As lockdown continues, and we face another few months of life without access to our traditional gym settings, I have been inundated with questions regarding training strategies that can be implemented at home.
If the answer is yes, you won’t be surprised to learn that you are not alone. Low back pain is the world’s leading cause of disability - calculated by “Years Lived with Disability”. It has been every year since the Global Burden of Disease study began in 1990.
According to the National Centre for Biotechnology Information (NCBI), ‘low back pain probably affects around one third of the UK adult population each year. Of these, around 20% (or 1 in 15 of the population) will consult their GP about their back pain’. That is a lot of us. Estimates from the British Pain Society report that ‘approximately 8 million adults in the UK report chronic pain that is moderate to severely disabling’, and overall, it costs the UK economy around £10 billion per year1.
Low back pain (LBP) seems mysterious, doesn’t it? It’s not just you that finds it frustrating and difficult to treat. It has been a mystery to many within medicine and healthcare for a long time. Let’s focus on just one of the mysteries. Perhaps the biggest and most important one and one which may seem like the million-dollar question; ‘What is actually wrong with your back?’
Disappointingly, there’s very little agreement between professions when it comes to diagnosis. In fact, you’d be hard-pressed to find two chiropractors or two osteopaths who agree on a diagnosis. I should know - I’ve been an osteopath for 30 years, and employed more than 25 other osteopaths in that time.
As for the medical profession, LBP is such a mystery that 90% of it is labelled as “Non-specific Low Back Pain” (NSLBP) by doctors.
Well, firstly there are two other categories; ‘Structural Abnormalities’ and ‘More Sinister Pathologies’.
Structural “abnormalities” causing LBP - Structural problems such as disc prolapses, degenerative changes, spondylosis, spondylolisthesis and more scary sounding labels make up about 10% of LBPs.
One problem with these diagnoses is that we know the amount of damage seen on an X-ray or MRI has very little to do with the amount of pain you’ll have, and the knock-on effect this will have on your daily living activities. And the idea that a twisted pelvis or a “bone out” is causing your pain has been widely discredited. Just because you get better after manipulation doesn’t mean that you need manipulation to get better. I’m not saying it's a coincidence. Manual therapy does help. But it doesn’t provide a lasting solution, does it? Otherwise, you probably wouldn’t be reading this!
We’re talking tumours, aortic aneurysms, and other nasties. However, these make up less than 0.1% of LBPs. I’ve probably seen more than 15,000 people with LBP and only a handful have concerned me. For further reassurance, see the “screening questions” below.
The first job for any clinician is to exclude the more sinister pathologies (or ‘nasties’). In order to do this, there are key questions that you will be asked which in turn may flag up whether you may have one:
If you are concerned you can complete the full list of screening questions by clicking here. Answering ‘yes’ to one of these does NOT mean you have a pathological condition. It’s all about building a picture, which our screening questions aim to cover, and in turn give a detailed overview of your unique situation.
Beyond that, it would be good to provide a label that ‘first, does no harm’, to quote the Hippocratic Oath. For the best part of the last 2000 years, doctors swore to adhere to the Hippocratic Oath. One of its principles is ‘primum, non nocere’ – ‘first do no harm’. For most medical schools this has been replaced by the field of bioethics.
Conventional LBP diagnostic processes fall down on this point. Because it turns out that what you are told influences the long-term outcome. The research2 shows that providing a structural diagnosis leads to a greater risk of long-term pain than not providing one. Crazy, eh? For many people, being told they have a “disc prolapse” or “degenerative disc disease” results in more disability than not being told this (despite actually having it). And as for the all-too-often voiced “There’s nothing that can be done, you’ll just have to live with it” - I think this is an offence against the Hippocratic Oath.
Of course, you ultimately want to know what’s wrong with your back. That’s completely normal and understandable. A diagnosis or label allows you to understand what is wrong and why, and how best to deal with the problem, right?
But what if the label you’re given is wrong?
What if everyone is wrong?
What if your doctor’s wrong, the physiotherapist, the chiropractor, the osteopath or massage therapist? What if no one really knows for sure?
Does that add to your pain?
Yes, it does.
