We are are back with another informative blog on lower back pain. We hope you found our previous blog on the misconceptions associated with LBP an interesting and educational read.
This weeks blog is focused on the different types of LBP. As we spoke about last week, LBP is seen frequently by our therapists. With LBP being so prevalent amongst our patients, it brings different types of pain associated with it. Different types of pain can be a clue to where the pain is coming from and what is causing it. The types of pain described by our patients during assessment can help to inform us of what the potential issues with the lower back are, and help to guide our rehabilitation plans.
Below are types of pain frequently seen and described by the patients in the clinic.
Mechanical pain is often described as being achy, a feeling of stiffness associated with pain and having a restriction in movement. Mechanical pain will come from the structures which influence and aid movement. These structures include bones, joints, nerves and muscles localised to the spine. As spoke about in our previous blog, even though this may involve bone or nerve, a scan is not always needed. Mechanical LBP is is so prevalent, it is reported that eight out of ten of us will suffer with it at some stage in our lives (Hill et al., 2011) . These areas can be targeted with treatments such as manual therapy, soft tissue work and a strengthening/rehab plan to aid recovery and prevent further injury.
Muscular pain is another frequently type of pain seen at our clinic. Patients generally describe it as a sharp pain associated with movement and can be dull at rest. It can be located anywhere across the lower back, due to the complexity of the muscular system here.
Muscular pain will restrict movement and patients may feel stiff. Lower back muscular pain can be caused by a variety of things, from strain in muscles associated with lower back movements, to just general stiffness within muscle bellies. This pain can come from the muscles creating the movements or other global muscles which aid these movement such as the deep abdominal muscles.
So what happens during a muscle strain?
When a muscle strain occurs, the collagen fibres which make up our muscles become exposed to excessive force and break. When these fibres break, the muscle essentially bleeds, due to this the body begins to protect itself by igniting an inflammatory response, this can be seen when swelling or heat is visible around an injury. This process does not have to be visible to the naked eye, this can happen at a cellular level depending on the level of injury. This phase can last up to 72 hours.
Once inflammation has began to subside, new collagen cells are formed to begin the rebuilding of the strained myo-fibres, depending on the extent of the strain this can begin to occur 24-48 hours post injury and can last up to 2-3 weeks depending on the extent of the injury. This phase is called proliferation phase, during these couple of weeks new fibres are laid down but unfortunately this is haphazard and there is no organised orientation. This means that they are not orientated to allow optimal stress through the tissue and are at risk of re-injury. Once these fibres are laid down, to counteract this risk of re-injury, the body starts to remodel the collagen, giving it back its properties of strength and elasticity. This can last up to 12 months depending on the strain extent (Jimenez & Jimenez .,2004). It is recommended that rehabilitation should start during the inflammation phase, as early as the first few hours after injury, to improve the healing process and ultimately lead to prevention of further injury.
How we grade muscle strains
We can gauge a muscle strain grade by our orthopaedic assessments, These are graded from 1-3. Grade 1 muscle strains occur when a limited number of fibres are damaged, grade 2’s occur when nearly a half of the fibres are strained and in a grade 3 a complete rupture is sustained.
When muscles are overstretched in the lower back the muscles can go into spasm. Spasm is an involuntary muscle contraction due to abnormal muscle activity which can be caused by overuse or overstretching and is essentially a protective mechanism to stop excessive movement Soft tissue therapy can be very effective initially for muscular LBP (Danaeu, Cantin & Descarreaux 2019). Strengthening and exercise has proved to be a beneficial treatment prescription for muscle pain (Babatunde et al.,2017). Like all our rehab plans, our therapists will tailor a massage plan to you as an individual, whether this be deep tissue work or superficial relaxation.
Disc associated pain
Disc associated pain is one of the frequently seen at the clinic. Patients will describe this as a nervy and sharp pain associated with forward bending. In between our spinal column we have circular discs made of fibrous and elastic tissue with the centre containing a liquid centre called the nucleus pulposis. The discs are surrounded by spinal ligaments, muscles and joints which firmly hold them into place. There is very little room for these discs to move due to these structures.
