Faaaaaaaarrrrr out! I’m SO over this pain! Make it stop…please!
There are no silver bullets when it comes to LBP, and sadly pain relief options are no exception. Instead, we’re left with a bunch of pain relief options which, depending on the severity of the episode, may not even touch the pain. Then again, sometimes they’ll make a HUGE difference. 😊
Even if by themselves these options don’t seem to do much, usually when they’re used together they should have a noticeable impact.
Since every episode of LBP is different, even if one exercise worked wonders for your neighbour, it may not work for you. Heck, what helped during your last episode may not even work at all this time! That’s why it’s great to try as many of these pain relief options as possible. In my experience if you do this, you will manage your pain better, and usually recover quicker.
Keep active (move within your limits!)
All major LBP guidelines now recommend that you keep active rather than try to rest too much.1 In fact, there is even evidence that too much bed rest can delay your recovery.2
So, what does it mean to keep active? Obviously, this varies on a case by case basis, but really it means if you can move without too much pain or discomfort, you should. If you get a terrible pain (sharp, or ‘unsettling’) with a particular movement, then stop! You’re probably aggravating your LBP. It may be that you can just change the movement, or perhaps you just need to be patient and wait a day or two. The idea is to return to your normal activities as quickly as possible, but without overdoing it. This includes both at home and at work and is important since improved ‘function’ (i.e. movement) is usually followed by a decrease in pain (not just the other way around!). During your recovery remember to reintroduce activities slowly if possible, gradually returning to your previous levels. Sounds like common sense, right!? Unfortunately, it’s more common for people to go ‘too hard, too soon’ once they start feeling better. And while this isn’t a big deal, it can set you back with your recovery. Therefore, the key to striking the balance right is to listen to your body, and even if you’re feeling good while exercising, perhaps err on the side of caution and pull-up before you get sore.
Tip: One of the best tips is simply avoiding sitting or lying down for extended periods unless you really have to (excluding sleep). Instead, make sure you get up and take short walks on a frequent basis. This is particularly important if you work in an office environment and often find yourself sitting at your computer for long periods. Set a timer to stand up and do a few gentle mobilisations (more on these below) and/or have a short walk every 20-30 minutes. You can also get apps which will remind you to do this (e.g. ‘Stand Up!’ Or ‘Move’).
Heat/cold (e.g. applying heat bags, ice packs, warm showers etc.)
Heat and cold can both be used as a source of temporary pain relief. And while it really boils down to personal preference, in my experience heat is usually the best option. There is also more evidence supporting its use in pain relief.3 One study even reported that heat was more effective than two over-the-counter painkillers combined (NSAIDs and paracetamol).4 That said, even though some people can react unfavourably to cold, if it does work for you, then go for it!
Tip #1: If you can tolerate cold, try following it immediately with heat. Start with cold for 5 minutes (anaesthetic effect), followed by heat (draws blood back to the area) for the same length of time. I’ve found this ‘flushing’ effect can be quite effective. You can repeat this whole process once more if you like, but then I would wait a few hours before trying it again.
Tip #2: Try not to use either cold or heat for too long. Even heat can be irritating if it’s used for more than 15-20 minutes (NB: This isn’t usually a problem unless you re-heat the heat pack or it’s some kind of continuous heat source).
WARNING: Talk to your doctor or pharmacist before taking any pharmaceutical drug (especially for the first time) and always take only as directed. Even so called “harmless” over the counter (OTC) drugs can have potentially serious side effects.
While pharmaceutical drugs can sometimes be useful for LBP, overall, they have limited effectiveness in my experience. However, once again it’s a case by case basis and I have also seen them make a real difference at times. The main OTC pain medications (analgesics) used for LBP, are ibuprofen (e.g. Nurofen, Advil and Brufen) and diclofenac (e.g. Voltaren, Cambia and Cataflam) which are both Non-Steroidal Anti-Inflammatory Drugs (NSAIDs). Recent LBP guidelines have moved away from recommending the use of paracetamol (acetaminophen) alone due to a lack of effectiveness.5 On the other hand there is some evidence that NSAIDs are slightly effective for treating LBP.6,7 Talk to your doctor or pharmacist about which type of NSAID is best for you. In my experience it can be a case of trial and error. If you’ve used one before with good effect, logic would suggest you continue using that drug. I’ve had cases though where patients have only benefited from NSAIDs after they changed types.
