One morning you wake up, get out of bed and find it difficult to straighten up. Your back is stiff. It’s hard to bend forward to put on your shoes. You sit down and find that your leg suddenly won’t bend enough to reach your foot. You take a hot shower and within an hour you begin to feel better and go to work. You forget about it until the next day the same thing happens. Whether you are 25 or 65 you may decide that this is just a sign of age when what it is telling me is that you are going to W.A.R. with your body. These are the early signs of low back pain and unless you recognize them you may go onto a full back pain attack.
Stages of Low Back Pain
View Video, WAR on low back pain https://youtu.be/7E0Tc0i-ZxQ
W.A.R. is the acronym I chose to represent the struggle of the mind and body that is an integral part of this injury and because it is a helpful for understanding the 3 stages of recovery. Like with any war, there are stages of engagement. Each stage has different characteristics and strategies. Ultimately, winning this WAR will be determined by identifying which stage you are in and applying the treatments that work for that stage.
3 Stages of Low back pain:
- W- Warning
- A – Attack
- R – Resolution
Choosing your treatment
The most common mistake I see made in the recovery or prevention of low back pain is when the wrong treatment is selected for your stage of recovery. Well-meaning friends, therapists or Dr. Google tells you about some amazing recovery from a certain type of treatment. Maybe it’s exercise, manipulation or strong stretching techniques like ART. Testimonials will encourage you to try it, but what is often unclear is whether it’s right for you.
While there is no doubt that each of these treatments can help reduce low back pain, if you want to win this WAR it’s critical to match the right treatment to where you are in your healing. The wrong treatment at each stage can have a profound effect on both your speed and resilience of recovery. The first step is to determine your stage of back pain recovery before you choose your treatment.
Stage 1 – Warning
Back pain often starts with subtle warnings. These warnings may go unrecognized or are ignored until suddenly you under Attack. The result of missing these cues can be a full-blown episode of back pain which puts your entire life on hold for weeks or even months. To win this WAR your first goal should be to avoid the full-blown Attack. This is best done by recognizing the Warnings and immediately making lifestyle changes.
Some of the most common symptoms of an impending back attack are:
- Back stiffness in the morning
- Back stiffness at the end of the day or after exercise
- Back discomfort rising out of a chair
- Back discomfort when standing. 
- Muscle tightness in your hamstrings or calves when you haven’t worked-out
When you feel any of these symptoms, recognize that they are warning you that your back pain may escalate and seek some help in managing this stage. Most people don’t need much treatment at this stage and prevention can be quite simple. The focus of therapy should be to identify your risk factors and to understand which modifications can make a difference.
Correcting factors such as a sedentary lifestyle, tight muscles, poor core, etc. can go a long way to avoiding the Attack. For many people preventing WAR can be as simple as reducing the length of time you are sitting and ensuring you are walking enough i.e. >8,000 steps per day. It can also be about ensuring you have a good ergonomic set-up for your computer and that you stop working on your laptop in bed or at the coffee table.
This is the stage that we all want to avoid however it is the one most people get to before they seek treatment. It’s not surprising that this is what takes you in to your therapist, as the pain can be overwhelmingly intense.
The intensity of the pain may make this stage seem quite obvious however it is important to determine whether you are really in a full-blown Attack or already in the first stage of Resolution. Some people skip the full Attack stage or progress into the Recovery stage very quickly. I find that these two stages are often confused and the treatment strategies are very different depending on where you are in your WAR.
The key characteristics of the full-blown Attack are:
- Unrelenting pain. The pain may wax and wane but you are never pain free.
- Short term relief may be felt from shifting positions but doesn’t last.
When you are in a full Attack the primary goal is to end it as quickly as possible. Managing this stage is best addressed by never going to WAR in the first place, however if you find yourself in the middle of the Attack, the most important elements of treatment are management of the pain and avoidance of becoming mentally incarcerated as a prisoner of pain. This is when you should discuss medications with your physician, pain relieving strategies with your physiotherapist i.e. acupuncture, manual therapy and educate yourself on recovery strategies.
I find that the most common mistake made is over-exercising during this stage. Knowing that core exercise is good you choose this moment to start your return to fitness. Remember you need to move but you should also avoid substantial increases in pain. My rule is that the pain should not increase for more than 20 minutes after movement or exercises.
Your final goal is to achieve full resolution. To do this you need a treatment plan which ensures your recovery is robust and resilient. This is what will allow you to return to all your favourite activities and avoid future WAR’s.
The most common mistake I see at this stage is a failure to recognize the early signs of recovery. Many of us use pain as our guide, expecting to get active once the pain stops. However pain doesn’t always shut off like a tap. The early signs of recoverycan be subtle. There are changes in the quality, location and in what provokes the pain. These changes tell me when you are ready to enter the final stage in the battle and really participate in therapy.
Signs of Resolution:
- Pain intensity lessening and/or becoming intermittent
- Pain localization (less leg or buttock pain)
- Pain improving with specific activities/directional preference i.e. walking or sitting
- Increasing function with no need to increase your medication
The second most frequent mistake I see is that we don’t focus enough on ensuring full resolution. This is the stage when you should really start to exercise. Restoring your core, re-establishing coordinated movements and strength is critical. You should be able to start weaning off medication and therapy shifts from pain relief to restoration of lifestyle.
Avoiding Future Wars
Depending on how well we manage the resolution stage determines whether we will keep going to WAR or whether our life returns to full and pain free. Many people come out of the Attack stage only to have it replaced with constant low-grade discomfort and stiffness. When you try to return to full activity or resume sports the Attack returns. You see numerous practitioners and no one can give you a clear answer why you can’t get rid of your pain. MRI’s, X-rays and other tests all fail to explain your ongoing symptoms. This reinforces the prisoner of pain. You begin to worry that something permanent is wrong with your back – which no one can find!
If you are having repeated episodes of low back pain and all your tests are clear, this tells me that your back is structurally healthy. If you are in the resolution stage you are ready to engage in therapy. If there is no structural damage of significance i.e. herniated discs, stenosis, there are also no significant restrictions to recovery. Even if you have structural changes your recovery can be good, it just takes a more thoughtful approach to planning your program.
The Recovery phase often requires the guidance of a knowledgeable spine therapist. Someone who understands which factors are challenging your recovery and can guide you into starting your exercise at the right level. Remember if your pain has lasted longer than 3 months you are now out of shape. You have also begun to lay down permanent motor memories which impact on your ability to recover. A solid approach to fitness and restoring coordination are critical at this time.
Join me in the WAR on low back pain
I would like you to help win the W.A.R. on back pain. Over the next series of articles, my goal is to help you become educated about recognizing what your body is telling you. This will help you to find the right therapist to guide you in your recovery. It will also help you to know when it’s time to make a change in approach. Winning this W.A.R. is also about helping you, your friends and even your children to avoid your first episode.
My next few blogs will explore each one of these stages more fully. I will provide a more in-depth look at the symptoms and which treatments are likely to help. In the interim please contact us for more information or call 416-925-4687 to book an appointment if you need assistance in managing or preventing your own personal W.A.R. on back pain.
 This one is harder to recognize as may people mask this symptom by avoiding standing activities such as cocktail parties, museums, shopping or cooking