How We Treat Low Back Pain, and Why:
Low back pain is currently my (Chad’s) favorite diagnosis to treat. As JFK would say, “not because it is easy, but because it is hard.” I have been practicing physical therapy since 1999 and have to admit that I always hated low back pain. With my background in strength and conditioning, I knew how to get people strong and I knew what exercises were best to strengthen hip and core musculature. In doing so, a lot of my patients with back pain got better, but a lot still didn’t and the improvements were sometimes slower than I would like. At the time I did all the traditional physical therapy modalities that I learned about in school and my patients would sometimes better after I gave them a massage/myofascial release/trigger point therapy/cold pack/hot pack/ultrasound/TENS etc. However, often as soon as they got up from the table, or by the time they returned to therapy the next visit, they would be back where they started.
I learned in PT school about William’s stretching exercises, stretching the spine into flexion (bending the spine forward) to treat back pain if extension (bending the spine backward) bothered the patient, or McKenzie extension stretches if flexion bothered them. However, as often as not, my patients with back pain had increased pain with both flexion and extension, and sometimes side bending and rotation as well. Neutral (in the middle), was generally where they felt best.
There were some studies coming out at the time with regard to therapeutic exercise for spine stabilization, but they were finding that spine stabilization didn’t do a better job than just general exercise; or so the study titles and abstracts/summaries would have you believe. Often when talking about spine stabilization exercises, therapists and researchers were referring to isolating the transverse abdominus and multifidus muscles, which later was shown to be an inferior way of stabilizing the spine to begin with; so no wonder they didn’t work. As such, scientifically back pain was still a big mystery, for which the research tended to indicate that nothing really worked that well, whether it be exercise, stretching, spinal manipulation, mobilizations, or modalities. It was to the point where some back specialists had all but given up on treating low back pain as a biological or mechanical issue and started thinking of it in more psychological terms, hence the development biopsychosocial model of low back pain. However, when adopted, it didn’t show improvements in low back pain outcomes either.
Somewhere around 2007, I read an MSN entry for back pain myths and I clicked on it thinking that it might be good for a laugh. On the contrary, it turned out to be written by Stuart McGill, a biomechanics researcher out of the University of Waterloo, where all he does is research low back pain. I was already familiar with McGill, as I had read some of his research regarding low back stress with squats and deadlifts in powerlifters back in the 90’s, and I remember thinking it was good material. His myths jived with my experience that stretching the spine in any direction hardly ever helped and frequently only increased pain. He had just written a book Low Back Disorders: Second Edition, which I immediately ordered and read. I later read his other book Ultimate Back Fitness and Performance: Third Edition, watched his DVD’s, and later attended his seminar when he was in Phoenix.
I found that his concepts were well researched, he was doing ongoing research on his own, and had a sound rationale as to why he did everything else. His books summarized relevant research regarding treating low back pain, as well as his laboratory’s own experiments regarding what stresses damage the spine, and what exercises did the most most increase back fitness levels while putting minimal stress on damaged/painful tissues in the spine.
A number of McGill’s exercises were similar to ones I liked with regards to strengthening exercises. Also, I adopted his “Big Three” exercises; curl ups, bird dogs, and side bridges (generally I use the modified side bridge) for core endurance, as they can be done at home without equipment. He was a big proponent of improving spine and hip motor control to lessen stresses during dynamic activities. I think that integrating this information into my strength and conditioning programs probably improved my outcomes 100%.
Below is a video of one of our patients going through a typical day’s exercises, for our Basic Low Back Pain Program, that are spoken about in the “Our Approach” section of this website. Exercise protocol changes dependent upon the extent of injury.
Most people don’t need any stretches in spine flexion, but rather total body fitness; perhaps some stretching/mobility around the peripheral joints (hips and shoulders), and motor control/postural awareness to maintain a neutral and pain-free spine position during work, play, and rest.
