Exercise For Low Back Pain

Fit girl lift weights at fitness gym center. Deadlift workout.

Any article about exercise for pain needs to cover one important fact before it goes on:

The body will tend towards self-correction/health/resolution, if, and that’s a big if, the right conditions are present.

The biggest challenge facing an osteopath, or any other therapist, is finding, or more likely, stumbling upon, the right conditions for the individual seeking help.

Whilst there are general guidelines to abide by, every one of us has a unique set of experiences, thus different stories, explanations, treatment techniques and movements are required to facilitate a recovery; not to mention all the environmental factors that come into play.

This article intends to discuss the general principles that should underpin your actions when exercising for/with low back pain.

Where Most Back Pain Exercise Programs “Go Wrong”

Most back pain exercises or exercise programs are based on the notion that pain is the result of specific factors, and that these factors can be specifically identified and then specifically addressed.

There are a variety of factors that can contribute to low back pain, but aside from a history of previous episodes of low back pain, nothing drastically stands out as being identifiable. (1)

As an aside, this perhaps points the finger at us, therapists and rehab professionals, who are not doing a good enough job in the first place (on a population, not individual level).

It is also highly important for sufferers of low back pain to understand, as many people decide to cease treatment/rehab as soon as their pain is gone, rather than concluding the full course of treatment and restoring “lost” function.

Unfortunately, it is very difficult to specifically assess and as a result, address them with targeted exercises.

So knowing that specific factors may be hard to identify and treat, it seems more important to build resilience with a complete mobility, strength and conditioning program.

Take home point number 1: exercise programs for low back pain should not attempt to be specific, but rather improve all physical qualities.

There Are No ‘Good’ And ‘Bad’ Exercises

Another misconception surrounding exercise for low back pain is the concept of ‘good’ and ‘bad’ exercises.

Generally, if you are reading a fitness article, the concept of “neutral spine” is mentioned quite a lot. Lifting should always take place with a neutral spine, regardless.

If you are reading a rehab article, limits might be imposed on external loading, as in, any lifting above 10 kg is bad, and must be avoided.

Or you might read a medical article which mentions you should simply avoid things that hurt.

All of these comments have a place, and are neither right or wrong without any context to define them.

A ‘good’ exercise is one that you can do safely, is suitable for your current ability, is able to be gradually progressed and fits in with your needs and wants (aka your goals).

Take home point number 2: blanket statements and absolutes do more harm than good. There are times when a moderate approach doesn’t work and more extreme action needs to be taken, but it is rarely either or. Exercise selection is based on your needs and wants, not an arbitrary definition of good and bad.

Self-Limiting Movements

This is a concept that was popularised by American physical therapist Gray Cook, in his book Movement.

Self limiting movements/exercises are those that have an inbuilt “coaching mechanism”, meaning doing them forces you to increase your awareness with movement, and often times with these type of movements you can only perform them correctly, or not at all.

Utilising self limiting movements as part of an exercise program for low back pain allows you to safely challenge your body and brain, leading to improvements, without the risk of overdoing it.

There are many different examples of self-limiting exercises. The specifics are not as important as being able to move with increased awareness and a low risk. This is a big focus of our exercise programming for low back pain, especially in the early stages.

Take home point number 3: a good exercise program will provide both a challenge and the option to “fail safely” – thus reducing the fear associated with facing more demanding movement challenges.

Our Approach To Programming

There is no one way to program exercise for low back pain. As long as the programming is underpinned by sound principles, and not “technique based”, then it should be sufficient.

We strive for more than sufficient, we strive for optimal.

As such, over the years our approach to exercise programming for low back pain has been refined to what it currently is. Chances are, in another 5 years it will be further refined, but the vast majority will be consistent, as it is all principle based.

First, we consider the body as a whole. We don’t only do “low back” or “core” exercises, but rather we devise a total body program. This is the underpinning principle of osteopathy, and is also applicable to exercise programming.

Second, we ensure that of physical qualities are developed in the right sequence.

If we start with osteopathic manual treatment in the consultation room, we then progress to mobility and flexibility exercises.

These will usually start on the ground, as this provides the most stable environment, thus is the least threatening.

Considering pain occurs when there is a perception of threat by the brain (if you haven’t already, have a read of Pain Basics), this is one of the best ways to regain movement and avoid inefficient compensation patterns taking over.

From there you are looking to build “motor control” – this is simply the ability to control movement well.

We can call this stability, but that implies static positions and discounts the movement component. This is actually achieved simultaneously with improving movement/mobility/flexibility.

We can consider mobility as “end range strength”, and we are simply progressively challenging you so that both qualities improve.

