Managing low back pain using a holistic lifestyle approach

“I just bent down to pick up a piece of paper and my back went”

“I just felt my back twinge while I was walking and now it hurts all the time”

“It just went into spasm while I was lifting a shopping bag into the car”

“I just woke up with pain in my back”

These are all extremely common complaints that we have all heard time and time again. In fact, low back pain is so common you are more likely to have had back pain at some point in your life than not; 70 – 90% of people will suffer from low back pain in some form at some point in their lives.

So why do some people get better with a few days of rest and a massage and others take years of treatment, medications, even surgery with minimal progress? Why do we see those with no pathology on x-ray/scans have debilitating pain and dysfunction and those with severe pathology run marathons or return to heavy work duties with no difficulties?

It seems to be that when we are dealing with the condition of being human, the cause and the solution for low back pain could possibly be different and unique for each person. Finding pathology wont necessarily always correlate with finding the actual cause of the pain. And conversely, finding no pathology does not always correlate with no symptoms or dysfunction.

The purely biomechanical, muscoloskeletal paradigm often falls short, leaving people searching high and low for answers. So where do we look to help these patients? Is it lifestyle?

There is currently no 100% fail safe “cure” for low back pain. However, in my experience, the more we can take a truly holistic approach, not only to the person’s back injury, but to the whole person and their lifestyle, we can improve outcomes. Especially for those whose only current options are more of the same thing, more physio, more medications, or more surgery.

Let’s take a look at some interesting data, research and clinical examples to provoke some thinking into where those solutions may lie.

Mind/Body connection

There is a growing body of research looking at the mind body connection, and while some alternative practitioners will have you believe that back pain is caused by feeling a “lack of support” or “being stuck”, it is important to not let the hippy speak taint our judgements on the validity of these concepts. Some studies have shown that Mindfulness Based Stress Reduction (MBSR) or Cognitive Behavioural Therapy (CBT) are actually more successful at helping people with chronic back pain than standard physical treatments^1,6. We also know that people who report having psychosocial complaints/issues along with back pain, take much longer to return to work following back injury and have poorer outcomes overall.

Essentially, this is all pointing to the fact that if there are psychological/emotional stressors that a person cannot manage, the body gets stuck in a state of survival. When there is perceived threat, it is not a time for regeneration and healing, it is a time for fight or flight. The sympathetic nervous system kicks in and we have set up the conditions in our body for action, which is great if it is short term. But if this becomes a way of life, where our brains get programmed to be on alert, waiting for the next message, the next email, the google alert, the tweet, the phone call or the caffeine hit, we are setting up the conditions in our body for chronic inflammation, immune suppression and depletion of energy. Throw in a back injury and you can see the chances of a quick recovery are pretty grim.

Dr Herbert Benson, Mind Body Medicine Professor of Medicine, Harvard Medical School has spent several decades researching the “relaxation response” and the healing effects this can elicit. By evoking the relaxation response, people are able to heal conditions of chronic pain, anxiety and depression, and, furthermore, are able to change gene expression. Through his research, he has shown that people can effectively treat any condition that is being caused or exacerbated by stress. He talks about his research in this video⁴, and promotes the use of this meditation practice in conjunction with traditional and conventional medicine.

Dr Joe Dispenza has also shown through his research the effects that meditation can have on lowering cortisol and up regulating IGA.

So there is a pretty strong case for incorporating some simple meditation and mindfulness practices into a treatment program, especially given the cost effectiveness and the minimal time required, 10 – 20 minutes, twice per day.

Brain/Body Connection

Function and co-ordination of postural stabilising muscles are controlled automatically by the central nervous system anticipating movement. Professor Karel Lewit and Professor Pavel Kolar have given us an understanding how this postural stabilising function can become insufficient or dysfunctional, specifically relating to the diaphragm’s role in controlling intra abdominal pressure. Therefore, assessing breathing patterns in those with both acute and chronic lower back pain can give insights into dynamic neuromuscular (core) stability and compensatory movement patterns.

“The ultimate strategy is to “train the brain” to maintain central control, joint stability and ideal quality of movement that is achieved through guidance from the clinician. Eventually, through repetition of the exercises, the central control establishes an automatic model that becomes a fundamental part of everyday movement and skills”².

Normalising breathing pattern can be an extremely powerful and simple way of regaining some core stability, and postural support and therefore break the pattern of tight/weak muscles, compensatory movement patterns that are usually present in those with back pain.

One of the added benefits of teaching patients a breathing exercise is that it can be co-ordinated with a meditation practice to elicit the relaxation response. Double wammy!

Nutrition and digestion

While you would not really extrapolate that poor nutrition can cause low back pain, there certainly is benefit in looking at how someone’s overall nutritional profile can either set them up for healing and repair, or, contribute to ongoing chronic inflammation. For some people, even just the act of focusing and changing some aspects of the daily eating habits, gives them a better sense of wellbeing and hence, can sometimes help with chronic LBP. Surprisingly, patients can have years of back pain and no one has even spoken to them about the importance of adequate hydration. That’s a pretty simple place to start.

It’s also worth considering the neurological links between the digestive system and the back, ie. the nerve roots supplying muscles of the lower back and hips also supply the digestive system. Many physical therapy disciplines have been studying these viscerosomatic connections for a long time and it seems there is merit it considering this connection. It could be the abdominal organs are referring pain to the back, or it could be that long term inflammation in the gut, constipation, poor absorption, leaky gut are contributing to lack of healing. Either way, it’s worth taking this into consideration as part of the overall picture of a person.

