How to Prevent Low Back Pain – A Physiotherapist’s Perspective

Many people will encounter low back pain at some point in their lives. Usually this is intermittent and after a fleeting struggle, many episodes of low back pain will resolve of their own free will. However, due to a more sedentary lifestyle and increased awareness surrounding ‘back heath’, the incidence of this problem, as seen by health professionals, has grown beyond measure over recent years. The question on everyone’s lips appears to be “how can I best look after my back and prevent back pain?” Well here are some simple steps you can take to help protect yourself against the rising incidence of low back pain and to restructure your life in a way that facilitates maintenance of a healthy spine.

It is important that you take the following information at face value, as it is sourced from my personal experience as a musculoskeletal physiotherapist. In no way should it be used to undermine the advice given to you by your doctor or other health professional.

1. Good Posture

Good posture is crucial to maintain correct alignment of the joints and the surrounding muscles. Optimal posture (I say ‘optimal’ and not ‘normal’, as there are many forms of ‘normal’) ensures that the forces transmitted throughout the body are distributed in a way that is symmetrical, most effective and requires the least amount of effort.

Just by observing others around you, it becomes apparent that there are many different shapes and sizes of body. For example, racket sport players often present with a forward shouldered posture (i.e. their shoulders are slightly rounded) due to the constant overhead action associated with their sport. Repetitive movement can over time, result in muscle imbalances in the body, which in this case, results in the muscles at the front of the shoulder becoming dominant and shortened; hence pulling the shoulders forward. However, posture itself is not only influenced by the sports and hobbies we participate in, but also by our chosen occupation and congenital factors (you’re simply born that way). Unfortunately, there is little wiggle room with regards to changing congenital factors (for example, an overly curved spine), however we can influence the other two parts of the equation to ensure maintenance of a healthy spine (and body).

As mentioned earlier, prolonged, poor posture can result in the associated shortening and lengthening of the soft tissues, therefore affecting joint alignment. Muscles and their relative attachments to the joints can exert abnormal forces on a joint, which can lead to the stresses of movement being transmitted through the wrong points on the body. Similarly, the muscles and joints over time, may become predisposed to overuse and can lead to joint inflammation and fibrosis (the formation of ‘muscle knots’). The best example for back pain, is the role of the deep core muscles, which function as a muscular corset to help stabilise the trunk and hip/pelvis. In most cases, the deep core (or stabiliser) muscles become neglected; the body therefore, seeks out a compensation strategy by utilising the larger and more superficial muscle groups (known as the ‘mobiliser’ muscles) to fulfill this stabilisation role. Over time, these muscles can become overworked and fatigued, which manifests as muscle tightness and potentially, muscle spasm.

Of course, it is all well and good to talk about good posture and the benefits it brings, but what fundamentally constitutes a ‘good’ posture? Essentially, an effective posture if one that promotes symmetry and protects the body from potential injury (and therefore pain). Going against logic, it is not always the case that persons with bad posture suffer from joint or muscle related complaints. Indeed, it has been my experience that persons with visibly ‘bad’ posture can go about their days quite happily without interference from pain due to being able to adequately compensate for their bad posture. However, a more in depth analysis and increased awareness of how bad posture may predispose to pain, takes on far greater importance once pain is present or has been present, previously.

It is my view that everyone can make a difference to their own posture, whilst working with what nature has provided. The most simplistic way to do this is to maintain symmetry in your everyday functional activities, therefore avoiding overuse via repetitive motion. Again, it is important to be aware that some occupations/sports will require repetitive motion, in which case utilising the opposing limb, frequently changing activity throughout your day or seeking regular massage therapy can all be simple, yet effective ways of preventing muscle imbalances or overuse- type injury. Additionally, regular rest breaks and exercise regimes such as Pilates or targeted strengthening to address weakened muscles can be useful to protect against the incidence of postural related pain.

Unfortunately, posture is far too big a subject to discuss all of the potential therapeutic options and self help strategies available to address posture and postural-related pain; however if you have been suffering with persistent pain and have identified your occupation or sporting hobby as a potential factor, it is advised to speak to a physiotherapist and arrange for an assessment.

2. A strong Core

In the maintenance of a healthy spine, strengthening the core muscles to help provide adequate muscular support is an important consideration. Muscles generally mimic the effects if scaffolding to a building, providing localised stability around the joints as we move. There are a whole host of exercises on the market, claiming to effectively strengthen the core muscles, most of which choose to focus on the Rectus Abdominis (or six pack). However, the core extends far beyond the six pack to include muscles of the deep core (Transversus Abdominis), the Pelvic Floor, Obliques Internus and Externus, alongside the Multifidus and Psoas muscles.

Taking this anatomy into consideration, the exercises most commonly advocated by fitness professionals can be argued to be ill effective, since the six pack constitutes only a small component of the larger core system. Similarly, bracing type exercises such as the ‘plank’ have been offered up to criticism, for their bias towards holding the breath to create an almost ‘false’ stability, as opposed to training the deep core muscles to stabilise the spine. That is not to say however, that research exists to confirm any kind of superiority of one exercise regime over another; indeed, the jury is still very much out on this issue due to the variety of different exercise regimens that are available on today’s market.