For conservative treatment of low back pain, I think the best course of action is to:
1. Increase strength and endurance of the core muscles while keeping the spine neutral/in its most pain-free position.
If patients’ spine extensors are strong enough to hold their spines neutral during daily activities, that would take pressure of the anterior vertebral bodies, which is increased primarily due to spine flexion. Based on this, and a lot of other spine research, I would think it’s prudent to do abdominal exercises (performed with the spine neutral and perhaps with a bias into extension), as well as hip and lower extremity strength exercises. These exercises make it easier for those with osteoporosis to lift with their legs as opposed to their backs; not to mention that those with osteoporosis need the weight bearing through their hips to increase bone mineral density there and lessen the risk of hip fractures.
The total body approach is best because a strong core does the back little good if the arms and legs are not strong as well. It’s not easy to bend over and pick up something heavy with a neutral spine if your legs and arms are not strong also. A strong core that does most of the lifting by flexing and extending the spine, rather than flexing and extending the hips still often hurts.
2. Strengthen hip and leg muscles while keeping the spine neutral.
Train one leg at a time so you know exactly how much catching up your weaker side has to do. I think it very prudent to include all around hip extensor strengthening with hip abduction exercises and my favorites for hip extensors being Romanian Deadlifts (RDLs).
Check out my blog to read more about Back-Extensor Strengthening.
3. Look at static sitting postures during the day.
Static posture is an important factor that McKenzie does address in his books; though in my opinion his recommended lumbar supports are on the extreme side, resulting in an extended rather than a neutral spine. The lumbar supports can be as simple as a couple throw pillows on a couch, perhaps adding a thin lumbar support to your car seat (but not so much as to push your spine into extension beyond neutral), and adjusting the seat position so it’s close enough and upright enough so that when your shoulders are back in the seat you can still rest your wrist over the top of the steering wheel. For cyclists, I would maybe suggest a higher handlebar position, or to keep your elbows extended.
Check out my blog to read more about Decreasing Low Back Pain While Driving.
4. Improve motor control, with regards to how one’s spine is moving during dynamic activities.
I would advise maintaining a neutral spine during dynamic activities; such that you bend over using your hips rather than at your waist/lumbar spine, and twist and rotate with your legs rather than through your waist/lumbar spine. When providing physical therapy treatment for low back or neck pain, it’s worth taking a look at car or truck seat position to make adjustments to decrease stress on the spine. I think spine awareness during activity is best taught through various resistance exercises, so it also has the benefit of increasing general strength and endurance.
5. Perhaps some conservatively prescribed stretches.
I do think some stretching has it’s place, but it should not be a foundation of one’s exercise program. People fall and break hips because they are not strong enough to prevent the fall. Generally nothing bad happens if you can’t bend over and touch your toes; plus the posterior direction of herniation in peoples’ discs indicates that they bend forward too much as is, and don’t need any special stretches in the same direction. Unfortunately, many physical therapy clinics base their lumbar rehabilitation programs on traditional wisdom and start their patients with supine knees to the chest stretches (which is only more spine flexion) and posterior pelvic tilts (which are also more spine flexion), which is probably not the best thing to do. As they say, traditional wisdom is often long on tradition and short on wisdom.
Hamstring stretches likely wouldn’t have any effect if you have a straight leg raise of at least 60 degrees anyway. For what it is worth, I will sometimes have a patient do static stretch for maybe 10 minutes in prone on elbows at most. In a McGill study, they tested repeated McKenzie type extension stretches on injured pig spines and found they did in fact reverse the posterior migration of the discs about half the time, and they tended to do so when the 60% of the disc height was retained. However, if the discs were damaged to such a degree that less than 60% of disc height remained, then the McKenzie type stretches were ineffective at reversing the posterior migration of the disc nucleus.
