It’s been estimated that over 80% of Americans will suffer from low back pain at some point in their lives and it’s counted as the fifth most common reason for doctor’s visits. Even if an episode of low back pain resolves, it is usually recurrent and can return with greater severity and disability with each flare up. Most patients will seek medication to resolve their low back symptoms, but in doing so they are seeking a short term palliative solution, while doing nothing to address the underlying cause of their pain. They’ve turned off the signal that’s warning them that there’s a problem and then continue with the same activities and behaviors that have created the problem in the first place. The inevitable outcome is greater damage with associated episodes of greater pain and disability.
Once pathology has been ruled out by the physician, it’s important to look at low back pain from a mechanical standpoint in order to improve the patient’s long term outcome. Most low back pain is not trauma related, but is the result of stress from repetitive daily activities to the lumbar spine and its associated tissues. The greatest and most damaging stress in the modern world is sitting. We are bipedal creatures that were designed to stand and walk, and until the past 50-100 years humans hadn’t generally developed the self-destructive habit of sitting all day. We’ve all heard the advice that we should lift with our legs, because forward bending (lumbar flexion) to pick things up can strain the back, even herniate lumbar discs, and yet as far as our low back is concerned, forward bending and sitting in a slouch are the exact same position. Over time, sitting becomes an extraordinarily damaging behavior. There are of course, many routes to injuring the lumbar spine, but for the sake of this brief article, I’m outlining only sitting due to the fact that it’s a primary risk factor in developing low back pain.
Identifying mechanical low back pain is relatively quick and simple. If the patient’s immediate pain is extreme, or there is no change in pain level in any position, the patient’s primary problem is inflammation and probably needs medication before mechanical correction can become the focus of treatment. If medication is successful in reducing the pain, it’s still important that the patient be educated on the mechanical component of their pain, so they can begin to take management of their low back into their own hands. However, if the patient’s pain is tolerable and they have positions of exacerbation and positions of relief or lessened pain, you know there is a definite mechanical component to the problem from the onset. Bending, sitting and rising from a chair are all examples of deep lumbar flexion, while standing and walking are examples of slight lumbar extension. If a pattern of aggravating positions that involve lumbar flexion emerge, then extension based stretches are the appropriate activity for reducing and managing the patient’s pain. There are many other components in managing low back pain of course, but this one simple piece of knowledge is astonishingly effective in improving a majority of mechanical low back pain cases.
The most important questions in determining how to manage mechanical low back pain are: What makes it feel worse? Specifically, what positions? Sit, stand, sit to stand, bend, walk, lying down or any other position or activity? Then, in what positions do you have less pain?
If the patient has increased pain in lumbar flexion and decreased pain in lumbar extension positions, then a series of extension based stretches should help with correction of the mechanical dysfunction. Some increase in discomfort is acceptable while doing the stretches, but if the pain level fails to drop back down to at least baseline severity, the patient should be advised to discontinue the activity and seek further advice regarding mechanical correction of their problem. The stretches are very simple and can be performed by even deconditioned patients. The standing extension example is a movement to be done with care. It can jam the joints of the lumbar spine due to pressure from the upper body arching over them and can also be dangerous for patients with impaired balance. Seated pelvic tilts, prone lying propped on elbows for short periods and repetitious prone lumbar extension press-ups are typically the most effective in treating flexion based pain.