One thing about NSAIDs is that they should only be taken for the shortest period possible to avoid any side effects (mainly to do with stomach and kidneys).7 This is fine for the majority of people who only need to take them for a few days to get their LBP under control. However, some people with pre-existing gastrointestinal or kidney issues may not be able to take NSAIDs at all. Fortunately, you can also get topical NSAIDs (gels/creams/patches etc.), which, because they’re absorbed through the skin (and not the stomach), are much less likely to cause these gastrointestinal side effects. Two separate Cochrane reviews (quality evidence) have already confirmed the effectiveness of topical NSAIDs for acute8 and chronic9 musculoskeletal pain (of which LBP is an example of). As always, talk to your doctor or pharmacist who will help you choose the best option. Personally, if you can afford paying a bit extra, I would suggest trying the topical version first (even if you don’t have any gastrointestinal issues).
One of the areas where I’ve seen analgesics work quite effectively is helping people get to sleep. Sleep is so important (to EVERYTHING) and therefore it’s definitely a priority if you want to recover more quickly. Sleep disturbance is common in patients with LBP although interestingly it’s only been reported as weakly associated with the intensity of the pain (which suggests other factors also contribute to sleep disturbances for these patients).10 In any case, it seems to me that patients who sleep better, recover faster.
There are various other classes of drugs that are used for LBP (opioids, muscle relaxants, anti-depressants) however these drugs are mainly prescription medications and therefore out of my scope of practice. For now, at least I’m quite happy to leave that discussion for you and your doctor! What I will say is that evidence supporting their effectiveness for LBP is a real ‘mixed bag’ and they also have a few noteworthy drawbacks (e.g. potential for addiction with opioids). For these reasons I would suggest that these drugs should only be considered for 1) the most severe forms of LBP; 2) persistent or chronic varieties; and 3) if you have other medical conditions (co-morbidities). In all of these cases your doctor will be the best person to inform you of their merits for your particular case.
Hot tip: Before you take any medication talk to your pharmacist first. You don’t need an appointment and they usually have all sorts of helpful advice that you may not have considered. This is especially important if you already take any other drugs (including OTC medications – not just prescription meds) or supplements (herbs, fish oil etc.), to avoid any adverse health effects.
Relieving positions (for severe LBP episodes)
In the early stages of a severe episode of LBP you will be lucky if you can move much at all. Your sole focus is decreasing your pain, which is the purpose of relieving positions.
One of the most reliable relieving positions is the ‘astronaut position’. Basically, it’s like sitting on your back. Lie on your back and put your legs up on a low chair or coffee table (so that your knees and hips are flexed up to 90 degrees). This pelvic position takes pressure off your lower back and therefore temporarily relieves most cases of LBP.
Relieving positions can be virtually anything (depending on the person, episode etc.), including lying on your back with a pillow under your knees, lying on your side with your leg dangling over the side of the bed, or even slumped in a chair (NB: get rid of any pre-conceived notions about ‘bad’ posture – more on this another time). It can be one or all of these positions. Basically, whatever gives you relief is fine (hint: only you will know what they are!). Once you know what your relieving positions are, you can gradually turn them into an exercise (movement).
Tip: During the early stages of a severe LBP episode, be careful of lying on your stomach for TOO long (especially if you get some kind of treatment like a massage). I’ve heard of several instances where people have gotten ‘stuck’ in that position during a treatment, resulting in the manual therapists having to call the ambulance! It’s probably caused by the tissues relaxing, only to be ‘shocked’ when the person goes to change position again sometime later, causing spasming and extreme pain (hence not being able to move!). Fortunately, lying on your back is unlikely to result in this painful (and rather embarrassing) situation!
Exercises for pain relief (including mobilisations)
Rather than simply providing a list of exercises that may or may not work for you, this section outlines the principles behind creating your own. It’s the ol’ teach a man to fish adage… The emphasis is on ‘pain relief’ rather than ‘treating’ your back (although these are by no means mutually exclusive). Longer term exercises, especially those prescribed by a health professional, will be covered in ‘What are my treatment options?’
In most cases of LBP, you should be able to begin exercises pretty much from the onset. They’re a vital component in ‘keeping moving’ and the notion that movement begets more movement. Rather than getting too technical about them (overthinking it), just try different movements that aren’t aggravating. It might help if you start with a relieving position and then build from there. This could involve a degree of creativity but it doesn’t have to either. Probably the best exercise you can do during a LBP episode is plain ol’ walking. This is great because you can walk in the majority of cases. Just remember to start small and build slowly (even if you’re feeling good!).
