The Problem Of Low Back Pain
I mostly see lower back patients (50% of my caseload) and the thing I hear all the time is “I had no idea who to see. There is so many options!”. They are not wrong. There is a huge amount of options when you are “Googling” a solution to your back pain and sciatica. Pilates, yoga, strength training, Keiser, Physiotherapy, Osteopathy, dry needling, acupuncture, Myotherapy, and it goes on and on. Everyone will know good friends and family members who will try and tell you how to fix your back, based on their own experience. The trouble with this is back pain is not a diagnosis, it is a symptom. And it will require a specific tailored solution.
Sadly, the problem of low back pain is one that affects a huge proportion of the population.
- 1 in 5 Australian’s suffer from chronic pain (1)
- Australia spends $4.8 Billion per year on management of low back pain (1)
- Around 25% of Australians suffer from low back pain on any day (1)
- 50% of Australians suffered from back pain in the past month (1)
Episodes of acute LBP often have a good prognosis, with rapid improvement within the first 6 weeks with appropriate treatment. After this period, the improvement unfortunately slows, and over 40% of patients may develop chronic LBP after 6 week of pain. Thankfully, usually only persists with only low levels of pain and disability (3). About one-third of patients who experience LBP and recover, will suffer further episodes of LBP within the year. Clearly there is a need to identify those at risk of developing chronic pain, and, to teach preventative strategies and self-management techniques so the patient themselves can reduce subsequent episode frequency and severity.
The economic burden for lower back pain in Australia is gigantic, with $4.8 billion of total health care expenditure in 2017 related to back pain. It is also the third leading disease burden in Australia, accounting for 3.6% of the total burden across all disease and injury.
The largest factors that drives up the cost of healthcare for low back problems is imaging and surgery.
Surgery
Surgery is a huge cost, and most people will do better without surgery so should be reserved for the very select few that truly need it, after all other conservative avenues have been explored.
The rate of back fusion operations has increased almost exponentially, despite almost every clinical guideline around the world on lower back pain not recommending fusion.
I regularly see patients who have tried various therapies like acupuncture, Pilates and Physiotherapy who have not had success in resolving their lower back pain. I am often their “last option” opinion, as they have seen a surgeon and are seriously contemplating going under the knife. Thankfully, as often as this occurs, a high percentage of these patients (I would estimate 90%+) do resolve with simple, targeted conservative therapy. I regularly hear the phrase “I can’t believe fixing this is so simple. And you are the first person that has explained this in a way that makes sense to me.” Patient centred, non-dependency developing approaches are key to successful interventions.
Imaging
Another big influence in driving up the cost for back pain is imaging. Imaging can be useful, but it is routinely done for many patients who do not require it. One of the problem’s with sending someone for a lower back MRI is that it can reveal a myriad of findings that sound scary to the patient but are in fact completely normal (and the report should read “normal age-related changes’).
As you can see from the table above (4), if you take someone that is only 30 years old, that has no back pain, around 40% will show disc bulging, and 50% will show disc degeneration. Sounds scary right? Now take someone aged 60 and almost everyone shows disc degeneration and bulging, with 50% show facet degeneration. These are essentially the normal changes that occur in the spine with ageing, but interpreted incorrectly can be very damaging, is important the sufferer with back pain has this explained with great care. In some cases, the description by the health care practitioner can be a significant factor in developing a chronic pain syndrome, where fear around “damage or degeneration” can be powerful factors in the propagation of pain.
Finding a solution for your back pain
Irrespective of who you see there are some aspects of your assessment & treatment you should expect, otherwise you are likely wasting valuable time and money, while increasing your chances of developing chronic pain if you do not already have it.
What you should demand:
- An individual and thorough assessment where you are questioned in detail about the nature and behaviour of the symptoms, and how these impacts your lifestyle & function
- Education about your condition and potential diagnoses, and how the treatment & assessment will help differentiate which type of problem you have
- Education about the prognosis and time-frames for recovery
- How long will it take to get better?
- How many sessions will I need?
- If there is no clear obvious improvement within a few sessions, why not and what does this mean?
- What you can do to assist in your own recovery
- You should be given specific exercises and strategies to improve your pain and function, along with a clear expectation of what to expect and how they should work
- An individual and thorough assessment where you are questioned in detail about the nature and behaviour of the symptoms, and how these impacts your lifestyle & function
- Education about your condition and potential diagnoses, and how the treatment & assessment will help differentiate which type of problem you have
- Education about the prognosis and time-frames for recovery
- How long will it take to get better?
- How many sessions will I need?
- If there is no clear obvious improvement within a few sessions, why not and what does this mean?
