A guest blog from Toby Pollard-Smith
The simplest thing I can tell you about back pain is that it’s not simple.
Sure, there may be some simple-sounding explanations out there, but when the pain lingers beyond a few days, we must look deeper and consider more elements.
In an attempt to find some structure amidst the chaos, I offer three steps to help my patients in their battles with persistent back pain. You might find these steps more abstract than you’d like, but have a read, and consider how you might integrate them into your back pain strategy.
Step One: Understand what’s wrong
We need a starting point. The best place to start is understanding the narrative. Therefore, when you meet a manual therapist (physiotherapist, chiropractor, or osteopath), they will want to know the story of what has happened to you, and more about you generally.
There will be clues in your narrative that help identify the nature of your injury and allow consideration of the causes. Perhaps your back pain really did come out of nowhere, but without knowing more about you, your general health, and how you’re coping, it’s hard to put the relevant pieces of information into context.
Next on our agenda is the dreaded term “non-specific back pain”. It is often used by medics but rarely explained to patients. It simply means that your back pain isn’t being caused by cancer, infection, a damaged blood vessel, or a list of other things. It’s good news, but all too often, clinicians stop there.
It seems that the term “non-specific” has been re-appropriated to mean “don’t bother trying to understand how they’ve hurt their back”. But I disagree. We should absolutely appreciate how difficult it is to nail all cases of back pain down to a simple set of causes, but at the same time, we can categorise patients into rough groups:
- There are those who have pain mostly when they bend forwards
- There are others who mostly have pain when they (guess what?!) bend backwards
- There are some who have a mixture
This basic information can get us off to a good start. We also need to understand whether your pain type is:
- Nociceptive – a result of damage to bones/ligaments/tendons/muscles etc
- Neurogenic – from damage to your nerves
- Nociplastic – a generalised state of pain maintained by your brain and nervous system.
(There’s plenty more to know about these – let’s just appreciate that there are differences for now)
Step Two: Find what’s good
The general idea here is to try things. Once you’ve seen a good therapist and identified a few features of your back pain, you should have some starting points. Examples would be:
- If your back hurts when you bend forwards, I’d suggest avoiding those movements when it feels really bad, but try to introduce a little more when it’s feeling better
- If your pain is largely inflammatory (nociceptive), I’d encourage you to use the right medications in the right way, and use ice properly to maximise its effectiveness
- If you’re able to keep active – even minimally – I’d plead with you to keep it going, trying to make it more of a daily habit than it might have been before
Examples like these need personalising to each person – they might not be the correct tactics for your back pain. This is why I feel everyone should get help.
As much as you think you know your own back pain (and patients often come up with some great tactics themselves), there is always value to be gained from having an external observer offer their expert advice.
This is the role of a good manual therapist, who should position themselves alongside you, not shouting down at you. They should educate you about the nature of your injury, encourage you to try tactics that should help, and can offer some tips and tricks gained from dealing with back pain patients in the past. Hands-on treatment can be helpful as well, but it should be the icing on the cake, not the cake itself.
The elephant in the room here is that things can get worse. While we don’t want patients to feel worse, we must acknowledge it when it happens, and use our shared knowledge of what has happened to help better our tactics and strategy. We don’t always get things right the first time.
Patients live with their pain for weeks/months/years, and therapists might only have 30 minutes to try and understand all the details and appreciate the patient’s lived experience. It sounds ambitious. So, we need humility to accept that things might worsen (or “flare-up”). Let it settle, accept that it happened, remember what might have caused it, avoid repeats, at least for now…
Step Three: Stir the pot
Hopefully, by having an idea of the nature of your back pain and by testing a set of tactics that minimise pain and maximise function, you can start to live better. This is great – real progress. As soon as we see people show any kind of improvement, we can all feel more positive about long term results. The journey might be long, but you’ve set off in the right direction.
However, beware of getting stuck in the groove.
As your condition improves, and your body heals (tissues, nerves, or the short circuits in your nervous system) you need to move out of your protective mode. This needs to be managed carefully, with the correct modifications and sensible dosing to keep you heading in the right direction but picking up speed. Again, a good therapist will help you achieve this, and shouldn’t merely deliver the same message/treatment over and over.
You must accept that there will be some “flare-ups” along the way, but without trying to break off the shackles, you might find that you’re needlessly guarding your movements. In fact, your body needs to take the next step. If you had an ankle injury, would you still be walking with a limp long after the ankle has healed? No.
We should target a return to normal. Not everyone makes it all the way, but it’s hard to make convincing excuses for not trying to head in the right direction. It can take courage, but without regular testing and listening to your body, you run the risk of getting stuck in a stagnant state of almost better.
I sincerely hope these pointers help bring some structure to the battle you face with your back pain. It’s not simple, it’s not easy. Embrace the chaos, engage in battle, change your tactics, confuse the enemy.