[NB: You might have realised by now that we’ve already (at least partially) answered this question in previous pages. However, given its importance, I have dedicated a separate page to provide some further points/clarifications.]
People are often surprised during an episode of LBP when I encourage them to continue their regular activities as much as possible (including work and exercise). It seems counter-intuitive when you’re in so much discomfort that movement will actually help you get better. And yet, keeping active and returning to work early are both core recommendations in all of the major LBP guidelines.
By now you’re very familiar with the two major manifestations of LBP – pain and disability. I began my clinical practice as a very ‘pain focused’ practitioner (which is a nice way of saying I was obsessed with it). During a consultation I would start by asking people about their pain levels. “What is your current pain level on a scale of 1-10? What’s the best/worst your pain level has been since I saw you last?”. I’d also ask things like “Is that painful?”, or, “Any pain with that movement?” etc. By emphasising pain like this, I was inadvertently encouraging these people to become pain-focused themselves. In theory this could increase the chance of these people developing unhealthy pain behaviours (e.g. catastrophising, hypervigilance, avoidance etc.). As we’ve covered previously, these yellow flags can adversely affect the prognosis of a LBP episode, specifically by contributing to the following vicious cycle:
The more you fear pain.
The more you try to avoid it (and the less you do stuff).
The more it sucks (increased levels of pain, disability and depression).
Eventually I learnt that I should have been using ‘function’ as the metric for patient-progress (not pain). This is important because disability (inversely related to function) often resolves at a faster rate, which means a person may still be experiencing pain after they have regained full function.1 If you are focusing too much on pain, then you are blind to many of the improvements during the initial recovery process. Also, from a patient’s perspective, once you understand that it’s normal to have some pain even after you can move freely again, it can provide some welcome reassurance.
Don’t shoot the messenger!
It’s natural to want to avoid pain. After all, that’s kind of its point – to alert us of potential danger so that we can stop whatever’s causing it. After associating this protective mechanism with injury or harm for so long, it has come to be viewed as ‘the enemy’ (think ‘pain-killers’). And while pain is definitely not the enemy, it’s useful to recognise that it’s not always as helpful as we’d like, either. In the case of LBP, pain is rarely a reflection of significant tissue damage. Instead, for some unknown reason, the body tends to ‘over-react’ to the initial insult, making it seem worse than it really is.
What does this mean for me? (Practical implications)
On a practical level it means as much as possible not being ‘ruled’ by your pain levels. And while this doesn’t mean pushing through extreme pain, it probably means moving with some discomfort (see next section). It also means it’s prudent to return to your regular activities (whether it’s work or exercise) as soon as your functional level allows you to (even if you still have some pain). In fact, if you wait until you’re completely pain-free before returning to your previous activities, you are playing into the whole ‘fear avoidance model’ above. The quicker you ‘get back to it’, the less muscle strength you’ll lose (use it or lose it’ principle) and the sooner you’ll benefit from all of those other positive effects from doing the things you want!
Good or bad pain?
In general, it is safe to continue a particular activity provided:
• The pain/discomfort is manageable (you can cope with it – i.e. ache vs sharp pain).
• The discomfort/pain plateaus (i.e. the level of pain stabilises after a while).
• The pain/discomfort gradually decreases after you finish the activity.
Assuming you can work or exercise within the above guidelines, then you’re in pretty good shape! As usual, ‘listen to your body’. If what you’re doing causes severe pain (especially pain with a sharp or electric quality to it), then stop! It doesn’t necessarily mean you can’t do it at all. Try modifying the activity or doing something else for a while. You may find that it feels better when you come back to it. If it’s still quite painful then it’s probably a good indication that you’re not ready for that activity yet.
One other thing worth mentioning is that if you’ve had any length of time off (even a day or two), you’ll probably want to ease your way back into things. For example, if you normally run 10km every afternoon, but you haven’t done so for the last week (due to your LBP), it’s sensible not to jump straight back into your old routine. Instead, you could modify the activity to make it easier by (for example) running slower, for a shorter distance, or even changing the type of activity (you could try walking interspersed with jogging or going for a swim instead). Remember even if your lower back feels good at the time (e.g. during running), if you do too much too soon you run the risk of aggravating it (which may not be apparent until the next day). Again, it’s not usually a big deal but it can be very inconvenient. It’s that ‘graded exposure’ thing again (start small and build gradually)! Importantly, this principle applies equally to any work-related activity too (including sitting at a desk!).
• Keeping active and returning to work early are important aspects of your recovery.
• Function, not pain, is the key metric when it comes to your (recovery) progress.
• The ‘Fear-Avoidance Model’ states that the more you fear pain, the less you do, the worse off you become (increased pain, disability and depression).
• Pain is rarely a reflection of significant tissue damage in LBP.
• Return to your normal activities (e.g. work or exercise) as soon as your functional level allows you to – even if you still have some pain.
• In general, it is safe to continue a particular activity provided the pain/discomfort 1) Is manageable (you can cope with it – i.e. ache vs sharp pain); 2) Plateaus (i.e. the pain level stabilises after a period of time); and 3) Gradually decreases after you finish the activity.
• Where possible, activity modification can be used to maintain your previous activities (e.g. work and exercise).
• Avoid returning too quickly to your original activity level after you’ve had any time off with LBP (start small and build gradually).
1. Henschke N, Maher CG, Refshauge KM, et al. Prognosis in patients with recent onset low back pain in Australian primary care: inception cohort study. BMJ. 2008;337(jul07 1):a171-a171. doi:10.1136/bmj.a171.