Back to the future on NSLBP

Great Scott!

A very happy lady just left the clinic. She had come in last week with acute non specific lower back pain (NSLBP), in a lot of pain she had difficulty moving and was quite worried something was seriously wrong. She came in today pain free like it never happened the week before. I hadn’t fixed her but I had educated her and reassured her. She had fixed herself.

It got me thinking about my management of NSLBP and how it has changed significantly over the last 10 years based on evidence. So I thought I would jump in my Delorean time machine and revisit my management of NSLBP in 2007 as a 2nd year physio. If the time machine still works ill then jump back into it and back to the year 2017 with my current management based on current evidence.

I arrive in the year 2007 (2nd year out of university) a few less grey hairs and not much social media present, probably no text neck (eyeroll) . A ‘patient’ hobbles into the room with acute LBP. My brain ticks over… definitely acute disc injury.

I start with the subjective, clear red flags and ask lots of questions but most likely not listening to the patients pain story. I’m already thinking what treatment techniques I can use out of my impressive tool box to get this patient bending, extending and moving better when they walk out the door. I’m also a bit worried, could I hurt their ‘disc’ more by doing the wrong movement or pushing them in the wrong direction and at times probably exhibited this fear.

I do a standard objective assessment and confirm my diagnosis. I continue to explain the disc anatomy and using pictures I show the bulging nucleus and without realising back then feed them a bucket load of catastropising and nocebic language. If the patient had obvious ‘yellow flags’ I would occasionally talk about central sensitization and in a confused manner try to explain the role of the brain in pain that probably didn’t make the slightest of sense. I was no psychologist and felt uncomfortable doing this.

Following a structuralist management plan I throw the kitchen sink at them. With an overflowing tool box I was keen to take away stiffness in joints, loosen up muscles and mobilise nerves. I used mobilisations, massage, dry needling, stretching, heat and ultrasound (actually no I never did use ultrasound).

The treatment results varied greatly one patient may have been moving better after treatment and the next might be stuck on the bed in more pain after some ‘pain relieving’ PAs in prone stirred them up more. Maybe the lumbar rotations didn’t work?

After some box taping to ‘support’ and ‘brace’ the spine and some gentle ‘pain free exercises’ I would encourage TrA activation for them to do at home. I educate them to avoid sitting, bending, twisting and lifting and to take care with all movements not to aggravate the disc. A treatment plan involving 2-3 sessions within a week is discussed so I could help them with their pain using my treatment (and to keep my boss happy, meet KPIs etc etc.). There was also likely a pilates program needed to restore ‘core strength’.

I probably forgot to reassure them that nothing was serious and to ad further worry I would have probably thrown in a ‘we might need to get a scan if things don’t settle down. (facepalm).

It was 2007 and I was treating based on what I was taught at uni, through my clinical placements and mentors. Sure most patients got better but there were mixed results and time frames for recovery varied a lot. I struggled with ‘difficult cases’ that required more pain education. Time to head back to 2017 I think!

I jump back in my Delorean and head back to the current year of 2017. Things have changed a lot! More grey hair, Donald Trump is president of the USA and a lot of new evidence on the management of NSLBP is available through various mediums online.

The ‘client’ hobbles in the room with what appears to be acute LBP. My brain ticks over… hmmm what’s triggered this I wonder? A BPS approach is used.

I listen to the patients story. I gain as much rapport as possible while I delve into their thoughts and beliefs about their pain and potential triggers leading up to the acute back pain episode. I rule out red flags and continue onto the assessment.

After watching them go through some movements in my assessment and encouraging them on their current movement abilities my initial treatment is reassurance. I acknowledge their pain but also let them know it’s not serious in nature and that most pain is not linked to damage but sensitivity. I explain the back is a strong robust structure but can also be highly sensitised at times that can feel very serious. We discuss NSLBP as a diagnosis. There would be minimal tissue structure discussion.

The tool box has been significantly emptied over the last 3-4 years. Depending on the ‘client’ I use some light manual therapy techniques to make them aware of the sensitised tissue state while educating them that I’m not releasing, moving or adjusting their joints or muscles. We talk about the complexity of pain mechanism in a laymans terms depending on the patients expressed beliefs and past experiences with pain and or management of this. If the common disc injury question is asked I often show them the MRI findings seen in asymptomatic people. There is no talk of core strength or stability around the spine.

Movement and continued activity as tolerated is encouraged and a home exercise program involving some movement and an activity the patient enjoys doing is recommended I explain they can work into some tolerable pain is during this.

After further reassurance and encouragement I suggest a follow up the next week to make sure they are progressing as we would expect. There are not set plans or time frames. There are no pilates classes.

Now who knows if I will look back at this management in another 10 years time and cringe as I do now at some of my 2007 treatments. I may now have bias to the BPS model but what I am seeing is quicker and more consistent positive outcomes with NSLBP than I did in 2007 especially the 'challenging cases'.

Healthcare is ever evolving, challenge your bias always and never stop learning. Evidence is now too readily available to have an excuse not to follow it.

Thanks for reading.

Hamish The Physio

Non guru