Once you have achieved adequate movement and control (adequate is based on your individual needs), if you want and/or need, we would add load. This might be in the form of external resistance, increased leverage challenge or even changing the tempo.

Only when you are moving competently under load do we add a conditioning component – that is, more volume of work. This is the challenge of fatigue to your new found movement abilities, and if done correctly, is the difference between breaking down when the going gets tough and being able to withstand (almost) anything.

Take home point number 4: whole body, principle based programming that utilises appropriate methods of progression yield the best long term outcomes (based on clinical experience and research) (2) for sufferers of low back pain.

Conclusions

There is a well worn quote:

Methods are many, principles are few. Methods always change but principles never do.

This served as inspiration for this post – there is no point showing you how to do an exercise with no context as to whether it is appropriate for you or not.

Rather, it is important to have an understanding of why you are doing something – even if you only care about the “what”.

This understanding means you will not chop and change based on the latest article in your newsfeed.

It means you will take the time to get things right, knowing that making progress is all the matters, even if it is “slow”.

It also means that you have a better chance at a good outcome and are less likely to become a statistic of low back pain recurrence.

Reducing the article to four sentences, we would end up with something like this:

  1. Do something you enjoy doing, that has intrinsic reward – there are no “good” or “bad” exercises.
  2. Ensure you take a “whole body” approach to exercise. Don’t simply focus on “low back exercises”.
  3. Start slowly, progress gradually.
  4. Vary the stimulus over time, but not too much or too often (or you won’t elicit adaptations).

 

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.

 



 

References

(1) Incidence and risk factors for low back pain: http://www.ncbi.nlm.nih.gov/pubmed/24462537

(2) Resistance training and low back pain in active males: http://www.ncbi.nlm.nih.gov/pubmed/20093971

Rethink Pain: Moving Beyond Muscles and Bones

Classical Anatomy

This is the first post in what will be a series about “re-thinking pain”, or rather, re-conceptualising it.

The aim of the series is to help you move from a tissue based understanding of pain to one based in neuroscience, which is more accurate and more correct (although a better term would probably be “less wrong”, as there is still so much to learn).

Why is this necessary?

  • The language we use around pain shapes the way we think about, and experience pain. Using tissue based descriptors of pain reinforces the idea of a “bottoms up” model of pain, which is wrong, and can often make things worse in the long term. Moving towards a neuroscience approach helps move away from this model.
  • Chronic pain is a massive problem in Australia (and around the world), affecting millions, costing billions and growing worse every year. Chronic pain often starts as poorly managed acute pain. One of the most important management strategies of any painful condition is education.

The Problem

To begin to understand how we have ended up with such a problem regarding pain requires tracing back through the centuries of medical and philosophical history.

In short, we used to describe pain as “coming from the tissues” up to our brains, where we felt it.

What is now understood, is that pain is a brain output, with many different “filters”, that are unique to each and every one of us, being applied before we are consciously aware of it.

Despite having this knowledge, we can see that even within the official definition of pain, the problem exists.

An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.

The definition of pain above has been put together by a group of highly intelligent people (International Association for the Study of Pain), who have spent a large portion of their lives studying pain, it’s effects and how to treat it.

Unfortunately, there is one small problem, and it has nothing to do with the definition itself, but rather, the fact that pain is “described in terms of such damage”.

When we explain all pain in terms of tissue damage we paint a picture in people’s minds. Unfortunately, when it comes to pain, this picture is not only incorrect, but harmful.

One can assume this became part of the definition because of what takes place in the real world:

  • Your back hurts, people say you have strained a ligament/joint.
  • Your knee hurts, people say it must be arthritis.
  • You have a headache, must be wear and tear of the head. No, that last one doesn’t sound quite right.

So how exactly is this harmful?

When pain is described in terms of body tissues alone and combined with the type of language typically used (words like torn, strained, scarred, degenerative) to describe tissue based pain, irreversible damage in the form of nocebo* can be caused.

This can lead you to think that something is wrong with your body that needs to be fixed, when things are in actual fact, completely normal.

Additionally, thinking in terms of body tissues leads to a mechanistic view of the body, one that wears out over time and the association of this “wear” with pain. The body is a biologic organism, one that is always adapting as best it can, it doesn’t “wear out”, but rather fails to adapt. There are lots of reasons for this failed adaptation though, it’s not just the result of “getting older”.

Check out this Facebook post on from September:

"It's probably just WEAR AND TEAR"My oh my, does that saying get tossed about. Usually, it goes something like this:…

Posted by Integrative Osteopathy on Wednesday, 30 September 2015

*Nocebo, is basically the opposite of placebo, ie causing harm when no harm has been done.

