up the healing process (as noted above, the protective spasm or muscle guarding that normally takes place in response to an injury actually restricts blood-flow to an area, slowing down the healing process).
Please note: I am not qualified to give pharmaceutical advise. Always read the label, and consult your doctor or pharmacist regarding the suitability of any given medication for you and your condition.
Stretching and Exercise
This is such a big topic that I will only devote a few words to it here, saving the rest for another blog post.
Maintaining mobility and flexibility is one of the biggest things you can do to help prevent injury, but in the instance that it’s a little bit late (after all, you’re reading this looking for tips as to how to manage your existing low back pain), there is also a lot you can do now. In general, the basic tenet is that movement is medicine, and both stretching to relax muscles and general mobilisation (taking the joints and muscles through their normal range repeatedly) can help significantly with your symptoms. For further details, please see here.