Low back pain is extremely prevalent across society (1,2), and one of the most common reasons people consult with an osteopath in Australia.
Unfortunately, whilst there are many published suggestions that low back pain is self-limiting, often this is just a repeated cycle of aggravation and remission (3), and thus professional management is required.
The good news is, that with appropriate management, there is a good prognosis for both the short and long term.
Most manual therapists like to say they “treat the cause and not the symptoms” of low back pain. Unfortunately, we know low back seldom has a singular cause.
My way around this is to use a modifiable system, in order to address the main factors involved with low back pain.
- Assess – basically, we want to work out what you can and can’t do.
- Educate and empower – I want you to know what’s going on, and what we can do about it
- Alleviate pain and discomfort – this goes without saying
- Restore function – absence of pain is not function
- Build resilience – mentally and physically, so it doesn’t happen again
This approach to treatment is further tailored to each individual based on their risk profile, personality and individual preferences.
This means, that you get the benefits of a systematic approach, ensuring your outcomes are more predictable and that nothing is missed along the way, combined with the individualisation of care, making your treatment, your treatment.
Types of Low Back Pain
Simply put, we can group low back pain into 4 main types:
- Acute low back pain with no lower extremity symptoms
- Acute low back pain with lower extremity symptoms
- Chronic low back pain with no lower extremity symptoms
- Chronic low back pain with lower extremity symptoms
— Nick Efthimiou (@NickEfthimiou) October 22, 2016
No matter what the tissue diagnosis is, these 4 groups of low back pain typically behave and respond in similar ways.
So, instead of getting caught up in whether you have a disc injury, a muscle strain or joint sprain, focus on which group you are in, and what stage of recovery you are at.
Then, you can focus your treatment on enhancing that stage of recovery.
We can do this, because we know that each aspect of low back pain has generalised features that occur as part of the pain response.
General Features of Low Back Pain
The general features of low back pain are, more accurately, general features of pain, as to an extent, they occcur with the majority of different musculoskeletal pain.
Pain is part of a threat response system.
Our nervous system is highly evolved, albeit sensitive, and pain is designed to alert us to possible danger.
When we experience pain, we also experience an increase in sympathetic nervous system (fight/flight) activity.
Some of the effects are elevation of stress hormones, an increase in heart rate, decreased visceral blood flow and “narrowed” thinking.
This stress response is important in the short term, as it allows us to “get to safety”. In the long term, it is an impediment to healing.
Osteopathy, in the form of a generalised whole body treatment can stimulate the parasympathetic nervous system (rest and recover), alleviating the stress response and accelerating recovery. (4)
Changes To Local Muscle Tone
As part of the threat response, our brains increase the tone of certain muscles, as a protective measure.
The increased tone of our muscles is the way our brains “brace” the area.
Unfortunately, beyond the very early stages of the pain response, this increased tone will often inhibit movement, which is actually helpful to the recovery process.
Osteopathic treatment can change this tone by affecting neural receptors in the skin, muscles, tendons and joints.
Impaired Motor Control, aka, You Can’t Move Normally
Nociception is the transmission of “danger” signals from peripheral nerves, called nociceptors.
Fast acting or slow conducting nociceptors transmit to the spinal cord. This is the primary driver of pain in the majority of cases.
Nociception affects motor control. Have you ever stepped on something sharp? I bet that your normal walk was altered, for at least a few steps.
Additionally, pain affects our accessory joint motion. This is the movement which is necessary for normal range of motion, but is not under voluntary control – for example: joint rolling and sliding. It allows us to move smoothly, and when it is lost, we lose that ability.
Osteopathy can inhibit nociception, thus allowing better freedom of movement. (5)
Impaired Fluid Dynamics
Deoxygenated blood and lymph (waste product fluid) moves passively, driven by muscular contraction and movement.
For reasons mentioned above, when we are in pain, we cannot move or contract/relax our muscles efficiently, which leads to fluid stasis. Coupled with blood vessel constriction resulting from an increased stress response (6), and we have a situation where there is poor clearance of metabolic and inflammatory waste products.
There are many osteopathic techniques designed to stimulate the lymphatic system and facilitate the circulatory system – enhancing the clearance of these waste products.
