Tips and Tricks for Treating Persistent Low Back Pain
By: Emma Campisi, MSc, 2nd year UofT MScPT student ∙ Estimated reading time: 8 minutes

Chronic back pain, a challenge for patients and practitioners

While most episodes of acute low back pain resolve, sometimes they are recurrent, or never “return to normal”. Among individuals who experience acute or subacute low back pain, the incidence of chronic low back pain ranges from 34% to 59%. 

Chronic low back pain not only reduces quality of life but also presents a challenge for physiotherapists in determining the optimal approach to patient care.

In the Embodia courses, Contemporary Management of Persistent Low Back Pain and Cognitive Functional Therapy - An Integrated Treatment Approach For Persistent Pain, Dr. Kieran O’Sullivan explores an integrated approach to physiotherapy treatment that can transform a patient’s chronic pain experience. 

Follow along, as I share the tips and tricks I learned from this course to assess and treat persistent low back pain. 

Pain

The International Association for the Study of Pain (IASP) defines pain as “an unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage.” It is a personal experience made up of biological, psychological and social factors. There are many ways we can classify pain, one way is a temporal classification. 

A patient is classified as having chronic or persistent pain after they have experienced symptoms for longer than 3 months. At this time, after the initial injury, the tissues have healed, but pain is still experienced. This is because pain is not just from the tissues, or pathoanatomy, but is multidimensional and multifactorial. 

Dr. O’Sullivan describes the 4 components of persistent pain - anatomical, physical, lifestyle, and psychosocial. 

Physical

Various physical factors significantly influence pain perception and management, particularly those related to the demands placed on the body. 

To illustrate this, consider comparing the experiences of a construction worker and an office worker, both dealing with low back pain. The physical demands of their respective jobs—such as prolonged standing, heavy lifting, and repetitive movements in construction versus prolonged sitting, less strenuous activity, and sedentary posture in an office—demonstrate how different work environments can affect the severity and nature of back pain.

Posture is a crucial physical factor that can exacerbate or alleviate low back pain.

Incorrect posture, whether due to prolonged sitting or standing, can strain muscles and ligaments in the back, contributing to discomfort and potential injury over time. For instance, slouching or hunching over a desk can place undue stress on the spine, while proper ergonomic setup and regular breaks can help maintain better spinal alignment and reduce pain.

Check out these courses to learn about how to optimize your home office set up and ergonomics. Both are free for Embodia Members!

Home Office Ergonomics with Dr. Jonas Eyford

Work From Home Ergonomics with Dr. Jonas Eyford 

Lifting techniques also play a pivotal role in back health. Improper lifting, especially when combined with heavy loads or awkward positions, can strain the muscles and lead to acute or chronic back pain. Construction workers, for example, often face challenges related to lifting heavy materials or equipment, whereas office workers may encounter strain from poor desk ergonomics or office setup.

However, pain is multifactorial, so if someone is lifting heavy, or has poor desk ergonomics- it doesn't mean they will have pain!  

Tension in the back muscles is another critical factor influencing pain. High levels of stress or tension, whether due to physical exertion or emotional stress, can manifest as tightness in the muscles of the back. This tension can contribute to discomfort and exacerbate existing low back pain, highlighting the interconnectedness of physical and emotional well-being in managing pain.

You can read more about psycho-emotional pain in our free blog, Yoga and Science in Pain Care - Transforming Psycho-Emotional Pain.

In summary, understanding and addressing these physical factors—such as job demands, posture, lifting techniques, and muscle tension—are essential in developing effective strategies for managing and alleviating low back pain in various occupational settings. 

Anatomical

From a patho-anatomical perspective, chronic low back pain can arise from various underlying conditions that affect the structures of the spine. These conditions encompass a range of pathologies, each contributing to pain in distinct ways. Here are some examples:

1. Spinal stenosis: This condition involves the narrowing of the spinal canal or the openings where spinal nerves exit, often due to degenerative changes or other factors. It can lead to compression of the spinal cord or nerve roots, resulting in chronic low back pain and neurological symptoms.
   
   
2. Degenerative disc disease: Over time, the discs between the vertebrae can degenerate, losing their flexibility and cushioning ability. This degeneration can cause chronic low back pain, especially if it leads to disc herniation or nerve root compression.
   
   
3. Spondylolisthesis: This condition occurs when one vertebra slips forward over another, typically due to a stress fracture or degenerative changes in the spine. Spondylolisthesis can result in instability of the spine and compression of spinal nerves, causing persistent low back pain and discomfort.
   