I think I mentioned in one of my blogs that I spoke with Stuart McGill by email after reading his study showing that repeated extension stretches sometimes helped reverse posterior disc nucleus migration. I asked him if that meant he was advocating those stretches, and he said no because he thought repeated end range extension stretches might lead to facet joint irritation/arthritis. Instead, he advocated just laying prone propped up on one’s elbows at most and holding that position static for 10-15 minutes (as opposed to the McKenzie floppy push-up where you repeatedly extend all the way up on outstretched arms). This way, you would hopefully get the benefits of extension with regard to the discs without the repeated facet joint trauma. If I recall correctly, he said he was currently collecting data to see if this lessened back pain but didn’t have results yet. He said he would certainly have patients discontinue the exercise immediately if there was any increase in pain resulting from it.
How We DON’T Treat Low Back Pain, and Why:
Why We Don’t Do Williams Flexion Stretches
Once you remove any placebo and gate-control effects of flexion stretches on pain, you are left with a motion that causes posterior displacement of nucleus material in the lumbar disc and stretch/creep to passive ligaments that are supposed to control spine motion; thus flexion stretches over time decrease spine stability, increasing long term pain and disability. The spine in full flexion, is known to be a position that contributes to lumbar disc bulges and herniations. Once you start losing vertebral disk height due to the herniations, the facet joints impact each other sooner and harder often becoming arthritic.
For example, if one already has a collapsed disk at L5-S1 causing facet joint approximation and arthritis at that level, we would expect to see worsened symptoms with back extension. Flexion stretching in this case might unload the irritated facet joint and provide short term relief, but would be putting the discs above (T12 and L1-L4) at risk for flexion-related injury.
Check out my blog to read more about Cyclic and Static Spine Flexion.
Flexion Stretches and Osteoporosis/ Osteopenia
There was a study conducted in 2013 specifically intended to raise awareness of the effect of strenuous yoga flexion exercises on osteopenic or osteoporotic spines. It was concluded that the development of pain and complications with some flexion yoga positions in the patients with osteopenia leads to concern that fracture risk would increase even further in osteoporosis. This finding suggests that factors other than bone mass should be considered for exercise counseling in patients with bone loss.
The author noted he had seen but not reported other compression fractures in women with yoga flexion stretches before and said they were considered incidental until other yoga related vertebral fractures were reported, at which point he decided to do this paper. With a lot of vertebral compression fractures going unreported, I expect the incidence is greater than this paper suggests. Despite that, the author did a good job of defining which yoga stretches are the problematic ones, which of those in which the person flexes their back or neck as they bend forward to touch the floor/their feet, or which of those that flex their neck as they bring their chin forward towards their chest. These flexion stretches mimic the direction that causes lumbar discs to herniate. Also worth noting is that extension strengthening, contrary to flexion stretching, has been shown to be protective against vertebral compression fractures and squats with accelerating progressive resistance has been shown to increase both hip and lumbar bone mineral density.
The right exercises are good, the wrong exercises are bad, and physical therapists need to differentiate what exercises are going into their programs to maximize rewards and minimize risks.
Check out my blog to read more about Vertebral Fractures after Yoga in Women with Osteopenia.
Why We Don’t Do Aggressive McKenzie Extension Stretches/McKenzie Method
In his books, McKenzie likes to use the example of having a person hold their finger backwards at end range until it starts to hurt, as analogous to what goes on in the discs during spine flexion, and that if you remove the stress on the finger and bend it the other way the pain goes away. I think that problem with this is that McKenzie goes too far the other way.
The solution to pain injury in flexion is not hyperextension but just eliminating the flexion and returning the joint to a more neutral position. A better method in this example (and in most cases of low back pain) would be teaching the patient to avoid both extremes in flexion and extension. This works with both the finger and low back. I would not cure the finger joint pain from prolonged extension by bending it the other way as far as possible and holding it there, rather I would just remove the stress. This would serve two roles: lessening stress and pain on the posterior facet joints, while also preventing further degeneration of the remaining vertebral discs. In my experience, the McKenzie stretches are as likely as not to cause more pain, rather than relief in the short term, and with regards to low back pain I don’t for a second believe that you have to go through short term pain for long term relief. Research has backed up my observations, as a meta-analysis of McKenzie method of treatment found it absent of clinically worthwhile effects and generally no more effective than advice to just stay active.