THERE IS NO SUCH THING AS A SLIPPED DISC!
Nearly all of our patients who come with disc associated pain will say “I think I have slipped a disc”. Due to the structure of the discs and the surrounding structures it is not possible for the discs to slip. However, during excessive forward bending the liquid centre of the disc can bulge outwards, with varying levels of severity. This can be a herniation, a prolapse or a sequestration. Due to one of these mechanisms, the disc can irritate or come into contact with the surround ligaments, joints and nerves. Not all herniated discs will press on the nerves or create symptoms. Lumbar herniated discs usually occur in patients between the ages of 20-40 (Haro 2014).
So how do we diagnose and disc associated pain?
Through our assessments we can determine the level of injury and level of the spine where there may be a possible herniation. The majority of disc related injuries can be treated in our clinic with a progressive manual therapy and exercise based rehabilitation plan. If we suspect there is a great extent of disc or nerve damage our patients will be advised to seek a scan but in the vast majority of cases this is not needed.
Facet joint pain
Facet joints help the spine bend, twist and extend in different directions. Each spinal vertebrae have two sets of facet joints, a superior and inferior joint both working like a hinge. Patients will generally complain of pain on one side of the the lower back usually focused to one or two spinal levels with associated pain during twisting and extension. Pain can sometimes radiate into the buttock due to the facet joints close proximity to the spinal nerves. When these joints become inflamed they can compress these nerves where by the pain can radiate down. The symptoms are usually described as feeling blocked or stiff in certain movements such as twisting and extension.
During the lumbar movements, ideally the local and global muscles should work effectively and smoothly, if these muscles are weak or there is an imbalance it can cause these joints to be over used and inflamed. The majority of facet joints injuries are rehabilitated by freeing up these joints thus increasing movement and flexibility by means of manual therapy and soft-tissue work on the surrounding muscles. A progressive strengthening plan aimed at targeting weak surrounding muscles is imperative in preventing further injury.
Ligament associated pain
Ligament associated pain usually comes about after a traumatic injury to the located area. This can happen in sporting and exercise capacities or by heavy lifting (Benjamin., (2006). The symptoms usually consist of sharp and achy movement associated pain which can be bilateral or unilateral. Like muscles if ligaments are stretched beyond their capacity they be sprained and an inflammatory response is initiated, which then progresses to healing, just like with muscles. As mentioned previously, if the surrounding muscles and tissues are weak and unable to create movements effectively, extra stress can be put on the the ligaments that surround the spine. Effective postural correction and strengthening of the surrounding tissues can help to reduce the stress on spinal ligaments. Our therapists will devise a rehabilitation plan focused on posture associated with movements during physical activities and daily living, alongside a strengthening of the global and surrounding muscles.
Neural pain is widely seen in the clinic and can come from many different sources. Usually neural pain can be described as a pain that refers downwards or is sharp, described as a hot poker or will have pins and needles and numbness associated with it. As spoke about previously the spinal cord and nerves associated with the lower back are closely associated to many structures. Many people assume if the have these type of symptoms, it is related to there disc and it is something quite serious. Just like the other types of pain spoke about, the majority of times there is nothing serious causing these symptoms.
The key to neural pain is not to delay assessment. With our assessments we can locate the areas of injury and it is often quickly remedied. Neural pain and symptoms can be caused by the compression of the nerves which can refer pain give off a sensation of pins and needles or numbness. Often, is is caused by something simple such as a muscle strain or spasm, with less likely causes being disc pathology. Neural pain and its associated symptoms can be rehabbed through a process of neural exercises, soft tissue work , electrotherapy, manual therapy and an exercise based rehab plan.
We hope you find this information helpful and informative in the description of different types of lower back pain. One of the main points we hope you take on board is that in the majority of cases, nothing serious is underlying but in order to return to normal function the injury must go through a sufficient rehabilitation plan to aid recovery and most importantly prevent further injury.
If you are worried about any ongoing lower back issues, don’t hesitate in contacting us here at BSC sports therapy for advice and guidance.
We will be back with another blog focused on the strengthening involved in the rehabilitation of lower back injuries and conditions.