Research detailed in the Physical Therapy and Rehabilitation Journal 3 shows that your beliefs hugely affect the amount of pain you experience.
Being provided with different explanations is upsetting, stress-inducing and tends to increase your pain. And at the very least, it results in you trying all sorts of different exercises and advice.
At the very least a diagnosis or label should do no harm. Ideally it should empower you, right? It should offer some insights into what you should and shouldn’t do to recover. Because the vast majority of LBPs resolve over about 6 weeks (and yes, even without treatment). But unfortunately, many people go on to have recurring episodes.
So, the pattern for most people isn’t pain that never leaves them. It’s episodes of pain that come and go across years, often decades.
The biological purpose of pain is to act as an alarm system. If you put your hand on something very hot, pain is there to tell you to stop. If you kept your hand there it would lead to significant damage. In the early stages of LBP, the pain happens before you actually do any damage. In fact, there is little correlation between the amount of pain you feel and the degree of damage.
Back to the optimal labelling process. There are things you should avoid - at least in the short-term - if you want your pain to improve. What you should avoid is particular to you. In the first few weeks of a back problem, let pain be your guide. My Golden Rule is ‘use it or lose it, but don’t abuse it’. We’re focusing on the second part here: try to avoid things that obviously aggravate your pain. This will be different from person to person. Although in my clinical practice, we find that 72% of our patients find sitting aggravates their pain.
Well, a lot of this comes down to ineffective or unrealistic planning when it comes to managing pain and developing strategies to help minimise episodes of pain.
I often see two main reasons most people have recurring pain:
At Active X Backs we use a labelling system that won’t do you any harm. It gives you a guide as to how long it may take to recover, and what to avoid if you want to allow the symptoms to settle.
The model we work with, and we provide to all our clients at Active X Backs is The Cliff of Pain ™
Too many people focus on avoiding triggers, and using ‘Relievers’ to climb back up The Cliff. If you want a long-term solution, guess where the safest place is? That’s right - as far back from the edge as you can get. An uncomfortable truth about most LBP is that it is lifestyle related.
Our approach at Active X Backs is based on experience and post-graduate training. Perhaps the most significant step forward in my understanding was studying for a Master’s degree in the Clinical Management of Pain at the University of Edinburgh. I focused as often as I could on lower back pain. My dissertation year was focused on scoping the ‘Optimal digital intervention for lower back pain’. It involved a review of International Clinical Guidelines, to make sure we put safety first and based our approach on the best available evidence. This is continuously reviewed and we’ve made lots of progress. So, if you’d like to find out your own empowering Functional Assessment (our approach to diagnosis), you can do that for free.
Many people elect to take the free assessment which generates a comprehensive report. This can then be used on an individual basis to begin to address low back problems themselves. For those who require more support, the beauty of our solution is that it can be delivered wherever you are at a time that is convenient to you. With no need for trips to a clinic; your personalised programme can be delivered to you in the comfort of your own home.
Absolutely, but it is vital that the overarching approach is one that empowers you. Too much therapy is a passive approach to managing your pain by way of having things done to you. If you truly want a long-term solution, you have to take back control and with the benefits of lifestyle management and individualised care.
In the last few weeks, our clients at Active X Backs have included a doctor from Florida, an artist in Belgium, a marketer in Myanmar, and all sorts of folk here in the UK. They have all had LBP, many including sciatica. Many of them have had pain of more than 7 out of 10, and been significantly disabled by their pain. Most of them have consulted therapists locally, and not achieved a lasting improvement, until they came to us.
Click here to start your unique journey into understanding and overcoming your low back pain and find out how the team at Active X Backs can help you.
Imagine playing a complex board game where everyone is playing by their own rules, except you don’t know what the rules are or how to invent your own. That’s what life can feel like when we haven’t learnt the skill of healthy personal boundaries.
The Health Suite is a Doctor-led private wellbeing clinic offering a wide range of medical and complimentary therapies all under one roof. Their extensive and collaborative multidisciplinary team are on hand to support patients' unique health needs.
I sincerely believe that everyone should have the opportunity of leading happy and fulfilled lives, feeling confident and secure to enjoy their life to the full.