Tip: If you find walking for exercise a bit dull, try making it as fun as possible by taking with you a delicious drink or snack and/or talking to a friend as you go (either in person or on the phone).
There are 1,340,012 exercises that help relieve LBP! 😉 However, whether an exercise is helpful for you will depend on at least a few different factors:
1. What’s causing your LBP;
2. Severity of the LBP; NB: In nearly all cases this is correlated with ‘How long you have had LBP’.
3. Your relieving/aggravating factors (positions, movements, activities etc. that make it feel better or worse)
Since we don’t really know what’s causing the majority of LBP cases, the main thing to take away from the first point is that each LBP episode is different (which is why no one set of exercises works for everyone). However, if you do have a ‘flare-up’ (recurrent vs ‘new’ episode), the same exercises you used before will probably work (after taking severity into consideration).
The next point refers to the severity of the episode. Generally speaking, the more severe your LBP, the more disability you will have, the less you will be able to move, the more restricted your exercise options will be. Naturally this means that as time goes by and you improve, you will be able to progress your exercises. I know what you’re thinking…Duh!
The final factor is linked with the first. It relates to probably the most intuitive principle of pain relief which is avoiding positions/postures/movements/activities that make your pain worse! In other words, avoiding aggravating factors. In contrast, the things you do which provide you relief are called relieving factors (thanks again, captain obvious!). And as basic as this may sound, this principle can help steer you towards the types of exercises that will actually work for you.
If your lower back hurts with extension (arching your back), exercises that flex your lower back will probably be good for you.
Example, ‘child pose’.
If your lower back hurts with flexion (bending forward), extension exercises may give you the best relief.
Example, ‘cobra pose’ (back extensions).
Of course, the aggravating or relieving factors aren’t always that obvious. In this case a good starting point during the early stages of an episode is an exercise called ‘knee rolls’. This has to be one of the least aggravating exercises for LBP and therefore the most commonly prescribed by manual therapists. It can be described as lying on your back with your arms out straight to each side, knees up with feet flat on the ground, and then gently rocking your knees from side to side. You should feel a slight stretch throughout your spine, pelvis and hip regions. As always, start slowly and with minimal movement and then gradually increase the movement until your knees are nearly touching the ground (it may take a week or two before you can do this pain-free). (NB: Two variations include straightening your top leg as you twist to the side to get a bit of extra stretch; and secondly tucking your knees into your chest). There are two reasons why I love this exercise: 1) It is so ‘safe’, yet effective – since it’s basically an extension of the astronaut position, and 2) it is a form of joint mobilisation for your spine and hips. Which brings me to my next point.
Mobilisations deserve a special mention since they’re one of the most commonly prescribed exercises for treating and managing LBP (with good reason). They are basically highly repetitive movements which put selected joints through their range of motion. They’re fantastic at getting everything moving, not only activating and stretching muscles but also other ‘passive’ structures like ligaments and connective tissues. They really get the ‘juices’ flowing, priming the body’s tissues in the process! (It’s basically just all-round goodness for your body!) 😊 I also tell patients that mobilisations are a great way of providing your brain with reassurance (‘neurological reassurance’). I use the analogy that during an injury your brain is like an anxious parent, fussing over their children (e.g. joints, muscles etc.). However, the rhythmic movements in mobilisations are like your joints’ way of saying to the brain, “Hey look! I can move this stuff without any danger, see!” and after a while your brain begins to believe it and relaxes. This is why I advocate doing these exercises for a good 60-90 seconds (NB: the ‘knee rolls’ exercise above is perfect for first thing in the morning – before you get out of bed). Mobilisations should be performed within your pain threshold (nothing more than a slight discomfort). Anything more than this kind of defeats the purpose. Mostly though they’re intended to feel gooooood! 😊
[Note: While stretches are fine, in my opinion they aren’t as effective as mobilisations which contain elements of both stretching and movement. I will discuss stretches in more detail at a later stage.]
In summary, the key to finding the right exercise for you is listening to your body. If it feels good, it usually is! This principle may seem like an oversimplification, but in my experience it’s important during the acute stage of an episode when you’re still in pain/discomfort.
More examples of exercises for your LBP.
Other pain relief suggestions (more general advice)
Minimise aggravating activities
The key word here is ‘minimise’. Rarely is it practical to avoid aggravating factors entirely (life doesn’t stop because you’re in pain!).
Some potential aggravating factors include:
• Seat height (this is potentially a big one!) – home furniture (especially low/soft couches), work/office chair, car seat. NB: In general, try not to sit for too long at any one time.