Check out my blog to read more about the McKenzie Method and Back Pain.
Why We Don’t Do Spine Rotation Stretches
While spine flexion stretches have been shown to cause posterior disc bulges and herniations, prolonged and repeated rotation stretches have also been shown to increase low back pain. Excessive lumbar spine rotation has also been shown cause delamination of the annulus layers in the intervertebral disks. That delamination combined with spine flexion has been shown to increase speed of herniation over that of flexion alone. So if you have had physical therapy in the past where you were encouraged to lay on your back and stretch your knees to your chest (spine flexion) followed by bending your knees from side to side (spine rotation), your therapist couldn’t have gotten things more wrong if they tried.
Check out my blog to read more about Spine Rotation Stretches and Low Back Pain.
Why We Do EMS Instead of TENS
Studies that have compared EMS (parameters designed to increase muscle strength) with TENS (parameters designed to decrease pain) show that the EMS parameters do more to decrease pain. TENS works by gate control theory and is more effective with increased intensity, while EMS, which by nature is more intense than most recommended TENS parameters, should work better. Additionally, these parameters allow for strengthening to occur simultaneously with pain relief.
I think the most intense core strength exercise is done with electric muscle stimulation, which if done properly not only increases muscle strength better than you can with curl ups or planks, but also does a real good job of acutely reducing back pain. I get a lot of results with short term pain reduction and strengthening of the core muscles by using EMS if it is too painful to do regular core exercises. Usually though, I have my patients do both EMS and exercises. Squats and deadlifts, if performed keeping the spine neutral, are two of my favorite spine stabilization exercises. If tolerated, I do think front and side planks/bridges are still a good exercise.
Check out my blog to read more about Why Chad uses EMS instead of TENS.
Why We Don’t Recommend Kinesio Taping
Kinesio Tape is that colorful tape you see applied to people’s body parts, often in fancy patterns, with an intent to make them heal better. In a systematic review of randomized trials to test the effectiveness of Kinesio Taping of patients with musculoskeletal conditions, results showed that Kinesio Taping was no better than sham taping/placebo in active comparison groups. In all comparisons where Kinesio Taping was better than an active or a sham control group, the effect sizes were small and probably not clinically significant or the trials were of low quality. The current evidence does not support the use of this intervention in these clinical populations.
It doesn’t surprise me in the least however that researchers are now concluding that it has no clinical benefit. Kinesio tape has been around for years, and this paper says it was first created by a Japanese chiropractor in the 1970s. I noticed it really got popular in and after the 2012 Summer Olympics, where Kinesio Tape was prominently displayed on a number of beach volleyball players. And sure enough, a quote from this paper states: “It seems that the growing use of Kinesio Taping is due to massive marketing campaigns (such as the ones used during the London 2012 Olympic Games) rather than high-quality, scientific evidence with clinically relevant outcomes.” So in other words, Kinesio Tape is popular because of good marketing and poor researchers. I think another problem is just a lack of critical thinking skills on the part of medical practitioners (which sadly includes a lot of physical therapists) who should know better.
Check out my blog to read more about Kinesio Taping
Why We Don’t Recommend Injections
Injections are hit or miss, but when they work sometimes they work really well and can give enough pain relief that the right exercises will be tolerated. If the nerve is too compressed, surgery might be necessary; afterwards all the exercises, motor control, and postural adjustments would be imperative to prevent problems up the spine at the next couple levels.
X-rays are relatively inexpensive and don’t sound unreasonable, but MRIs for low back pain show a lot of false positives (spine abnormalities shown in otherwise normal subjects without pain). MRIs haven’t been shown to provide information that positively influences outcomes.
