Breaking Down the Complexity of Low Back Pain

Written by Teo Buzas, PT, DPT

When it comes to low back pain, it is relevant to differentiate acute low back pain and chronic low back pain.

Acute pain is most simply defined as pain that lasts less than 12 weeks.

Chronic pain is most simply defined as pain lasting greater than 12 weeks.

As pain becomes more chronic in nature, it lasts longer than known tissue healing time frames. The longer your pain persists the poorer it is associated to injury.

Acute pain is usually related to a specific injury and responds according to known tissue healing time frames. Chronic pain has been found to have a poorer association with injury/tissue damage.

Pain can be a complex experience that is often the result of multiple factors.

Research (1) helps to reduce the “complexity” of low back pain and start to make sense of what we can do.

What you need to know:

1. Less than 5-10% of ALL low back pain is due to a specific underlying spinal pathology.
2. The remaining 90-95% has no indication of a serious cause and respond well to conservative treatments (education, exercise, physical therapy, pain management, etc).
3. Imaging may do more harm than good when serious conditions are not suspected and is likely to prolong recovery.
4. Primary concerns of whether pain is caused by something serious and improving recovery can be addressed by good information and intervention, without the need of imaging.

ACUTE low back pain:

The New Zealand Acute Low Back Pain Guide is an excellent source for evidence-based treatment for acute low back pain. These guidelines aim to provide the latest information on best practice management of pain.

Acute low back pain is common and episodes typically last less than 3 months.

In the absence of trauma and red flags, acute pain is generally non-specific to one structure as the source of pain. Precise diagnosis may not be possible and more importantly not necessary. Contrary to common and popular belief and practice, you do not need to have a precise structural diagnosis to effectively treat low back pain.

Spending time searching for the exact “cause” of the low back pain is looking for a problem that may not exist. This has led to medicalizing back pain. In looking for a “problem” a nocebo can be created. A nocebo is a harmless thing that causes harm because you believe its harmful (e.g. posture, SI joint dysfunction, out of alignment, lifting incorrectly, tight hamstrings, etc).

In this acute phase, it is important for people to be empowered with correct facts, treatment, self-management techniques as well as avoid over-medicalization. Find someone who focuses on the solution of what you can do, developing a plan with you to help you manage your own recovery.

If pain radiates down the leg (often referred to as sciatica), there is a greater chance that symptoms are caused by a herniated disc. This may sound scary, but it need not be. Sciatica herniated discs responds well to conservative treatment. Herniated discs can heal and symptoms can resolve completely.

The long-term results of surgery for back-related leg pain are no better than those of conservative management.

Recurring episodes and occasional pain are common after an acute episode of low back pain. It is important to recognize this and get the best advice and care so that you know what to expect and what to do when this occurs.

Key takeaway messages:

• Acute low back pain is common. Episodes are nearly always short-lived. Reassurance of this is helpful.
• Investigations of a “root cause” in the first 4-6 weeks do not provide clinical benefit unless there are red flags present. There are risks associated with early unnecessary radiology.
• Physical activity and exercise are very important. Progressively increase physical activity and return to usual activities, including work as soon as possible.
• Manual manipulation may provide short-term symptom control.
• Some interventions may be harmful, especially extended rest, use of opiates, medicalizing “spinal abnormalities,” and using imaging to find structural changes.

Red Flags:

• Severe worsening pain, especially at night or when lying down.
• Significant trauma.
• Unexplained weight loss, history of cancer, fever.
• Cauda equina (difficulty urinating; significant leg weakness; numbness around the buttocks and genitals; loss of bowel and bladder control) – cauda equina syndrome is a medical emergency and requires urgent hospital referral.

Barriers to recovery in the acute phase:

• The belief that pain and activity are harmful.
• Extended rest.
• Treatment that does not fit best practice.
• Lack of social support and overprotective family.
• Low or negative moods.
• History of back pain and time off from work.

CHRONIC low back pain:

The 2018 Lancet Low Back Series raised much needed awareness of the rising global burden of low back pain. It provides evidence-based recommendations for prevention and treatment (2).

As we have seen, most low back pain is unrelated to a specific identifiable spinal abnormality, posture or an exact pathoanatomical “root cause.” This applies to most persistent non-traumatic musculoskeletal pain disorders (3). Refer to blog pain to see how it is multifactorial as well as blog chronic vs acute pain for details.

