Lower Back Pain – What we know, and where to focus

Pain

A deep dive in to the evidence

You’ve recently developed lower back pain, or you’ve been in pain for a while. Chances are, you’ve tried a number of different types of exercise therapy, stretches or specific exercises. Some can work really well and some seem to not do so much.

Trying to find the best way to treat lower back pain can be challenging especially when there are so many articles, devices, medications, treatments and professions that claim they can help make your back pain disappear.

All this can get really confusing, and to be honest, a lot of what’s out there is not so well researched and can offer minimal outcomes.

In light of recently updated exercise guidelines for the treatment of lower back pain by the American Journal of Sports Medicine (ACSM), we aim to give you an evidence-based approach to what to focus on when living with low back pain, and what the evidence says about exercise and outcomes.

Firstly, what does the evidence say about back pain?

Lower back pain is a normal experience and usually recovers, with most people experiencing at least one bout of it in their lifetime (Hoy et al. 2010). This is not to say that your pain is not significant, and it is not taking away form the fact that it may be taking a while to recover, but more so that back pain is often viewed as a scary construct that may seem more serious than it is at a physiological level (but we will dive deeper in to that later in this article).

90% of low back cases are deemed non-specific in nature. That is, the particular structure involved is not certain, with current literature not supporting a definite cause for initial bouts of low back pain (Brukner et al. 2012, ACSM. 2020). Of these 90% of cases, favourable outcomes are very common, with non-specific lower back pain having a good natural history – ie, gets better on its own regardless of treatment that’s given.

So in most cases, lower back pain does not have a significant or relevant measured cause that suggests poor outcome. We also know that de-emphasizing the anatomical cause of back pain is recommended for best outcomes according to the ACSM 2020 Guidelines for Low Back Pain. So trying to find that muscle, bone, disk or joint that may be causing your back pain may not be very relevant for your recovery, and can potentially actually lead to poorer outcomes if an investigation is not indicated.

But what about when it’s not getting better? This is where it usually gets slightly more complex, especially if you have had investigations that have shown nothing too conclusive.

To put it most simply, we know that pain in general is not equal to tissue damage or injury (another reason why it may be favourable to not focus too closely on the exact cause of the pain). Pathologising the pain and health professionals promoting fear towards your pain leads to worse outcomes, so if your health professional is making you feel scared about your back pain it might be worth finding other opinions from another health professional. (ACSM 2020) The spine is exceptionally strong and robust with an amazing ability to heal and adapt.

What does the evidence say for exercise and back pain?

The first thing our ACSM guidelines suggest is that exercise is a valid and effective way to improve lower back pain. Woohoo! The second thing it suggests based on the current evidence is that there is no ‘special’ exercise for lower back pain. This isn’t to say that exercise is not helpful (because it is extremely beneficial, and statistically has a proven effect), but rather that the specific type of exercise or that wizz-bang protocol you’ve seen that claims to ‘cure’ your back pain is no better than going for a walk.

When selecting exercises for back pain, it is best to work with exercises and activities you enjoy and can do with minimal discomfort. What seems more important than the exercise itself is confidence, comfort, gradual progressions of your exercise and regularity of movement over the specificity of exercise itself.

As movement professionals (exercise physiologists, physiotherapists, etc), we should focus our treatment of you to finding what exercise works best for your individual circumstance and building confidence in you and your back pain. Following on from this, ACSM directly mentions that a focus on core stability is not valid, reliable or useful when compared to normal guideline care. So don’t let someone tell you your weak core is the primary reason for your pain!

If someone claims they have the ‘best’ exercise or modality to prevent or treat your pain, they’re probably not providing much help. Get up, get moving and do what you can, and seek guidance if you are losing confidence or if you are finding comfortable movement difficult to find.

What to focus on, based on the current guidelines:

To summarise the above in to digestible chunks:

  • We don’t know the cause of most cases of low back pain, and it isn’t crucial to know for a majority of presentations.
  • Remain confident in your back, and move where you can comfortably. Most cases have a favourable natural history and will resolve with time.
  • The human spine is exceptionally strong and robust, with an amazing ability to heal and adapt
  • Exercise can be extremely beneficial for treating lower back pain
  • There isn’t much evidence suggesting a specific type of exercise is better than another – the best exercises you can do are the ones you enjoy and that help de-threaten the pain
  • If you find a health professional is provoking fear about your lower back pain, seek a second opinion where you can.
  • Seek help if you are not sure what exercises might suit you and your pain best.

Still not sure about how to attack your back pain? Come and talk to our evidence-based Exercise Physiologists to help guide you through your lower back pain to gain the confidence, reassurance and ability you need.

Book your FREE 20 minute discovery session to find where we could fit in to your health journey at the link  below the references.

References:

American College of Sports Medicine. ACSM’s Guidelines for Exercise Testing and Prescription.

Hoy D, Brooks P, Blyth F, Buchbinder R. The Epidemiology of low back pain. Best Pract Res Clin Rheumatol. 2010 Dec;24(6):769-81. doi: 10.1016/j.berh.2010.10.002. PMID: 21665125.

Brukner, Peter, Karim Khan, and Peter Brukner. 2012. Brukner & Khan’s clinical sports medicine. Sydney: McGraw-Hill.

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