Specific Features of Low Back Pain
Mechanical strain occurs when nerves in the low back are tensioned beyond their tolerance.
Mechanical low back pain is often described in terms of joints, ligaments and muscles, and whilst these tissues can be strained, it is the deformation of nerve tissue that is responsible for pain – muscles and joints don’t sense, nerves do!
Nerve tissue is highly sensitive, and it’s role is protective, so often we will experience pain without any major strain to other tissues, which is very typical of low back pain.
This type of pain is characterised by an aggravation, or relief with certain movements and positions. As a result, using manual techniques designed to facilitate movement and resolve the strain pattern, most mechanical low back pain responds well to osteopathic treatment.
Generally it is advised to continue moving as normally as possible during the recovery process.
Treatment of mechanical low back pain should also include a graded movement approach, to restore function, so that you can return to doing the activities that make up your life. You should also increase the loading of the tissues, to build resilience, so it doesn’t happen again.
Inflammatory Low Back Pain
Inflammation is a normal immune response, involved in the process tissue repair.
When we experience trauma to body tissues, there is a local inflammatory response. The trauma can be overt – fall, lifting, contact injury or repetitive – work related, sport related.
When inflammation affects the dorsal root ganglion, a collection of sensory nerve bodies near the spinal cord, then we experience pain.
Inflammatory low back pain is characterised by presence in a wide variety of positions. There is often an overlap between mechanical and inflammatory low back pain, the issue is finding the dominant factor and addressing that primarily.
The common recommendation for inflammatory low back pain is to use NSAIDs (anti-inflammatory medication). This can help in the short term, but there are side effects, which include the inhibition of certain factors required for the remodeling of the tissues. NSAID use should be determined on an individual basis by your healthcare practitioner, with a full discussion of the risks and benefits.
Rest, or more accurately, avoiding aggravating activities can help with short term relief.
Osteopathy can help with inflammatory low back pain in a few ways. Addressing the strain patterns that caused the initial tissue trauma and thus inflammation, enhancing immune response and affecting local circulation. (7)
So far we have outlined the general and specific features of low back pain and how osteopathy can help. However, the question still remains, does osteopathy work for low back pain?
To be perfectly honest, this is one of the hardest questions to answer.
Research Says Maybe
In research, individual studies are performed, and then studies that investigate similar things are reviewed to see if there is a consistent outcome.
There have been 3 notable reviews of osteopathic management of low back pain.
The results show low to moderate effects. (8,9,10) This is generally positive, but not unequivocal.
However, there isn’t any treatment for low back pain that is (unequivocal).
What does this mean to you?
Well really, low back pain is quite individual, studies and reviews take averages, thus discarding the individual differences in response to a certain effect.
For example, if you took a room full of 10 men and 10 women, the average number of ovaries per person is 1.
Research can be like this, a few people can respond really well, and a few really poorly, and thus the average effect is unremarkable, though for the people whom it worked really well, this is not reflective of their experience.
Is It Safe?
Whilst there are risks involved with osteopathy, there is a sparcity of evidence directly studying osteopathy, so we must draw on broader manual therapies, which show mild side effects (short term soreness) are pretty common (40-50% of people experience this) and serious adverse effects (disc herniation, cauda equina syndrome) range from 1:~38,000 to 1:3.7-100,000,000 respectively. (11)
Those who do not seek appropriate management for their low back pain initially tend to experience more frequent bouts, for longer.
Osteopathy is relatively low risk, and there is supporting evidence for the treatment of low back pain using manual therapy and exercise/rehabilitation.
Usually you should see improvement within the first 2-4 visits, however, osteopathy, like anything worthwhile, takes time.
One of the biggest issues I see is people who don’t complete a course of treatment.
Thus, they improve, but they do not completely resolve – some of the protective behaviours are still present.
In order to prevent this, the use of outcome measures (functional tasks, movement assessments and psychological screening) enable us to detect change beyond “it doesn’t hurt anymore”.
In most circumstances, a pain free period of at least 3 consecutive months, in addition to positive changes on outcome measures would be deemed a resolution.
This blog post was written by Dr Nick Efthimiou (Osteopath), founder of Integrative Osteopathy.
This blog post is meant as an educational tool only. It is not a replacement for medical advice from a qualified and registered health professional.