   
4. Facet joint osteoarthritis: The facet joints, which link the vertebrae together and enable spinal movement, can degenerate due to wear and tear over time. Osteoarthritis of the facet joints can lead to chronic low back pain, exacerbated by movements that stress these joints.
   
   
5. Chronic muscle or ligament strain: Prolonged overuse, poor posture, or repetitive stress can lead to chronic strain and tightness in the muscles or ligaments supporting the spine. This can result in persistent low back pain, affecting mobility and daily activities.
   
   
6. Cauda equina syndrome: While rare, this serious condition involves compression of the nerves at the base of the spinal cord (cauda equina). It can cause severe low back pain, along with bowel or bladder dysfunction and numbness in the saddle area. Cauda equina syndrome requires urgent medical attention.

It’s important to note that many people have anatomical changes but no pain at all.

Leading physicians at the Department of Neurosurgery at the University of California strongly recommend AGAINST the routine use of MRI for low back pain since they have found NO LINK between degenerative changes seen on x-rays or MRIs and low back pain.

Read more here.

When providing physiotherapy treatment, we should always be mindful to exclude red flags, and provide patient education as appropriate. Check out these pain education resources for patients available in both English and French. 

Lifestyle

A patient's lifestyle encompasses a wide array of daily habits and choices that can significantly influence their experience of pain. These lifestyle factors can encompass behaviors that either positively or negatively support overall health and well-being. 

The quality and quantity of sleep play a crucial role in pain management. Poor sleep hygiene, characterized by irregular sleep patterns, inadequate sleep duration, or sleeping in uncomfortable positions, can exacerbate the pain perception. To learn more about how to educate your patients about sleep check this out. 

Regular physical activity promotes musculoskeletal health and can help alleviate chronic pain. Conversely, prolonged periods of inactivity or sedentary behavior may contribute to stiffness, muscle weakness, and increased pain sensitivity.

Excess body weight places additional stress on the spine and joints, potentially contributing to conditions like osteoarthritis and low back pain. Maintaining a healthy weight through proper diet and exercise can help alleviate pressure on the musculoskeletal system.

A balanced and nutritious diet that supports overall health can positively influence a patient's pain experience. Smoking, excessive alcohol consumption, and recreational drug use can all negatively impact pain perception and management. 

By addressing these lifestyle factors in patient care, physiotherapists can help optimize pain management strategies and improve overall health outcomes. Incorporating interventions that promote healthy sleep patterns, encourage physical activity, support balanced nutrition, facilitate weight management, and address substance use can all contribute to reducing the impact of chronic pain on daily life.

Psychosocial

Psychosocial factors encompass a broad range of cognitive and emotional experiences that profoundly influence how patients perceive and manage pain. These factors can either exacerbate or alleviate pain symptoms, highlighting their significant role in patient outcomes. 

Negative Psychosocial Factors

• Stress: Various stressors such as financial difficulties, family conflicts, or work-related pressures can intensify pain perception. Chronic stress can lead to muscle tension, increased inflammation, and heightened sensitivity to pain stimuli.
  
  
• Worry: Persistent concerns about health outcomes, uncertainty about recovery, or fears about the future can amplify pain perception. This type of worry can contribute to heightened anxiety levels, which in turn may exacerbate pain symptoms.
  
  
• Depression: Clinical depression can coexist with chronic pain and worsen its severity. The emotional distress and negative thinking patterns associated with depression can magnify pain perception and reduce tolerance to discomfort.
  
  
• Frustration: Feelings of frustration or helplessness related to ongoing pain management challenges can negatively impact a patient's ability to cope. This frustration may lead to decreased motivation, poorer treatment adherence, and overall reduced quality of life.

Positive Psychosocial Factors

• Strong social support network: Having supportive relationships with friends, family, or a community can provide emotional reassurance, practical assistance, and encouragement during times of pain. Social support networks can foster resilience and improve coping strategies.
  
  
• Optimism about the future: A hopeful outlook and belief in the possibility of improvement or recovery can positively influence pain management outcomes. Optimistic attitudes can enhance motivation, promote engagement in treatment plans, and contribute to better overall well-being.
  
  
• Self-efficacy: A sense of self-efficacy, or belief in one's ability to effectively manage pain and achieve desired outcomes, is crucial. Individuals with high self-efficacy are more likely to engage in proactive pain management strategies, persist in efforts to improve health, and maintain a positive mindset despite challenges.

By recognizing and addressing these psychosocial factors in patient care, physiotherapists can develop holistic treatment plans that integrate strategies to enhance coping skills, promote emotional well-being, and optimize pain outcomes. Taking a comprehensive approach to pain management that considers both physical and psychosocial factors is essential for improving the overall quality of life for individuals living with chronic pain.