- What you can do to assist in your own recovery
- You should be given specific exercises and strategies to improve your pain and function, along with a clear expectation of what to expect and how they should work
- An
assessment of your posture to determine if it influences your pain
- This will not be a critical factor for every back-pain patient, but for many the posture is a key element to correct
- Education about the role of thought, mindset and psychology in your lower back pain
- This is particularly important if your pain has been going on for months or years. The below short video called Tame the Beast is an excellent resource to help understand how the brain and thoughts can play a massive role for some people
Simple effective solutions
I am trained in the McKenzie Method, which is a highly effective, research based post-graduate training (for more information see http://www.mckenzieinstitute.org/).The cornerstones of the McKenzie Method, also known as MDT (Mechanical Diagnosis & Therapy) are based around education and self-management.
Essentially you are put through a comprehensive mechanical evaluation, after obtaining a detailed history from you about how your pain behaves and how it impacts your life. The mechanical evaluation involves testing to determine if posture affects your pain, followed by assessing you with repeated movements and sustained positions until we understand what type of back problem you have. This detailed assessment will help determine if there are specific strategies you can do that immediately reduce your pain as we work toward a true long-term solution.
It is highly effective, cost saving, efficient and empowers you to fix yourself. I became an MDT practitioner after fixing my own chronic back problem, despite many years of pain and wasted money and time on ineffective practitioners and solutions.
As fantastic as MDT is (and it truly is!), that is not the purpose of this article. And I acknowledge there are other practitioner’s with different methods to approach your problem which will also get fantastic outcomes through low cost, education focussed and targeted treatment. What prompted me to write this blog is frustration with continually hearing terrible patient experiences.
As an example, I recently had a patient who hurt her back for the first time training on her own in the gym, she unfortunately began her rehab journey seeing a physiotherapist in a well-known exercise machine-based type of therapy, who advertise as specialist treatment for back pain. On the first consultation she was told she needed ongoing treatment (despite having pain for 1 day in her life!), should not expect to be pain free for 6 weeks, and that a weak core was the problem. I am not sure why the general public believe a weak core is the cause of low back pain, as this is not the case (2), but it is something I hear every day.
The patient was terrified after the consultation and was considering booking in then and there for ongoing sessions for the next 3-6 months. This patient was very strong from regular strength training with one of our performance coaches, played sport at a high level, and had never had a day of back pain before. As an industry we need to be better than this! I am embarrassed to hear patients tell me of other physiotherapists and health professionals providing ongoing treatment with no clear plan or diagnosis, using ongoing passive treatments like ultrasound and shock wave therapy, that have been proven by research to be placebo at best.
If you have a sore back, make sure you see someone who will assess you thoroughly, provide excellent education and timeframes for recovery, and involve you in your own rehabilitation. On average I see patients 3-4 times. If they are not showing clear, measurable improvement by then I have identified why and provide an alternate path (e.g. a patient whose pain is from an inflammatory disorder of which they are unaware I will refer to a Rheumatologist).
Make sure you do your research and see someone that is skilled enough to figure out the nature of your problem, and will ensure you get the best treatment and advice that you need. You should always be given clear expectation of how long your recovery should take, and that self-management is at the forefront of your treatment. It should be cost-effective, practical and logical, and your goals of treatment and lifestyle should be a factor in shared decision making.
Written by Joel Laing
Senior Physiotherapist at Absolute Health & Performance
Diploma in Mechanical Diagnosis & Therapy (MDT)
References:
- Medicine, Nursing and Health Sciences. (2019). Global burden of low back pain – a consequence of medical negligence and misinformation. [online] Available at: https://www.monash.edu/medicine/news/latest/2018-articles/global-burden-of-low-back-pain-a-consequence-of-medical-negligence-and-misinformation [Accessed 16 Jan. 2019].
- Bodyworkmovementtherapies.com. (2019). Journal of Bodywork and Movement Therapies. [online] Available at: https://www.bodyworkmovementtherapies.com/article/S1360-8592(09)00093-X/fulltext [Accessed 16 Jan. 2019].
- Mja.com.au. (2019). [online] Available at: https://www.mja.com.au/system/files/issues/208_06/10.5694mja17.01152.pdf [Accessed 16 Jan. 2019].
- Brinjikji, W., Luetmer, P., Comstock, B., Bresnahan, B., Chen, L., Deyo, R., Halabi, S., Turner, J., Avins, A., James, K., Wald, J., Kallmes, D. and Jarvik, J. (2014). Systematic Literature Review of Imaging Features of Spinal Degeneration in Asymptomatic Populations. American Journal of Neuroradiology, 36(4), pp.811-816.
