Winning the War on Low Back Pain – Recovery or Recurrence?

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One of the biggest problems I see when you are recovering from low back pain is that you are tricked into thinking you are completely better when the truth is that you still have a long way to go.

Maureen Dwight

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Low back pain

Low back pain

Relief changes to despondency.  Not realizing that the problem is your lack of a rehab plan you start to worry that whatever is wrong with your back is serious and for life.  You go into an emotional tailspin – reinforcing your return to being a  Prisoner of the Pain.

Avoiding mistakes in recovering from low back pain

The most common mistake I see in the Recovery stage of winning the WAR on low back pain is trying to do too much too quickly. This happens because we equate the absence of pain to full recovery.  The reality is that pain often abates when strength is around 40% of normal.

Whenever pain lasts for more than a few weeks most people are weaker than they realize.  If you have had a pinched nerve the weakness is compounded by loss in the strength in muscles supplied by the nerve. This weakness can be quite profound, causing;

Even when the pressure comes off the nerve the muscle may not immediately regain strength.

These are often the reasons your recovery fails.  Unless you understand these imbalances and look to correct the impact they are having on your body, your recovery can be very hit or miss.

3 Stages of Low Back Pain Recovery

The changes caused by low back pain and nerve pressure mean you need to make good decisions in your recovery from low back pain.  Your decisions need to build logically on each other until you return to your full and active lifestyle with a step-by-step plan.  These decisions start with the knowledge that recovery has 3 stages.

  1. Resolution
  2. Robust
  3. Resilience

Most people go through each stage sequentially however the stages typically overlap.  Each stage requires a change in therapy and should become progressively more demanding as you regain your strength, stamina, flexibility and coordination.

Recovery Stage 1 – Resolution

The hallmark of this stage in your recovery is that the pain is intermittent. Typically, the pain is provoked by certain activities and feels better when you do other things.

You may have trouble identifying the links between what makes the pain better or worse.  At this stage what is most likely happening is that your back is exhibiting what is called a “directional preference”. This technical jargon simply means that your back prefers certain positions and is made worse by other movements.

Most commonly the back has one of two preferences – it either likes to flex (bend forward) or extend (bend backward).   The therapy goal of this stage is to control pain  through movement. This is often when you can reduce or eliminate medication.  Your exercises will make you stronger and more flexible but most importantly they should make you feel better or at least not worse.

Flexion (bend forward) preference:

Flexion preference typically achieves pain relief with sitting and is made worse by walking.  The most likely structures at fault are the facet joints or spinal stenosis.  If this is your pattern, exercises such as knees to chest, Figure 4 stretch and stationary bike are the places to start.

It is  important to avoid/limit the direction you back doesn’t like.  In this case we term it an extension intolerance.  This means you should limit activities that put your back into an arch such as standing for too long, Yoga cobra poses or deciding this is the exact moment you need to paint your ceiling.

Extension (bend backward) preference:

Extension preference is often associated with pain relief from walking.  It is typically made worse by sitting. The most likely structures at fault are the discs or tight hip muscles (psoas, quads). Exercises such as Yoga cobras, sloppy push-ups, bridging and lots of walking can substantially reduce your pain.

In this early recovery stage you should avoid activities that put your back into flexion such as toe touches, hamstring stretching or deciding that you finally have to beat your high school sit-up record.

Recovery Stage 2 – Robust

The marker that you are entering the next stage in recovery is that you have minimal pain with basic activities such as sitting, walking, standing etc. It is still relatively easy to aggravate your back with heavier or sustained activities.

At this stage it may feel OK to bend forward to pick up a muffin or a Kleenex box but you still hurt if you go to the gym or lift the laundry basket.  You know you’ve overdone it when you pick up a case of beer for the long weekend and feel an immediate urge to crack open a bottle to relieve your back muscle tension.  In other words the intensity of the activity is the limiter, not the direction of the movement.

Often at this stage your pain gets worse as the day goes on. The more tired you are, the more you hurt.

These symptoms indicate that the intensity of the activity and fatigue are the irritating factors.  This tells us that it’s time to make a plan to resume cardio, strengthen your core and restore your flexibility.

At the start of the robust stage you may be still be exhibiting a directional preference.  You can still exercise however the strengthening and flexibility must respect the preference i.e. strengthen in extension.  As you progress you should be able to restore some  degree of the opposite direction of movement.

Recovery Stage 3 – Resilience

Resilience is about our ability to recover from our mistakes.  We all do it.  The weather improves and we decide to go for a two hour walk when the longest walk we have done in the last 6 months is 20 minutes. We decide to clean up our garage or return to gardening when the heaviest thing we have lifted in the last month is our coffee cup.

The problem with these decisions is that you have increased your physical demands too quickly.  However pat yourself on the back if you only experience mild discomfort or stiffness and recover from your low back pain within a day or two.  Mild symptoms and a quick recovery are indicators that you have restored some degree of resilience.

To fully  restore resilience your recovery plan needs to uncover and correct compensatory patterns.  We need to identify those pockets of profound weakness that the pinched nerve left behind and bring these muscles back to normal strength and coordination.  The failure to restore normal movements and efficient, coordinated movement patterns is what I find is the most predictive of recurrence and of your recovery not resolving within the expected 3 months.

How do you know you need to restore resilience?

  1. Exercise dependency. Your back exercises really help but whenever you stop them the pain returns.
  2. Inability to return to exercise, sports or household chores without provoking pain.
  3. Constant, low grade pain. The intense pain has lessened but now the pain never leaves.
  4. Your pain is still intense after 3 months

To get to the truly resilient stage you may need to find a spine therapist who understands how to find and correct the weaknesses and compensatory patterns left behind by your injury.  If you have pinched a nerve and the symptoms have lasted for longer than 3 months I can almost guarantee that these imbalances will be there. You and your therapist need to determine what is missing in your recovery and specifically address these imbalances.

Over the next few blogs I will explore each one of these stages more thoroughly and help you to find your own direction of recovery and to assist you in creating a dialogue with your spine therapist to partner in winning the WAR on low back pain.  Please contact us at 416-925-2687 or if you need assistance in putting your Recovery plan into place.

This service pro­vides gen­eral infor­ma­tion and dis­cus­sion about therapy, health and related sub­jects. It is not meant to replace advice and/or treatment from your health care professional.