Tip: In most cases it will be easier for your back if you sit on higher rather than lower chairs – so try not to sit with your knees any higher than your hips! If unavoidable (e.g. car), this can be remedied with a range of different cushions and foam inserts to help raise your hips!
• Workplace ergonomics – this could be to do with various factors not limited to your desk or workbench height, computer screen position and/or height, or even the position of your phone
Tip: You may be able to get an ergonomic assessment from your employer
• Aggravating activities (work) – this could be virtually anything depending on what you do, although sitting for too long and lifting are possibly the most common ones.
• Aggravating home activities (home) – E.g. cleaning, lifting kids, other home activities.
Manage your mental and emotional state
This is just as important as physically managing your pain. There is a well-established body of evidence which demonstrates how powerful the mind-body effect is.
Firstly, be optimistic. To do this, you may need to reassure yourself by remembering the following two things:
1. The prognosis for the majority of LBP episodes is good!
2. Your back is strong…and in terms of LBP, pain does not equal harm.11
Evidence suggests your expectations are powerful. One study looking at occupational low back disability reported that the expectations of recovery of study participants was the most important predictor when it came to their return to work status and disability duration.12 And while this primarily concerns people with chronic LBP, there’s no reason why it shouldn’t also apply to more acute cases too.
Besides, ‘staying positive’, another approach is to avoid getting overly emotional about your pain.
There is no doubt that pain is a deeply emotional (subjective) experience – just look at anyone who is in severe pain.
Rather than the relationship between pain and emotion looking like this:
Increased pain Increased emotions (unidirectional)
It’s actually more like this (bi-directional):
We’ve already seen that LBP is associated with a range of pain behaviours such as ‘fear avoidance’ or ‘catastrophising’. ‘Catastrophising’ is a harmful pain behaviour in which a person has irrational thoughts which leads them to believing something is worse than it actually is. As you can imagine, it’s easy to do with LBP when there is such a discordance between the extreme pain levels and lack of tissue damage! Unfortunately, this increased fear (emotions) feeds back into the pain loop resulting in a heightened sense of pain.
So instead of letting your emotions ‘run riot’ each time you experience that horrific pain in your back, try being as objective as possible (easier said than done, I know). If the rationalisations above don’t help, try ‘getting curious’. Instead of thinking (or screaming!), “Ah f**k this pain is bad!”, try thinking to yourself, “That’s interesting, my pain is definitely worse this afternoon, have I done anything this morning that could have aggravated my LBP?”. Sounds ridiculous but with practise you can learn how to respond (rather than react) to your pain. This should hopefully lead to (slightly) reduced pain levels (and better relations with your neighbours!). It might look something like this:
Increased pain increased curiosity increased rational thoughts decreased negative emotions decreased pain (In theory at least!)
WARNING: If you take any pharmaceutical drugs please talk to your doctor or pharmacist before taking any new supplements. Even so called ‘natural’ supplements can interact with other drugs and cause potentially adverse health effects.
Some supplements I’ve come across that are used to treat LBP include:
• curcumin (turmeric)
• fish/krill oil (omega-3)
• vitamin D
With the exception of glucosamine, the other supplements had only limited amounts of quality studies perform research on them. For years I’ve come across people who have been taking glucosamine for their joint health, mainly knees and hips (but also backs). The last time I read a journal article about glucosamine, there was enough doubt about its effectiveness for me not to actively dissuade patients from using it (instead I’d tell them “It’s probably not doing anything, but if you don’t mind paying, it’s not going to hurt”). Now though there is a damning amount of evidence against its effectiveness so my future response will be, “Don’t waste your money because it doesn’t work!”.
One quality study did examine the effectiveness of comfrey in the treatment of LBP. The authors reported that, “Comfrey root extract showed a remarkably potent and clinically relevant effect in reducing acute back pain.”13 Sounds very promising but I guess we’ll just have to see if it’s corroborated by future research.
While major guidelines recommend against using traction as a treatment for LBP1, In the name of pain-relief I think it’s worth a try. So, the next time you walk past a playground, have some ‘hang-time’ on the monkey bars! 😊
The list of pain relief options above is by no means exhaustive! For now, it’s just a few of the basics to help get you off on the right foot (I’ll add to this at a later stage).
• Sadly, there are no silver bullets when it comes to pain-relief for LBP. Most options are mildly to (at best) moderately effective by themselves.
• Often a combination of different pain relief options leads to the greatest pain reduction.
