Low back pain: A physiotherapist's personal experience

Dr Breanne Kunstler (BBiomedSci, BHealthSci, MPhysio, PhD). 

Physiotherapist, behaviour change scientist and run coach.

"Ahhh! What the f*ck just happened? Christ. My f*cking back is killing me and I can't move!"

I hurt my back a few weeks ago while lifting Abby out of her high chair. And when I say that I hurt my back, I really hurt my back. 

We all experience some back pain, stiffness, ache-iness, not-quite-right-ness occasionally. That's normal. It's normal to have pain sometimes. Not even just back pain, but also knee pain, foot pain, ear pain, throat pain (let's not talk about that during the COVID-19 pandemic!). It's not the end of the world. It hurts for a bit, it gets better, we move on. 

This back pain experience was different. This pain was intense, sudden, frightening and debilitating. It was also a great learning opportunity.

Physiotherapists treat dozens of different musculoskeletal conditions but, by far, low back pain is the one of the most common musculoskeletal complaints we deal with. Low back pain is one of the largest contributors to disability in Australia (second only to arthritis), negatively affecting the economy because it leads to people taking time off work and regular activities, as well as seeking government-funded care. It is the most common musculoskeletal condition seen in general practice, thereby putting a strain on the health system as so many people seek care for their pain. 

Acute back pain (back pain that has only just started and has lasted less than 6 weeks) often resolves by itself pretty quickly (within 6 weeks), but people worry about it. This worry/fear exacerbates the pain. They seek help to fix the pain and make it go away (not just the pain, but also the worry). 

Unfortunately, people with back pain might seek treatments that feel nice in the first instance (e.g. rest) and appear to have immediate beneficial effects. They have an idea of what causes and treats back pain, yet these ideas are often misguided (Image 1). The fact that the pain comes back the next day after initial treatment is over worries people, they think that they are 'beyond treatment' or that they need surgery. This leads them to seek more help, which might involve asking for scans and seeing a doctor to be prescribed pain medications so that they can sleep and/or work. These medications can be dangerous, addictive and simply not fix the problem (e.g. opioids). This creates additional issues where acute low back pain becomes chronic (back pain that lasts longer than 6 weeks), potentially leading to a reliance on addictive medications that lose effect over time and, consequentially, the person experiencing a much bigger problem than a just a sore back.

Image 1: Quashing back pain myths with science (credit: BJSM)

Evidence-based management of low back pain relies less on medication, rest and surgical interventions and more on lifestyle change and minimising fear of movement (Image 2). These are not 'quick fix' strategies, but they work. They take time though and people can lose confidence in them because they don't experience immediate effects. Physiotherapists often feel frustrated that patients don't "adhere" to these evidence-based treatments and might end up blaming the patient for not getting better as a result. 

Image 2: Prevention is better than cure (credit: Australian Physiotherapy Association)

I think it's important for physios to experience back pain before they assume that patients don't get better because they cannot be bothered doing their exercises, following their treatment plan or just want a "quick fix". 

My (horrid) experience of back pain

Monday morning (July 6): I felt some general low back pain after finishing a 25km run and lifting Abby from her cot. I didn't think much of it. I reassured myself that it's normal to feel pain from time to time. I started to focus on lifting and carrying things close to my body to reduce the amount of pain I felt during these activities, but I didn't take any medications or rest. I usually tell my patients to keep moving, rather than putting themselves to bed or resting on the couch, when they have back pain. I walked a lot during the day and avoided sitting down for extended periods. The pain improved with walking.

Monday morning (July 12): I felt more low back pain after another 25km run. I remembered that I felt the same pain the week before but it got better pretty quickly. So, again, I wasn't bothered and expected it to go away. 

Wednesday afternoon (July 14): "Ahhh! What the f*ck just happened? Christ. My f*cking back is killing me and I can't move!" I hurt myself lifting Abby out of her high chair. I twisted while bending and lifting. I remember one of my lecturers telling me that it's a common way to hurt one's back.

Image 2: I think babies are the real cause of back injuries (credit: NY Times)

The pain felt like shocks, or even bullets, shooting down the back of my thighs. I couldn't bend or sit without "extreme" pain. This was pain unlike I had every felt before. I felt my body bracing with every movement and I started walking like a rusty robot. I was so tempted to put myself to bed and stay there...forever.