“Degenerative” structural changes in the spine as observed on MRI, are highly prevalent in pain free populations (4). These changes are often age related and do not always cause symptoms for people.

Traditionally a specific diagnosis about a root cause is about structure. It is thought that the structure is the cause of the pain. Structures in the low back are difficult to specifically targeted as the source/cause of pain. Pain can be much more multifactorial than that.

Blame has been placed on many body structures that have failed to show an association or to be the cause of lower back pain (5):

• Spine asymmetry (excessive arching; scoliosis)
• Disc degeneration, disc bulge, spondylolysis
• Hamstring or hip flexor tightness
• Foot mechanics
• Pelvic angle
• Unstable spine; weak core

There is a common belief by health care practitioners and an expectation by clients that we must know the exact pathoanatomical cause of pain. Without the diagnosis of a specific “root cause,” treatment is perceived as less specific, less beneficial, and less effective. But is it?

Consider what the late Alf Nachemson, leading spine physician, researcher and surgeon who worked in the field for a half century has said: “one of my main goals of my career has been to determine the cause of non-specific low back pain. I didn’t know the origin of low back pain in those days, and I don’t know now” (7).

In the management of these chronic pain conditions, the focus should not be on providing the “cure” to a root cause problem because there is not one. Focusing on this is not supported by best evidence and continues to delay the recovery process.

Rather, the recovery should revolve around providing an empowered self-management plan with a focus on the solution, controlling the pain and improving function and lifestyle.

Guidelines encourage active treatments, focusing on improving function and desired activities (8, 9, 10). Physical activity, education and exercise are consistently recommended as first lines of treatment.

Imaging (x-ray, MRI) should not be routinely used as part of early management, but rather reserved for patients for whom serious conditions are suspected (2).

So, what if the focus needs to be less on the problem and more on the solution?

What if the focus should be less on the structure/damage and more on improving function?

What if we focused more on health care rather than disease care?

When we change our perspective, we see opportunities instead of barriers.

Ultimately, your recovery and relief of pain depend on several factors. Understanding pain getting active again and restoring/improving function empowers you to gain freedom from pain and live your best life.

If you have been dealing with low back pain, we can help. We are here for you

At Bridging the Gap Physical Therapy, we are here for you. We offer full body evaluations and discuss your treatment plan. This includes your diagnosis, your goals, and the plan for getting you there. Find out more by speaking to our team today at 239-676-0546.

1. Hall AM, Aubrey-Bassler K, Thorne B, Maher CG. Do not routinely offer imaging for uncomplicated low back pain. BMJ 2021;372:n291.
2. Nadine E Foster, Johannes R Anema, et al. Prevention and treatment of low back pain: evidence, challenges, and promising directions. The Lancet. 2018;391(10137):2368-2383.
3. Koes BW, van Tulder MW, Thomas S. Diagnosis and treatment of low back pain. BMJ 2006;332:1430-4.
4. W. Brinjikji, P.H. Luetmer et al. Systematic literature review of imaging features of spinal degeneration in asymptomatic populations. AJNR Am J Neuroradiol 2015;36:811–16.
5. Lederman E. The fall of the postural-structural-biomechanical model in manual and physical therapies: Exemplified by lower back pain. Journal of Bodywork and Movement Therapies. 2011;15(2):131-138.
6. Maher C, Underwood M, Buchbinder R. Non-specific low back pain. Lancet. 2017 Feb 18;389(10070):736-747.
7. Lippincott W. A tribute to Alf Nachemson: The spine interview. The Back Letter. 2007;22(2).
8. Stochkendahl MJ, Kjaer P, Hartvigsen J, et al. National clinical guidelines for non-surgical treatment of patients with recent onset low back pain or lumbar radiculopathy. Eur Spine J 2018; 27: 60–75.
9. Qaseem A, Wilt TJ, McLean RM, Forciea MA, Clinical Guidelines Committee of the American College of Physicians. Noninvasive treatments for acute, subacute, and chronic low back pain: a clinical practice guideline from the American College of Physicians. Ann Intern Med 2017; 166: 514−30.
10. UK National Institute for Health and Care Excellence. Low back pain and sciatica in over 16s: assessment and management. November 2016. https://www.nice.org.uk/guidance/ng59.