The Solution

We need to rethink pain, to conceptualise it as a dynamic process, arising in the nervous system and governed by our brains.

Yes, pain is often a result of tissue damage. However, there are many cases of severe tissue damage with no pain experienced at all and vice versa.

Additionally, the intensity of pain is very poorly correlated with the severity of any tissue damage.

Finally, when tissue damage has occurred, there are three scenarios.

  1. It is quite severe and needs medical intervention at a hospital. Think of compound fractures, 3rd degree burns, deep cuts etc.
  2. It is not severe enough to require medical intervention beyond basic first aid.
  3. It is somewhere in the middle.

In all 3 cases, with time, the body will heal as best it can.

As long as there is adequate rest, nutrition and then re-loading of the tissues in a progressive manner as governed by the condition and individual requirements, you’ll get as full a recovery as possible.

So initially, once the need for medical intervention is ruled out, the important thing to do is treat the pain.

This goes against almost all manual therapy and allied health advertising to “treat the cause of your symptoms”.

Alleviating pain will, in many cases, sort out a lot of associated “findings”, the so called causes of your pain, and then beyond that, allow your body to heal.

If you came to us for treatment, here’s how we might do that:

  • Explain all of this information about pain, in a way that makes sense to you, so that you aren’t as stressed or anxious about it anymore.
  • Have a look at you stand and move and suggest ways that might make standing and moving less painful.
  • Get hands on and apply some really pleasurable manual techniques. There is no need to dig in deep for the sake of it. The goal isn’t to change the tissue, it’s to change the perception and get the brain releasing pain relieving chemicals.
  • Do some breathing techniques to help you relax. You’d be surprised at how poorly most people breathe, even when they are concentrating on doing it properly.

All of these techniques are based on the same principle – once the threat is reduced to an acceptable level, the brain will stop protective behaviours, which include pain and altered movement.

So to summarise a blog post in a sentence:

Pain is all about threat perception, it doesn’t mean damage and body tissues can’t produce pain, only the nervous system can**, so we must focus on the nervous system, including the brain, when describing and treating pain, so as to not cause further complications via nocebo.

 

 

**Yes, the nervous system is a body tissue, but for the sake of the argument we are using simple language.

 

This blog post was written by Dr Nick Efthimiou (Osteopath), founder of Integrative Osteopathy.

Integrative Osteopathy is an osteopathic practice located in the heart of Fitzroy North, within the reputable Healthy Fit gym. For all inquiries, call 0448 052 754, or to make an appointment online, click here.

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.

 

Pain Is A Verb, Not A Noun

Brain
When you seek treatment for pain, part of that process should be a thorough education about pain.

This education should cover the basics:

So that you understand the physiological process, at least at a basic level.

Many people think pain is only a marker of tissue damage. It’s not. It is a multi-factorial sensory and emotional experience.

To help people change their understanding of pain, I like to describe pain as a verb, not a noun.

For those of you who can’t remember primary school English (or never learnt it in the first place):

  • Verb = doing word
  • Noun = thing

Thinking about pain as something you experience, instead of something you have is empowering.

It gives you an active role in your pain experience. This means you can influence your experience, for better and worse

How? With your thoughts, feelings and actions.

Pain Is A Body and Brain Experience

All pain has three major components:

  1. Physical
  2. Cognitive (thoughts)
  3. Emotional

The relative contribution of each component varies.

Often we can determine which factor is likely to be the primary driver of each pain experience, but we can’t measure by how much.

Even though were aren’t always aware of each component, they are always there.

If the primary driver of your pain is physical, then physical treatment approaches tend to work best.

This is the same for psycho-emotional pain, which response best to psycho-emotional treatments.

Kind of obvious yeah?

Where it gets tricky, is that even physical approaches have cognitive and emotional aspects.

There is no separation.

Get Involved In Your Treatment

The best outcomes in pain treatment occur when you and your practitioner are working together.

This maximises the effects of treatment.

The more effective your treatment, the faster your resolution of pain. Again, kind of obvious yeah?

You are probably more involved in your treatment than you think.

First, you chose your practitioner (hopefully). The act of choosing is both psychological and emotional. You want to choose someone who is good at what they do, and who you like.

Second, you are probably already doing things to help your recovery. They may or may not be the best things, but you’re already changing your behaviour.

A good practitioner will point you in the right direction of what change is best, but you’ve made a start.

How To Change Your Pain Experience

Our mental and emotional state influences our perception.