Physiotherapy Management: Cognitive Functional Therapy 

Physiotherapists are well-positioned to effectively treat patients experiencing chronic or persistent pain through a combination of exercise programs and self-management techniques. However, considering the multifaceted nature of chronic low back pain, treatment approaches must be equally multifactorial and tailored to individual needs.

One evidence-based physiotherapy intervention particularly suited for addressing chronic pain is Cognitive Functional Therapy (CFT). This therapeutic approach integrates three core components to address various aspects of pain and its impacts on daily life:

1. Cognitive component: CFT addresses cognitive factors such as beliefs and perceptions about pain, helping patients understand how their thoughts and emotions can influence their pain experience. By promoting positive cognitive restructuring and reducing catastrophic thinking, CFT aims to shift patients towards a more adaptive and empowered mindset in managing their pain.
   
   
2. Movement component: Central to CFT is the incorporation of movement-based interventions tailored to each patient's specific functional limitations and goals. Physiotherapists use targeted exercises and functional activities to improve mobility, strength, flexibility, and overall movement patterns. By addressing physical impairments and enhancing functional abilities, CFT aims to reduce pain and restore optimal physical function.
   
   
3. Lifestyle component: Recognizing the impact of lifestyle factors on pain, CFT includes strategies to optimize daily habits and behaviors. This may involve education on ergonomic principles, sleep hygiene, stress management techniques, and nutrition guidance. By promoting healthy lifestyle modifications, CFT supports long-term pain management and enhances overall well-being.

By integrating these three components—cognitive, movement, and lifestyle—CFT provides a holistic approach to treating chronic low back pain. This comprehensive method not only targets the physical aspects of pain but also addresses psychological and lifestyle factors that contribute to its persistence. Through personalized treatment plans and ongoing support, physiotherapists can empower patients to actively participate in their recovery, improve functional outcomes, and achieve better overall quality of life.

To learn more about how to integrate CFT into your physiotherapy practice, check out the following Embodia courses taught by Dr. Kieran O’Sullivan. 

Contemporary Management of
Persistent Low Back Pain 

and

Cognitive Functional Therapy - An Integrated
Treatment Approach For Persistent Pain

References

Kamper, S. J., Apeldoorn, A. T., Chiarotto, A., Smeets, R. J., Ostelo, R. W., Guzman, J., & van Tulder, M. W. (2014). Multidisciplinary biopsychosocial rehabilitation for chronic low back pain. Cochrane Database of Systematic Reviews, (9). 

Lacasse, A., Roy, J. S., Parent, A. J., Noushi, N., Odenigbo, C., Pagé, G., ... & Ware, M. A. (2017). The Canadian minimum dataset for chronic low back pain research: a cross-cultural adaptation of the National Institutes of Health Task Force Research Standards. Canadian Medical Association Open Access Journal, 5(1), E237-E248.

Laird, R. A., Gilbert, J., Kent, P., & Keating, J. L. (2014). Comparing lumbo-pelvic kinematics in people with and without back pain: a systematic review and meta-analysis. BMC musculoskeletal disorders, 15, 1-13. 

Lærum, E., Indahl, A., & Skouen, J. S. (2006). What is" the good back-consultation"? A combined qualitative and quantitative study of chronic low back pain patients' interaction with and perceptions of consultations with specialists. Journal of rehabilitation medicine, 38(4), 255-262.

Nolan, D., O’Sullivan, K., Newton, C., Singh, G., & Smith, B. E. (2020). Are there differences in lifting technique between those with and without low back pain? A systematic review. Scandinavian journal of pain, 20(2), 215-227. 

O'Keeffe, M., Purtill, H., Kennedy, N., Conneely, M., Hurley, J., O'Sullivan, P., ... & O'Sullivan, K. (2016). Comparative effectiveness of conservative interventions for nonspecific chronic spinal pain: physical, behavioral/psychologically informed, or combined? A systematic review and meta-analysis. The Journal of Pain, 17(7), 755-774.

O'Keeffe, M., O'Sullivan, P., Purtill, H., Bargary, N., & O'Sullivan, K. (2020). Cognitive functional therapy compared with a group-based exercise and education intervention for chronic low back pain: a multicentre randomised controlled trial (RCT). British journal of sports medicine, 54(13), 782-789. 

Raja, S. N., Carr, D. B., Cohen, M., Finnerup, N. B., Flor, H., Gibson, S., ... & Vader, K. (2020). The revised International Association for the Study of Pain definition of pain: concepts, challenges, and compromises. Pain, 161(9), 1976-1982.

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Date published: 30 July 2024
Last update: 30 July 2024