Wednesday night - Thursday morning (July 14-15): I had the worst night sleep I've had since I was in labour with Abby. At 3am I decided it was time for some paracetamol. I tried sleeping with a pillow under my back because that felt better than having a neutral/flat or flexed/bent spine, but the relief didn't last long. I tried sleeping on my side, with and without my body pillow between my knees, but none of those positions felt perfect either. The next morning I started taking regular ibuprofen and paracetamol (every 4-6 hours), used a heat pack non stop (not recommended), wore my post-natal compression shorts to "cuddle" my back, avoided sitting (walking meeting anyone?) and kept moving as much as possible. I decided to use these strategies based on what I know has worked clinically.

Thursday morning (July 15): I usually do some kind of exercise each morning. I could not fathom the idea of running; the 'jumping' feeling of each step would create too much pain. I usually encourage patients to do a less intense activity, like cycling or swimming. I decided to go for a bike ride because I'm not a swimmer. That was a bad choice. As I mentioned, bending my spine was painful. Well, my handlebars are so low that I am constantly in flexion on my road bike. The whole ride was hell. I rode only half as far as I usually would in the same amount of time because the power in my legs was so poor. I think my tears also created a slip hazard (I didn't actually cry but I certainly felt like it!). I had a lot of pain not only in my back but it also travelled into my hips and thighs. The lack of strength I had in my legs was worrisome. 

It is common for people to feel pain in areas other than the back when they have a back injury. This is called referred pain. People have often heard of pain from an impending heart attack being felt in the arm and/or jaw. This is a very common example of the heart referring pain elsewhere in the body. Referred pain can be scary because people don't understand why another part of their body hurts when they didn't actually do anything to that body part. They feel like they are falling apart (suddenly their hip is damaged too!), exacerbating the fear they already have associated with their back pain. It is well established that fear is associated with worse pain experiences; it's a vicious cycle and something that should be avoided. 

I spent the next week changing my activities by running shorter distances, avoided single leg activities (e.g. single leg skipping) and I did more strengthening exercises (e.g. gluteal and abdominal training). Basically, I knew I needed to keep moving, but I avoided activities that made me feel uncomfortable. Activity modification, as well as wearing compression shorts and using a heat pack throughout the day and night, really helped. I only used ibuprofen and paracetamol regularly for a couple of days, quickly reducing my intake to once a day for a couple of days and then I was taking none at all before one week was up. I also reassured myself that I didn't have new injuries (remember the weird hip and thigh pain?) and that back pain often resolves by itself, thereby minimising any fear I was feeling. 

What did I learn from this experience?

Back pain is scary. I am privileged to understand the anatomy and physiology (and, to an extent, the psychology) behind the experience of back pain and I was still scared that I had done permanent damage and that I'd never be able to do the activities I enjoy again (extreme, I know!). This knowledge allowed me to avoid allowing fear to take over my recovery (e.g. I didn't think that I was permanently damaged or that I had damaged my hip and thighs too).

I was really tempted to do all the things I encourage my patients not to do (based on evidence-based clinical guidelines), such as: rest in bed, avoid activity, eat comfort food to feel better, see a doctor, ask for a prescription for strong pain medication and get a scan to see what was wrong. So, as a physio, I need to remember that these behaviours are extremely attractive to patients and to not blame them for being tempted to participate these behaviours. 

As a physio, I can give patients with back pain dozens of strategies that won't work for them. For example, cycling as an alternative exercise might not work if flexion is painful and all they have is a road bike! Alternatively, I can give them several strategies that will work for them if I firstly ask them questions like: 

"What helps to minimise your pain?"

"What makes your pain worse?"

"How does your pain make you feel?"

"What does the pain mean to you?" 

"What do you think your recovery looks like?"

"What activities can and can't you do because of your pain?"

"What alternative activities will work for you?"

"What do you want to achieve during your recovery from back pain?"

There are several more questions that I'd ask but these are the ones that come immediately to mind after reflecting on my own injury experience.

The main lesson here is to listen to my patient and treat the person, not the injury. 

Be well, my fellow humans.