Remedies for Non Specific Low Back Pain - the “common cold for the spine”

Mark Shepherd is a physio who has likened non specific lower back pain to the common cold for the spine. I love this analogy because it helps us realise that sometimes our back is sore but, just like a cold - with the right care it will pass. And even without the right care, it may also pass.

Just as we are vulnerable to catching a cold when we are tired, run down or stressed so too are we more likely to experience pain in the same state. Why? Because pain plays the functional purpose of catching our attention and motivating us to escape danger. When we define pain as an apprehension of threat to ourselves it makes sense that our non specific back pain flares up either when life is very difficult, or just after.

This makes sense when we understand that pain perception occurs in two ways. We experience pain as a result of messages sent from the body to the brain as well as from messages descending from the brain to the body. Pain is modulated in our central nervous system and can be amplified or reduced depending on our perceived level of threat. The image below shows bottom-up red and green pathways and top down blue pathways. The blue pathway is generating noradrenaline and 5HT (which is a serotonin precursor). These neurotransmitters are sending "safety" messages to the body. When there are more safety messages than danger messages in our nervous system our pain is reduced. This is why recovering from back pain is often seen as a neurological healing process rather than a structural one.

We know how to take care of ourselves when we have a cold - what about when we have a back pain flare up? A recent systematic review has shown that non specific back pain is best managed with non-pharmacological treatments such as exercise, heat pads, manual therapy and education. Among pharmacological interventions, NSAIDs and muscle relaxants offer the best harm-benefit balance.

Because a picture is worth a thousand words I have some infographics for you. This first one reminds you how necessary it is to move when you have back pain and how an acute episode can transform into chronic lower back pain.

This infographic shows that pain comes with lots of threat messages. These can be reduced through education and exercise.

This next infographic helps you to plan your exercise and is structured like a burger. It reminds you that your recovery from back pain has layers. Your exercise will be for a set period each day - perhaps only ten minutes to start, but this schedule helps you to avoid doing too much and tiring yourself out or from avoiding exercise entirely. The exercise will be graded which means that it will increase incrementally. There are no studies showing that one exercise modality is superior to any others so move in a way that you enjoy. This is sandwiched between mindset training and pain education. The American College of Physicians’ Guidelines calls physicians to also take into account the need for stress management; to assess fear and activity avoidance; to look at mood; social withdrawal, correct false beliefs about the back pain; and build confidence in coping strategies. When we understand pain perception this makes sense to us. When a doctor refers you to CBT for your back pain this is not because the pain is in your head. It is because your nervous system needs retraining and we can do this by manipulating our descending inhibition - the messages flowing from our brain down to the body.

I have one last infographic to show you that helps explain why exercise is good for the nervous system. and why exercise is so marvellous for reducing pain. Through mechanisms that people don't really understand, and through testing on hamsters and mice running on treadmills - studies are showing that exercise reduces inflammation and actually boosts anti inflammatory states in our nerves. Glial cells support neurons firing their (pain) messages and exercise quietens their activity. Astrocytes support neuron behaviour during sleep and microglia destroy invading microbes and clean up debris, exercise helps these cells work efficiently. Exercise also releases endorphins which are our feel-good "safety" chemicals. A 12-week exercise program demonstrated increased pain thresholds and decreased pain flare ups in people with osteoarthritis. Lastly, pain makes us feel out of control, exercise is a tool that helps us take back our command over our body.

So, that's it. Your non specific lower back pain will pass. You can get a massage, you can put a hot water bottle on it, you might find meditation helps. What you absolutely must do - is get moving! Identify your baseline level of function, this may be walking around the house, or around the block to start with. Determine a rate of progression that you think is safe and achievable - perhaps once around the block, three times throughout the day today, and twice tomorrow? This is essential to your recovery so you'll need to schedule it in every day. If you fall off course, start again with something fun - could you meet a friend for one of your walks? Could you go with a friend to a local Tai Chi class? Lastly, as long as your doctor has ruled out red flags remember that pain does not equal tissue damage, you will need to move gently through pain to get out of pain. You've got this.

xx

P P