• All major LBP guidelines recommend you keep active rather than rest too much during an episode. This includes avoiding sitting or lying down for extended periods (excluding sleep).
• Heat and cold can both be used as a source of temporary pain relief.
• WARNING: Talk to your doctor or pharmacist before taking any pharmaceutical drug (especially for the first time) and always take only as directed. Even so called “harmless” over the counter (OTC) drugs can have potentially serious side effects.
• According to research the most effective OTC pain medications for LBP are ibuprofen (e.g. Nurofen, Advil and Brufen) and diclofenac (e.g. Voltaren, Cambia and Cataflam) which are both Non-Steroidal Anti-Inflammatory Drugs (NSAIDs).
• NSAIDs should only be taken for short periods as they commonly cause gastrointestinal side effects (things like stomach pain, stomach ulcers, heart burn).
• Topical NSAIDs are also available and are less likely to cause these gastrointestinal side effects because they are absorbed through the skin (and not the stomach).
• Relieving positions, like their name suggests, are any positions during a severe LBP episode which reduce your pain. One of the most common relieving positions for LBP is the ‘astronaut position’.
• Exercises are a key component of keeping active during a LBP episode. They don’t have to be anything fancy (e.g. walking), and in the early stages may just be an extension of a relieving position.
• One of the most commonly prescribed exercises for a person with LBP is ‘knee rolls’ (especially in the early stages of an episode).
• Mobilisations are a popular form of exercise used to treat LBP. They are basically highly repetitive movements which put selected joints through their range of motion.
• It’s important to minimise aggravating factors whether they’re at home, work or in the car! Common aggravating factors include (but are not limited to): seat heights (home, car and office), bench heights, repetitive lifting, cleaning etc.
• Managing your mental and emotional state can help reduce your pain levels.
• There is currently no clear evidence to support the use of most supplements in pain relief for LBP. The exception to this is comfrey which in a single high-quality study was reported as strongly effective in acute cases.
1. O’Connell NE, Cook CE, Wand BM, Ward SP. Clinical guidelines for low back pain: A critical review of consensus and inconsistencies across three major guidelines. Best Pract Res Clin Rheumatol. 2016;30(6):968-980. doi:10.1016/j.berh.2017.05.001.
2. Hagen KB, Jamtvedt G, Hilde G, Winnem MF. The updated cochrane review of bed rest for low back pain and sciatica. Spine (Phila Pa 1976). 2005;30(5):542-546. http://www.ncbi.nlm.nih.gov/pubmed/15738787. Accessed May 21, 2018.
3. French SD, Cameron M, Walker BF, Reggars JW, Esterman AJ. A Cochrane Review of Superficial Heat or Cold for Low Back Pain. Spine (Phila Pa 1976). 2006;31(9):998-1006. doi:10.1097/01.brs.0000214881.10814.64.
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8. Derry S, Moore RA, Gaskell H, McIntyre M, Wiffen PJ. Topical NSAIDs for acute musculoskeletal pain in adults. Cochrane Database Syst Rev. June 2015. doi:10.1002/14651858.CD007402.pub3.
9. Derry S, Conaghan P, Da Silva JAP, Wiffen PJ, Moore RA. Topical NSAIDs for chronic musculoskeletal pain in adults. Cochrane Database Syst Rev. April 2016. doi:10.1002/14651858.CD007400.pub3.
10. Alsaadi SM, McAuley JH, Hush JM, Maher CG. Prevalence of sleep disturbance in patients with low back pain. Eur Spine J. 2011;20(5):737-743. doi:10.1007/s00586-010-1661-x.
11. O’Sullivan K, O’Sullivan P. The ineffectiveness of paracetamol for spinal pain provides opportunities to better manage low back pain. Br J Sports Med. 2016;50(4):197-198. doi:10.1136/bjsports-2015-095363.
12. Schultz IZ, Crook J, Meloche GR, et al. Psychosocial factors predictive of occupational low back disability: towards development of a return-to-work model. Pain. 2004;107(1-2):77-85. http://www.ncbi.nlm.nih.gov/pubmed/14715392. Accessed May 21, 2018.
13. Giannetti BM, Staiger C, Bulitta M, Predel H-G. Efficacy and safety of comfrey root extract ointment in the treatment of acute upper or lower back pain: results of a double-blind, randomised, placebo controlled, multicentre trial. Br J Sports Med. 2010;44(9):637-641. doi:10.1136/bjsm.2009.058677.