Treatment and Management of Mechanical Back Pain
Author: Mark Kelly (Registered Myotherapist and Exercise Professional).
The following outlines contributing factors associated with Mechanical Back Pain (MBP) and how these can be managed with a focus on being multidisciplinary.
MBP can be difficult to manage as there are many anatomical structures associated with the spine and pelvis that can produce pain. The mechanics of how the spine moves and takes load can also be complex. According to J. S. Will, D, C. Bury 2018 et el, the specific tissue injured and diagnosis can be identified in only 20% of cases with regard to MBP.
According to the Australian Institute of health and Welfare (2019). Between 2017 and 2018 “About 4.0 million Australians (16% of the total population) had back related problems” that effected their activities of daily living moderately. Back pain effects males and female similarly, is more prevalent in lower socioeconomic communities and has a higher ratio in Indigenous vs Non Indigenous Australians.
As we age the instances of back pain increase. Chronic / persistent back pain has been reported to effect up to 14% of the population. Back pain can be disabling and is an economic problem due to the cost placed on treatment and loss of work place productivity.
Pathophysiology (physiological process associated with MBP)
Mechanical back pain may arise from areas including vertebral (spinal bones) and joints, discs (rings cushion the made up of cartilage with a gelatinous centre that spine) (Ref Roberts, S, Evans, H 2006) or surrounding soft tissue including muscles, ligaments and connective tissue. Pain is felt when tissue is injured, compressed or if there is disease associated. This injured tissue triggers an immune response that aims to protect and heal the tissue. The nervous system also transmits pain messages via nerves. These nerve fibres will have specific connections to bone, joint structures and soft tissues. The body will then heal and repair the effected tissue over several weeks depending on the severity. Once this healing is complete the patient’s pain or complaint resolves. Sometimes changes can occur during this process resulting in chronic mechanical back pain (CMBP). Special nerve fibres called nociceptors send pain messages from either the skin, bone, joints, muscles or organs to the to the brain for processing. These messages however can be controlled on their way to the brain at the spinal cord through what’s called interneurons. These are located at each vertebrae level which act to control pain signals during various stages of injury. In Chronic pain, there is over sensitisation of these nerve fibres from the injury site. In some cases more pain messages start to get through the interneuron region and proceed to the brain more easily thus, promoting longer lasting pain. There can be many reasons for this which are discussed later in the article. The over stimulation results in people who experience CMBP to have heightened responses to such things as, touch over related areas or one or more movements in a particular direction that easily aggravate pain. (ref Allegri, M, Montella, S, 2016). One Mechanism more likely to contribute to CMBP related to disc injury is, re-injury during the healing process causing longer lasting inflammation. (Ulrich J A.; Liebenberg, E 2007)
Other factors that contribute to chronic mechanical back pain.
There are many interrelated factors that increase the likelihood of a person developing chronic pain from an injury in this case MBP. These factors involve how a person responds to an injury and focusses on the “whole person” (K Beavers 2016), their biology and genetic makeup. A person can be predisposed to developing chronic pain (there may be other members of their family that experience chronic pain from an injury). Psychologically how a person’s emotions to pain heighten pain. In instances of fear avoidance (where someone may avoid performing one or more activities due to their injury or a particular type of pain) and pain catastrophizing (the belief that the problem is worse than it actually is) increase stress or depressive mood as a person in this situation becomes frustrated with this cycle about the pain and not being able perform activities of daily living as well as they could before. this can be noted as psychological deconditioning. Physical deconditioning or weakening of stabilising muscles and changes in coordination and posture can then start to contribute to CMBP. Other contributing factors can include those who have lower socioeconomic background who don’t have adequate access to services. Cultural background may prevent a person from accepting certain types of treatment that aim to manage MBP. ( ref K Bevers, L Watts 2016).
Management with a multidisciplinary approach.
Managing MBP depends largely on the mechanisms of injury, how long the problem has been there and contributing factors that can either predispose the person to getting pain and factors that contribute to the pain not resolving. History and assessment are an important part of managing MBP as there are many possible contributing factors for example, spinal joints can be sprained (injury to the ligaments that stabilise the joint) from a fall or a collisions in contact sports, muscles can be strained from lifting or from repetitive overuse patterns. Similarly spinal discs can be injured from repeated lifting especially with poor posture or while twisting the spine. Other factors that can predispose (influence) a person to having disc related pain include degeneration, smoking dehydration and increased MBI and genetic factors. Degenerative changes also contribute.
Patient education on the importance of early movement while working within pain limits and in a controlled manner has been shown to deliver improved recover outcomes. The importance of returning to work as early as possible even if in a modified setting, then progressing to more regular duties has also been shown to improve recovery outcomes. (Ref J S Will, David C. Bury 2018).
Often combining activity for example yoga or corrective exercises with doing enjoyable things such as going out on day trips or taking a small holiday can aid in decreasing stress. Often doing these types of activities promotes the release of endorphins such as dopamine and serotonin which can act on pain levels and promote wellness. This is important as it can help shift the focus off a patient thinking that I can’t do anything because of my back pain. This has been shown to help prevent MBP becoming chronic. (Ref J Setchell, M Turpin 2020)
Determining postures and movements that aggravate and relieve pain are important. These factors enable the therapist is guide a patient through treatment and advice during the different stages of recovery. To put this into perspective, for someone who is worse moving in flexion (forward bending of the spine) management can involve, education on preventing sitting in slouched flexed postures. Encouragement of a more upright or extended sitting position with lumbar supports is also recommended. Educating the patient on how to develop more neutral lumbar region during movement i.e. walking can also be effective. Corrective Exercises can be used such as “sit to stands, squats and forward bending” with a focus on encouraging the recruitment of more muscles. The aim of this is to change the way the person is flexing forwards at the spine and encouraging a more neutral pelvis position. For a person who experiences aggravation extending (bending the spine backwards) management would differ. Often people with this presentation sit, walk and move with an increased lumbar lordosis curve (curved to the front). Patients with this presentation benefit from adopting a more neutral flexed spinal posture to decrease the lordosis. The use of soft tissue therapy by a Myotherapist or other qualified Practitioner is important, as it helps to promote lengthening to short and tight muscles running up the spine. Additionally, treatment can be applied to muscles at the front of the hips and pelvis that contribute to this increased lumbar curve. Exercises can be used such as crook lying (knees brought to chest), sit to stands with a focus on promoting some spinal flexion, squats, forward bending to encourage the lumbar region to flex more and the hips to be more neutral. Researchers discovered that for people who experience lumbar pain during flexion there was a loss of lumbar stability while moving through mid-range spinal flexion that resulted in pain and other muscles having to compensate these muscles are hip extensor muscles such as the gluteal muscles. Aiming to engage muscles that encourage a more neutral spine will help prevent this area of instability. (Ref M. Shahbazi, M Seraj 2018)
Adopting a holistic approach to the management of MBP has been shown to have greater results. With a focus on working collaboratively with medical practitioners and other Health Practitioners. with effective treatment strategies to help people with mechanical back pain.
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AIHW (2019). Back Problems www.aihw.gov.au
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