Of course it is extremely common to see people who have used eating as part of their coping mechanism for their LBP, particularly those who have had to be off work and are sitting at home with nothing else to do. While this is often brushed under the carpet, it doesn’t make sense that at a time when the body needs optimal nutrition and hydration for healing and repair, it is getting loaded with chips, chocolate and coke. In my experience, patients are motivated to change once they realise there is a reason to increase their nutrition beyond the few kilos they might be putting on.

Co-morbidities

Is it the chicken or the egg? Does chronic lower back pain result from inactivity associated with conditions such os obesity or does the obesity come from the inactivity caused by chronic lower back pain? Probably both and the answer is different for each person. Of the estimated 3.7 million Australians who report having back problems, approximately 2 million of these report also having one or more of the following selected chronic conditions³.

Cardiovascular disease (CVD)
Arthritis
Mental health problems
Asthma
Diabetes
Chronic obstructive pulmonary disease (COPD)
Cancer

The important thing is to establish with the patient the connections and to treat lifestyle factors as part of the treatment for LBP.

Don’t ignore the obvious!

Of course, if someone is sitting all day twisting to the right to use a computer and complains that the right side of their back and neck is constantly sore, then don’t ignore the obvious biomechanical load. (Yes, true story……it happens all the time). If someone is lying around in bed all day with back pain, get them up and moving. If someone has nerve root compression, then no amount of breathing is likely to help them.

But for those that the answer is not obvious, a truly holistic approach can offer more options for resolution, recovery or management of lower back pain.

Low back pain hacks

Teach abdominal breathing

Even if this is not done 100% technically correct according to DNS principles, I have found that it will at least start the foundation of “core” activation in a synergistic and co-ordinated fashion. And, for those patients who struggle to engage in any sort of MBSR, meditation or relaxation strategies, this can be a more socially acceptable way for them to start. If we can teach them to start this as a regular practice, it has potential to momentarily elicit a relaxation response in the body and switch on the healing mechanisms. Start with lying on the back, either with knees bent or extended. Place the hands on the belly, one hand above the umbilicus and one below. As the patient inhales, the abdomen should expand, and as they breathe out, it should relax. Look for expansion of the abdomen both anterior and lateral. Once the patient has been able to master this, they can progress over a couple of weeks to doing the breathing seated or standing.

Join a group

Get people involved in a group such as bush walking, yoga, swimming, pilates. Gentle exercise is always better for back pain than doing nothing, and the psychosocial benefits of belonging to a group add to the healing benefits.

Teach stretches that can be done standing up

Sounds odd, however, if people have to lie down to do stretches they simply wont do them, or they can’t. Teach them how to stretch the major muscles groups of the lower back, hips and legs while standing up and encourage them to do them regularly throughout the day.

A note on surgery. I have seen many people over the years who have had spinal surgery with limited relief of pain. In my opinion, surgery is best reserved for those who have spinal nerve compression with numbness or weakness in the legs or loss of bladder or bowel control. These people seem to typically get great relief and return of function following surgery. I have noticed, those people who have surgery when their main complaint is pain, tend to get limited results from surgery. And, if surgery is offered, ask what the surgeon is proposing to do. It’s always an interesting conversation when spinal surgery has been offered with no reason other than “to have a look” or “tidy things up”!

References

Braden BB, Pipe TB, Smith R, Glaspy TK, Deatherage BR, Baxter LC. Brain and behavior changes associated with an abbreviated 4-week mindfulness-based stress reduction course in back pain patients. Brain Behav. 2016;6(3):e00443. Published 2016 Feb 16. doi:10.1002/brb3.443
Frank C, Kobesova A, Kolar P. Dynamic neuromuscular stabilization & sports rehabilitation. Int J Sports Phys Ther. 2013;8(1):62-73. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3578435/
Australian Institute of Health and Welfare (AIHW). Back problems snapshot. Published 2018 July 28. https://www.aihw.gov.au/reports/chronic-musculoskeletal-conditions/back-problems/contents/back-problems-and-associated-comorbidities-the-numbers
Benson, H. The Relaxation Revolution: Enhancing health through mind body healing. WGBHForum. Published 2012 Sept 10. https://youtu.be/KZ7JfC3_Zgc
Kolář, P., Šulc, J., Kynčl, M., Šanda, J., Čakrt, O., Andel, R., . . . Kobesová, A. (2012). Postural Function of the Diaphragm in Persons With and Without Chronic Low Back Pain. Journal of Orthopaedic & Sports Physical Therapy, 42(4), 352-362. doi: 10.2519/jospt.2012.3830
Cherkin DC, Sherman KJ, Balderson BH, et al. Effect of Mindfulness-Based Stress Reduction vs Cognitive Behavioral Therapy or Usual Care on Back Pain and Functional Limitations in Adults With Chronic Low Back Pain: A Randomized Clinical Trial. JAMA. 2016;315(12):1240–1249. doi:10.1001/jama.2016.2323

This article has been written for the Australasian Society of Lifestyle Medicine (ASLM) by the documented original author. The views and opinions expressed in this article are solely those of the original author and do not necessarily represent the views and opinions of the ASLM or its Board.

Jacqueline Edser is a qualified Occupational Therapist, Certified Lifestyle Medicine practitioner and offers Lifestyle Medicine Coaching.

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