Managing Acute Back Pain

I wrote an article for the Journal Orthopedic Clinics of North America a few years ago with my colleague Mike Kane, PT a physio in Yakima, WA. The premise was Functional Rehabilitation Strategies of the Lower Back. In that article I laid out the full picture, and also talked about acute lower back pain (LBP). Since 80% of people suffer lower back pain, and a third of them in the last 24 hours, I thought that I would share my successful strategy for dealing with acute back pain in greater detail.

First of all, realize that most episodes of lower back pain are self limiting. Very often, the pain will resolve within a few days, and 8 out of 10 times, within a month, 9 out of 10 times within 2 months.

Because we are not very good at diagnosing LBP (something like 15% of the time is a diagnosis determined to be accurate), the underlying cause is not really important in dealing with acute LBP.

The literature strongly suggests that a person suffering LBP should not curtail their activities. If you are a runner, keep running, a walker, keep walking, a swimmer, keep swimming.

But lets say you experience a severe episode of LBP with or without pain into the leg, you should know this: It is a medical emergency if you actually lose control of your bladder. If that happens, go to the ER immediately. You only have a limited amount of time to address this problem or you face the permanent loss of bladder control.

In the alternative, here is my fail safe almost 100% successful acute LBP treatment strategy:



1. Start out lying on your back on the floor in the 90/90 position with your legs up on a chair. Stay in this position for about a minute focusing on your breathing. Try to relax as you do so. The reason that this position is useful is that in this posture, the intra-discal pressure is the lowest it can be, and that usually means less pain.


2. In this position, start by dragging your right foot along the chair as you bring your knee toward your chest. Use your hip flexors and abdominal muscles to bring your knee up to your chest as far as you can. Try to move as quickly as you can PAIN FREE. When you achieve the maximum ROM, then push your foot back along the chair and repeat the move with your left leg. Repeat this activity back and forth 30 times with each leg. Remember, move as quickly as you can as far as you can, but drag rather than lift your leg.

3. The next exercise involves you bringing both legs up at the same time. Make sure to spread your knees apart as you do so in order to clear your pelvis. Again try to really curl up by engaging the lower abdominal muscles. Repeat 30 times. Be sure to drag your feet rather than lift them, and make sure the movement is as rapid as possible, but again, PAIN FREE.

4. The next exercise is desigend to engage the trunk in a rotational movement pattern. Wrap both arms around your chest and pick your head up. Keeping your butt on the ground, roll onto your right shoulder, then onto the left shoulder. Repeat 30 times in each direction as quickly as possible, PAIN FREE.

5. OPTIONAL. This exercise I make optional for people. The activity is in sidelying, but you have to roll up a blanket and put it under your ribs. Push it up to the arm pit to reduce the ROM, or further down to increase the ROM. Place the up arm on top of the body, and grab the top shoulder with the bottom arm. Perform 10 reps of side lifts PAIN FREE. Roll over, reposition the blanket and repeat on the other side.

Perform all these exercises 3 times through - it will take about 20 minutes.

The final exerise is key. You need to do this exericse at the conclusion of your previous exericses and again every hour throughout the day, or whenever you LBP irritates you.

6. Half sit on a table with your feet firmly planted on the floor shoulder width apart, your arms wrapped tightly around your chest, one arm above the other. Maintain an erect spine posture, but lean slightly forward at the waist. The exercise is a 5 minute drill of left and right rotation only. The key, as you might already guess, is to move as quickly as possible, PAIN FREE. Gradually increase the ROM as you do the exercise and can tolerate more motion.

Franky, this last exercise is almost magical. Almost everybody with very few exections will benefit from the exercise.

Finally, you need to use ice to inhibit the muscle guarding. In our clinic we have found that crushed ice plus a little water in a plastic bag right on the skin for 30 -40 minutes is the best solution. The reason this is important is that it takes 10 minutes for the ice to penetrate 1cm (about a half inch), and the muscles that are guarding live about 3 cm deep. So prolonged ice inhibits the pain, decreases muscle guarding and reduces edema that might be present.

Add to that 30 minutes of walking and you have a very very very effective acute LBP management program. We call this program Phase 1 LBP Managment.

Good luck

Lets talk about Core Stability

"Why should I do core exercise?" is the most common question I field for people suffering lower back pain.