Think about watching a movie. If you are on a first date, it’s a very different experience to watching the same movie with your long term partner after you’ve had a fight.

Same stimulus, different psycho-emotional status and thus different perception/response.

This principle can be applied to factors affecting pain:

  • Take control of your emotions. First, identify your thoughts and emotions around pain. Commonly these include fear, anxiety, overwhelm and frustration, among others. Then you can change them. A good practitioner will help you with this.
  • Improving your stress management. Stress is dictated by the way we frame an experience. Any event has the potential to be stressful. By learning to change your framing of stressful scenarios, you can minimise your stress load.
  • Change your environment. Our environments shape us, for better and worse. Sometimes, as hard as it is, the best thing you can do for your pain is change or leave aggravating environments.

Conclusions

It might be strange to consider pain as a verb, not a noun. But as I outlined, it can make a massive difference to both your pain and suffering.

Taking a different view on things is the first step to changing your outcomes.

And while different views can be quite confronting, it is the only way to grow.

Hopefully, this growth means improving or eliminating your pain.
Nick Efthimiou Osteopath

 

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.

 


 

 

Exercise For Fibromyalgia

 

Couple walking on the beachFibromyalgia is a common and debilitating condition.

It affects around 2-5% of the population. (1)

It is under-diagnosed, because of the vagueness of many of the symptoms. For those who do get a correct diagnosis, it can take years.

Fibryomyalgia was originally though of as a rheumatic (joint) condition.

Now, research has shown it is mainly a problem with the central nervous system (the brain and spinal cord).

Due to the lack of understanding of the condition, there aren’t many treatments that provide good, long term, results.

Currently, the best treatments for fibromyalgia are (2):

  • Exercise
  • Stress management and relaxation techniques
  • Cognitive behavioural therapy
  • Manual and physical therapies
  • Certain medications

The Benefits of Exercise for Fibromyalgia

Of the treatments above, exercise is low cost, available to all and has minimal side effects. This makes it an excellent primary management strategy for chronic pain.

Exercise has the potential to improve fibromyalgia. It works by a combination of both specific and non-specific effects.

Some of those effects are:

Decreased Pain

We don’t know exactly how exercise helps pain. We do know there are probably a few different effects involved.

One of the main ones is descending modulation. This occurs when the brain secretes natural pain relieving chemicals. Commonly known as endorphins, they target different nerve receptors, inhibiting potentially painful messages.

 Improved Cellular Energy Production

Suffers of fibromyalgia often report increased fatigue. To make matters worse, many have difficulty getting restful sleep.

Exercise can help increase mitochondrial density (3). Mitochondria are the cellular power plants. They convert glucose into ATP, which cells use to fuel their activity.

In theory, increasing mitochondrial density should improve cellular energy production.

In practice it’s kind of like installing a bigger engine in your car. It has the potential to make it go faster, but everything else need to work well too.

Better Hormonal Balance

Regular exercise improves hormonal balance. It decreases catabolic stress hormones and increases anabolic sex hormones.

This balance is thrown off in people with fibromyalgia.

Better hormone balance leads to a more positive psychological state, improved emotions and healthier physiology.

It’s not hard to see how this could benefit a chronic pain condition like fibromyalgia.

Stimulates the Lymphatic System

Many people are aware that exercise improves blood flow. But, few know that exercise also improves function of the lymphatic system.

The lymphatic system is the body’s “waste management system”. It has a network of vessels all around the body, like arteries and veins. These vessels remove cellular and immune system “waste” from the local area.

When you are sick, your lymphatic system becomes more active, and you can often feel your lymph nodes.

Of interest to fibromyalgia sufferers, the brain, hormonal and immune systems are connected. One of the ways they communicate during an immune response is via the sympathetic nervous system (SNS). (4)

It’s a complex relationship, but the stress hormones can both improve or inhibit immune functions.

With fibromyalgia, one of the mechanisms involved is an overactive SNS.

By stimulating the lymphatic system, we can influence the SNS. However, we have to do it in a way that does not cause a flare up.

How To Exercise With Fibromyalgia

Exercise with fibromyalgia is often challenging for two main reasons:

1. Pain (both during and/or after)

Pain is an obvious barrier to exercise for someone with a chronic pain condition. Sometimes though, you need to endure the early pain to get a bigger benefit in the long term.

To deal with this, research on chronic pain suggests a pacing approach. Pacing means doing a little at a time, within your limits, and increasing that amount at a gradual pace.

A good exercise program for fibromyalgia should have pacing built in. It will also have a “plan B” for those days when you feel terrible, and don’t want to do anything, but know you should.