Taking into account research on how pain affects muscle activation, there is a general consensus that the presence of pain leads to reduced activity or ‘inhibition’ of the stabiliser muscles i.e the muscles whose job it is to provide support to the joints. This reduced activity manifests as pain when performing relatively low level activities such as walking, sitting, standing and stair climbing, since the joints are left relatively unsupported and movement has as a result, become destabilised. Unfortunately, even once pain resolves, this same inhibition fails to spontaneously resolve, therefore leaving the affected person more vulnerable to future injury, unless there is time dedicated to retraining the stabiliser muscle groups. This can therefore explain why such a high percentage of persons who experience low back pain, suffer a recurrence not long after their initial episode despite a full resolution of pain previously.

In order to retrain the stabiliser muscle groups, specific and targeted exercises must be employed to change the body’s recruitment strategy If you visualise the body a large circuit board with wires connecting into different areas, pain results in faulty connections in the wrong areas. These are the areas of increased muscle activity. The premise behind retraining exercise is to challenge these faulty connections and reconnect the wires into the correct areas to address weak links in the body, therefore promoting balance and symmetry in the muscle system.

Again, exercise retraining is a large topic area and demands expert guidance from a health professional. If you wish to look further into this area, I advise you source out a Pilates trained health professional who can offer their individual expertise on exercising for the correction of low back pain.

3. Keep Moving

When experiencing back pain, it is in our nature to try avoid painful movement at all costs and generally, walk around like a stiff board. The important thing to know about backs however, is that a prolonged avoidance of movement, in most cases, can be detrimental and compounds the original problem.

By not moving for a prolonged period, the joints and muscles fail to receive their normal movement stimulus and can become very stiff, very quickly. Once the initial pain has subsided therefore, you can potentially be left with a very sore and painful back, simply from the fact that the joints and muscles haven’t been moved. Imagine trying to stretch an elastic band that simply doesn’t want to budge. If prolonged, our behaviours can lead to a ‘fear avoidance’ of movement that manifests as a loss of movement, which can turn an acute episode of low back pain into a chronic one if left unaddressed.

The best and most simplistic way to gauge activity levels when experiencing back pain, is to lead by symptoms. It is important that during an episode of pain, persons find a happy medium- somewhere between rest and activity- where you are able to continue to move the back, but not to a point where the pain is excruciating. If you move too much into pain, this promotes a reflex ‘guarding’ response in the muscles, which can lead to further tightening and even muscle spasm.

A helpful tool can be to visualise a scale from zero to ten (zero = no pain and ten = worst pain possible). It is important, in the early stages to keep as low a pain score as possible, whilst maintaining as close to normal movement of the spine. This is the level where your activity is unable to aggravate your back pain further and therefore, provides that all important window of time for symptoms to settle.

Similarly, simple changes to the ways in which you choose to perform an activity or the length of time for which you choose to do it are important factors for consideration, in order to maintain those crucial low pain scores. Use a trial and error technique to pinpoint a happy medium and be careful not to push it on the days where symptoms appear more settled than usual. Giving into this temptation can leave you feeling very sore and sorry for yourself the following morning!

4. Heat and Ice therapy

I often get asked “do I use ice or heat therapy for my back pain?”. Obviously, the sensation of heat is preferable to that of ice and therefore, most people opt to use heat as a first port of call. However, it is important that you select either of these therapies, with thought to what best suits the stage your back pain.

For example, for pain that comes on suddenly and is sharp and aggressive in nature, it can be helpful in the first few days to use ice therapy to limit inflammation at the affected area. Apply a pack of frozen peas, wrapped in a towel directly over the area of pain for fifteen-twenty minutes at a time and repeat this every 3-4 hours- limit this time if you are known to suffer an adverse reaction to cold or suffer from circulatory problems or lack sensation.

Differentially, for chronic back pain (dull, longstanding pain) heat is advocated to help increase blood flow to the affected area and therefore, help to stimulate the healing response and relax tight muscles. Sometimes your therapist may recommend contrast therapy- a mixture of heat and ice applied to the site of pain. Just make sure you don’t attempt to apply them at the same time or you will end up with a soggy carpet at the end of it!

5. Know when to take it further

Sometimes, the steps we take to self-manage our back pain aren’t enough. It is therefore, advisable that when pain is unrelenting or you are experiencing other symptoms alongside your back pain, that you make an appointment with your GP or physiotherapist. During your consultation, your health practitioner will take a history from you, asking you questions about your pain and examine your movement. It may be that you will be prescribed some pain relief medication or are advised to undertake an episode of treatment. This can include modalities like massage, joint manipulation, acupuncture, exercise and electrotherapy.

The most important thing is that you don’t ignore the problem and hope that it will go away by itself. In most cases, people who have sought help earlier often make a quicker recovery. By ignoring your back problem when pain chooses to ensue, you are giving it chance to manifest, which could lead to a delayed recovery time and potential complications, as a result of changed movement strategies and an altered walking pattern.