First, the anatomy - segmental instability occurs because a motion segment (vertebra - disc - vertebra) allows a component motion of sheer which is not anatomic. In other words the vertebra above should never sheer against the vertebra below. This abnormal motion would occur when a disc has lost its volume and therefore its height. we see this as a narrowing of the disc space on x-ray. Once sheer is allowed, it is safe to assume that the static stability of the spine is lost.

In this image you can see the loss of disc height.






Muscularly, there is an opportunity to stabilize the spine dynamically using the muscles that surround the core. In front and on the sides are the Rectus Abdominus, the Internal and External Oblique muscles and the Transverse Abdominus as well. In addition there is the strong lateral stabilizer - the Quadratus Llumborum and the posterior structures including the deep paraspinal muscles Multifidus and Rotatores and others. Further, there is the large back muscle Latisimus Dorsi that inserts into the thoraco-lumbar dorsal fascia and the Gluteal muscles that also do so and provide additional tension to the structures. Finally, there is the diaphragm above and the pelvic floor below that both play a significant role in providing true core stability.




Key core exercises tackle all these muscles. Front, back, sides, top and bottom. The secret is that it is not possible to compress water, and so by having a dynamic compression of the contents of the core, stability is created whereby the segmental instability described above is restricted from movement by the compression of the abdominal contents. Make sense?

There are other considerations such as muscle tightness and joint restriction above and blow the spine that contributes to the load at the unstable segment, perhaps perpetuating the instability and the consequence of that instability


on the pain one experiences. For example, the Hamstrings insert on the Ischeal Tuberosity and it is easy to imagine how the tight hamstrings would limit the ability of the pelvis to tilt forward during forward bending, which means that as one bends forward, the unstable segment in the spine would carry the load INSTEAD of the hamstrings. And because it is moving under load more than it should, and because the motion takes it past normal ranges due to sheering, an unstable segment is more likely to become even more unstable causing yet more pain and dysfunction as time passes.

What this means is that core stability needs to be a priority, but normalizing hip and thoracic spine mobility also need to be addressed for the core exercises to matter and for their effect to last.

Acute Back Pain

Here's the thing, even this episode is probably going to get better soon. Most acute episodes of Lower Back Pain (LBP) get better within 24 hours. If not, 8 out of 10 times, LBP resolves after a month, and 9 out of 10 times within two months. OK, but you hurt now, so what should you do?

During the last 26 years I have observed the following:

- Ice really works. Not blue ice packs, not frozen peas, not one of those cloth ice packs you get at a pharmacy, I am talking about refrigerator ice AND water in a plastic bag placed right onto the back in full contact with your skin. And it takes a half hour to an hour to penetrate to the deep tissues that need to be inhibited. 10 minutes per 1 cm, so think that the deep tissues are about 3 cm deep (if you are fat, add time accordingly!) What ice does is a. combat inflammation and edema, b. inhibit muscle guarding, and c. reduce pain.

- Get out and move. It is really important not to lie around when your back is hurting. You need to stay active. Ice will help, but go for a walk at a pace fast enough to work up a sweat. The reason for this is that inactivity promotes muscle guarding, and like the ice, activity helps keep the muscles from guarding. In the spine, the deep rotators "spy" on the adjacent vertebra up to five levels up and five levels down. Activity keeps your uninvolved muscles uninvolved, "quiet", if that makes sense.

- Rotation is key. In a half seated position (feet on the floor butt on the table, wrap your arms tightly around your chest, and rotate back and forth quite quickly (pain free though) for about 5 minutes every hour. Again, this both inhibits muscle guarding and encourages hydration and nourishment of the deep dense connective tissues. And it usually feels much better.

- 90/90 position for rest. Lie on the floor with your legs bent 90 degrees and the hip and 90 degrees at the knee, and your feet supported against the wall. This position is know to be the position with the least amount of intradiscal pressure compared to others.

- What if I am shifted? Well this is a complication for sure...but your first line of defense is described above.

- When should I see the doctor? If you have pain into your leg below the knee, numbness tingling or weakness, or intractable pain, any or all of these symptoms, go see your doctor.

- Is there an emergency situation? YES - if you lose control of your bladder, go to the ER - that is an emergency situation that is time dependent. Wait too long, and your bladder control will not likely return.

Finally, take a deep breath, use ice, go for walks, rotate, this too shall pass.