Why We Don’t Do Spinal Manipulation
Spinal motion can not be reliably felt or tested for by palpation; more training doesn’t help, and even if it did it still doesn’t matter because spinal manipulation can not target a specific joint anyway. In fact, cracking the back using a technique opposite of what proponents think they need to correct perceived joint dysfunction “works” just as well. In a study reviewed on my blog, it was seen that poor to fair inter-rater reliability for spinal mobility testing has been observed (van et al., 2005; Seffinger et al., 2004) and these findings are not improved with training, experience, or discipline (Seffinger et al., 2004; Billis et al., 2003). Additionally, the traditional clinical decision making approach necessitates the correction of a specific dysfunction with a specific technique; however SMT is not specific to a given segment (Kulig et al., 2004; Lee and Evans, 1997). It was actually seen that collectively, these studies suggest a general biomechanical effect of SMT as opposed to an effect specific to a targeted segment.
Patients were more likely to respond favorably to spinal manipulation if they had the following five characteristics:
- Pain duration of less than 16 days
- Fear avoidance beliefs work subscale score of less than 19
- Hip internal rotation on one side of at least 35 degrees
- Lumbar spine hypomobility
- Pain not extending below the knee
That being, the positive benefits you all see with spinal manipulation is in your head, and/or it’s in your patient’s head. It’s placebo effect, barely propped up by poorly controlled studies and likely a fair degree of publication bias. Patient expectations are likely a factor, and it’s lot easier to sell a patient on ideas that make sense rather than some nebulous general effect.
Check out my blog to read more about Spinal Manipulation and Manipulation and Mobilization for Chronic Lower Back Pain
A report from the twelfth international forum for primary care research on low back pain states “Although there is good evidence for the role of biological, psychological, and social factors in the etiology and prognosis of back pain, synthesis of the three in research and clinical practice has been suboptimal.” This paper was my first introduction to the “biopsychosocial” model of low back pain that was started with Gordon Waddell’s, 1987 paper. I actually thought Gordon’s paper was great for the time, and when I read it I recall having few initial objections. However, it seems to me that his concept has been taken too far– with followers who want to overemphasize psychological components of pain having to ignore a great deal of subsequent physiological findings with regards to the causes of spinal degeneration, how those causes can be avoided and what exercises do in fact stabilize the spine. Subsequently, a large number of practitioners are treating low back pain primarily as a psychological issue, and telling them to continue to work with little in the way of tools to help them avoid further pain. Now after 25 years of doing so, they are having to deal with the fact that their hypothesis (though containing degrees of truth) is not helping patients lessen low back pain and disability.
Check out my blog to read more about the Biopsychosocial Model of Low Back Pain.
Vertebroplasty and Kyphoplasty
Outcomes thus far appear similar as both procedures have been shown to be effective in rapidly reducing back pain in those with painful vertebral compression fractures. There is still debate among physicians as to whether one procedure is safer or better at restoring vertebral height.
One complication, however, is a high incidence of additional compression fractures above and below the one being stabilized. There is some debate remaining as to whether this additional fracture rate is secondary to the stiffness of the treated vertebra after being stabilized or if it is resultant from the ongoing osteoporotic changes in the spine. This study found that by adding back extensor muscle training they were able to significantly reduce the refracture rate. They used exercises begun in sitting and progressing to back extensions and bird dog type exercises in prone or quadruped. Unfortunately they did not give much in the way of details as to when the exercises were started after the procedure, frequency, sets or repetitions performed. However, so far it’s the only study that addresses exercise after vertebroplasty so sometimes you just have to take what you get and develop your physical therapy programs with less than perfect data.
Check out my blog to read more about Vertebroplasty / Kyphoplasty and Low Back Pain.
In a comparative meta analysis review on lower back pain and manual therapy, that I reviewed on my blog, it was stated that exercise with authoritative support is an effective strategy for acute and chronic low back pain. Treatments serve to motivate, reassure, and calibrate patient expectations–features that might reduce medicalization and augment self-care. Social support is the long ignored link between personal responsibility and professional care. For patients coping with pain and change, psychological support is necessary. I think that good exercise with social support seems the way to go. I think that social support should include a fair amount of patient education about environmental influences to low back pain, how to avoid pathological stresses with better postures and motor control, both of which can be influenced positively with exercise as already mentioned.
Check out my blog to read more about Manual Therapy and Low Back Pain.