2. Fatigue

Fatigue is the second big issue associated with fibromyalgia.

As mentioned, exercise can potentially help reduce fatigue in the long term.

In the short term, focus on pacing during exercise. In pain management terms, pacing is where you work within yourself and gradually increase the amount over time.

Then afterwards, look to enhance your recovery as much as possible to help minimise accumulated fatigue.

If you avoid common exercise mistakes, you can get the benefits of exercise for fibromyalgia whilst minimising flare ups.

What Type of Exercise Is Best?

There are many types of exercise, which can be organised into 4 broad categories: flexibility training, motor control/skill training, cardiovascular/endurance training and strength/power training.

Each of these has potential benefits for sufferers of fibromyalgia, but overall, there is no clear consensus on which is best, so it is safe to say that the best exercise is the type that gets done and is enjoyable, while producing the least negative effects.

Cardiovascular Exercise

Cardiovascular exercise is a great place to start with fibromyalgia. The majority of research looking at exercise for fibromyalgia has studied various forms of cardiovascular exercise.

One of the downsides of cardiovascular exercise is the potential fatigue it creates. That can be minimised with careful planning and paying attention to biofeedback during and after sessions.

This allows appropriate scaling of volume and intensity, as well as an optimal rate of progression.

The beauty of cardiovascular exercise is that there are a variety of ways to perform it.

Some include:

  • Walking
  • Running
  • Cycling
  • Swimming
  • Rowing
  • Elliptical machines
  • Skipping
  • Rebounding

Remember, always start well within yourself, and progress slowly. It takes patience, but it is the best way to avoid flare ups.

Resistance Training

Resistance training offers complementary benefits for fibromyalgia. Increased strength helps to maintain function throughout your life.

Resistance training is also very scalable, making a pacing approach easy to implement.

Recent (2017) research showed that strength training is both safe and effective for people with fibromyalgia.

Strength training is safe and effective in treating people with fibromyalgia, and a significant decrease in sleep disturbances occurs after 8 wks of intervention.

Strength training can be performed at home, with body weight exercises or using home based equipment, in a gym or at a clinic. There are many forms of strength training, but the principles are the same: progressively load the muscles with increasing resistance over time.

Flexibility Training

Flexibility training is another good option for suffers of fibromyalgia.

It has a myriad of benefits, most relevant to fibromyalgia are decreased stress and increased cellular energy production.

Stretching is requires no equipment and can be performed anywhere, at any time, to varying intensities. This makes it a fantastic intervention for people with limited access to transport or those who live in unsafe environments which prohibits outdoor activity (extreme weather, crime etc).

Conclusions

A good approach, depending on your personal preferences, would be to incorporate a variety of exercise activities. This gives you benefits in multiple areas of health and function, increases enjoyment (variety) and minimises potential overloading issues.

The most important factor, is to apply pacing principles to your chosen activity.

If you do that, with activities that you enjoy, you can’t go wrong. While you may have the occasional flare ups, over the long term, the benefits are much greater.

 

 

Nick Efthimiou Osteopath

 

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.

 

 


 

 

 References

(1) RACGP – Fibromyalgia

(2) Fibromyalgia – Treatments and Drugs

(3) Exercise and mitochondria

(4) The Sympathetic Nerve – an integrative interface between two supersystems: the brain and the immune system

(5) What Is the Effect of Strength Training on Pain and Sleep in Patients With Fibromyalgia?

Osteopathy For Low Back Pain

Low Back Pain

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.

  1. Assess – basically, we want to work out what you can and can’t do.
  2. Educate and empower – I want you to know what’s going on, and what we can do about it
  3. Alleviate pain and discomfort – this goes without saying
  4. Restore function – absence of pain is not function
  5. 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:

  1. Acute low back pain with no lower extremity symptoms
  2. Acute low back pain with lower extremity symptoms
  3. Chronic low back pain with no lower extremity symptoms
  4. Chronic low back pain with lower extremity symptoms

 

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.

A process based approach to recovery, Eyal Lederman, PhD.

A process based approach to recovery, Eyal Lederman, PhD.

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.

Stress Response

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

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)

Effectiveness

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)

Conclusions

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.

 



 

References

1) Incidence of adult LBP

2) Incidence of adolscent LBP

3) Prognosis of LBP

4) Osteopathy and ANS

5) Cutaneous regulation of motor control

6) Neuronal control of circulation

7) Neuronal control of skin function

8) Review of osteopathy and low back pain 1

9) Review of osteopathy and low back pain 2

10) Review of osteopathy and low back pain 3

11) Adverse events in manual therapy