Mastering persistent low back pain management: Expert strategies revealed

Persistent low back pain is a common cause of loss of function and can be tricky to manage for physios. Here, we are referring to back pain that persists for more than three months and is non-specific (i.e., lacking a clear patho-anatomical cause). After a thorough assessment (see this blog on assessment of persistent low back pain!) we should have a full picture of the factors influencing our patient’s pain and what functional activities we need to work on. Our management approach centres around progressing patients towards their desired activities through behavioural experiments, education, and developing a home program to make it all stick. The implementation of this plan must be individualised to each patient, taking into consideration their presentation, beliefs, and expectations. In this blog we’ll walk through Dr. Kevin Wernli’s excellent Practical on the management of persistent low back pain.

If you’d like to see exactly how expert physio Dr. Kevin Wenli manages persistent low back pain, watch his full Practical HERE. With Practicals, you can be a fly on the wall and see exactly how top experts assess and treat specific conditions – so you can become a better clinician, faster. Learn more here.

Approaches to retraining

To retrain any functional activity or posture, it’s useful to use several approaches, such as:

• Highlighting behaviours: increasing patients’ awareness of behaviours which may be contributing to their pain, such as excessive trunk bracing. Most of these come from our initial exam, however, we will likely uncover more as we observe the patient in the clinic.
• Behavioural experiments: modifying movements/postures, then getting feedback from the patient about how said modifications change their pain.
• Deconstruction: breaking down movements to a smaller range of motion, a position of decreased spinal load, and/or a non-painful starting position.
• Repetition: practising movements/postures that are less painful, to reinforce the experience of comfortable movement.
• Graded exposure: gradually increasing the range of motion, load, speed, and/or variability of movement as tolerated by the patient.

In this blog, we’ll cover interventions for the following functional activities:

• Sitting and sit-to-stand
• Forward bending
• Lifting objects

Retraining sitting and sit-to-stand

Sitting

For sitting, we first want to raise the patient’s awareness to any aberrant habits that may be contributing to their pain, such as apical breathing with excessive trunk bracing. Then we’ll cue them into a different position, as Dr. Wernli demonstrates in the below video from his Practical:

It’s important to note that we are not simply instructing patients to sit differently. We take them through a different experience and ask them to contrast how the “new” posture feels compared to their “old” posture. Such experiential learning is quite powerful and sticks better than simply giving advice.

After the patient has experienced sitting in a less painful way, the door opens for education about sitting posture. Patients often experience cognitive dissonance, because the posture that actually feels good may not coincide with common postural recommendations they have heard. Here we can highlight that there is no “best” posture for every person and that posture does not consistently correlate with pain.

Sit-to-stand

As with sitting, we retrain the sit-to-stand by first increasing the patient’s awareness of aberrant movement habits, like trying to maintain an upright trunk position. Then we encourage them to move in a different way. A crucial point is that we have the patient repeat the sit-to-stand to reinforce the experience of comfortable movement. For many such patients, they have experienced hundreds of painful sit-to-stands with their “old” way of moving. In the safe environment of the clinic with a physio, they can rewrite that neural pathway and experience the sit-to-stand with less pain.

Retraining forward bending

Bending forward is an important, yet often quite painful functional movement. To retrain it, we will use a similar approach to that of sitting and the sit-to-stand, however, we often have to deconstruct this difficult movement and then build it back up. This may be over a single session or even multiple sessions.

When a patient’s back is highly sensitised, we can start forward bending from a hook lying position. From there, we will gradually expose them to more challenging movement experiences, while making sure their pain levels are tolerable and helping them regulate their sympathetic nervous system response. For example, a starting point may be simply visualising forward bending. Then we could progress to knee-to-chest exercises, posterior pelvic tilts, and other low-load lumbar flexion movements. Once the patient’s sensitivity has decreased, we can progress to forward bending from a sitting position. Like with hook lying, we are gradually exposing the patient to more challenging movements, while ensuring their pain levels are tolerable and that they can regulate their sympathetic response. See the below video from his Practical in which Dr. Wernli demonstrates a progression from sitting to forward bending:

Retraining lifting

We address challenges with walking and lifting in the same way – we highlight aberrant movements, cue them to move differently, and then contrast how the movements feel. With movements like lifting it can be useful to introduce variables like speed and a variety of directions, in order to train the body for the demands of real world lifting. Dr. Wernli demonstrates how to modify lifting technique and progress such variables in the snippet from his Practical below:

Home program and progression

At the end of the session, we recap patient-specific pain drivers (e.g., stress, fatigue) and highlight the behaviour experiments of the day. This ties into prescribing a home program which consists of:

1. A habit program: a plan to integrate “new” ways of moving into their daily activities.
2. An exercise program: a schedule (usually daily) of performing a few functionally relevant exercises.
3. An education program: homework on pain science education, such as videos or reading.

When discussing the home program, we need to work with the patient to help them integrate the plan into their daily routine. A rule of thumb is to start small and gradually introduce changes over time. When wrapping up, be sure to discuss the big picture progression and encourage patients to share activities that they want to return to. We also need to discuss flare-ups. We should remind patients that flare-ups are normal and discuss a plan for how to deal with them. The patient should leave the clinic not having simply “done some exercises at physiotherapy” but with confidence in a plan to live a fuller life, not limited by back pain.

Wrapping up

Managing persistent low back pain is a fluid process, which centres on progressing patients towards their desired activities and consistent dialogue to engage the patient throughout the process. We rebuild a patient’s capacity through behavioural experiments, education, and a home program that meets them where they are and gives them a solid plan to move forward.

To see exactly how a master physio manages persistent low back, check out Dr. Wernli’s full Practical HERE.