What Type of Back Problem
Do I Have?
by Adam Brown
updated July 15, 2020
The reality is 80% of us will suffer from back pain at some point in our lives. And yet, getting the correct treatment to alleviate back pain can be a frustrating and challenging task–for both patients and healthcare providers alike.
Anytime such a large percentage of the population suffers from an ailment, you can be certain an entire economy will pop up purporting to be able to solve the problem. For this reason, there’s a lot of nonsense out there about new and unique methods to “cure” back pain. As a general rule, the word “cure” is misleading and deceptive, and will leave patients frustrated and disenchanted with their progress. However, with the right treatment approach we can effectively manage back pain and reduce the negative impact it can have on your life.
Many of the solutions marketed to patients treat back pain as a single diagnosis. In fact, the term “back pain” is not really a diagnosis at all, rather a description of a symptom. Treating all patients that present with back pain the same is like prescribing antibiotics to every patient with abdominal pain. Just as there are many diagnoses that cause abdominal pain, there are several distinct types of back pain. A skilled physiotherapist can diagnose your issue by identifying the specific type of problem you have, and customize a treatment plan. Accurately matching the diagnosis to the treatment plan is crucial to ensuring a good outcome. This is a relatively rare skill, requiring training and experience to develop strong diagnostic skills, so finding a qualified physiotherapist is paramount.
Below are some of the more common types of back pain, and many of you may recognize your own symptoms in the descriptions. These are followed by key elements and strategies that should be included in a treatment plan for that particular issue. However, it’s critical to note there is no substitute for a full assessment performed by an experienced physiotherapist.
5 Types of Back Pain
1. FLEXION DOMINANT
Often, this type of back pain is described in terms of injury to the disc (though not always the case). More importantly, the pain and symptoms tend to follow a familiar pattern:
- Symptoms are made worse by sitting, bending, lifting
- Symptoms improve after standing and walking for short durations
- Can include spine pain, leg pain or both
- May experience tingling/numbness
- Can progress to leg weakness
- Often has pain with cough/sneeze (but not always)
- Loss of range of motion (difficulty straightening up after rising from sitting)
Effective care for Flexion Dominant pain includes a directional exercise/stretch that you perform at intervals throughout the day to maintain your spinal range of motion and to reduce pain. After performing this stretch, you should have less pain and your back should feel more flexible. The exact stretch that is right for you is best determined by a trained physiotherapist, but often passive, repeated extension of the lumbar spine is a decent place to start. Click here for a video of this exercise. With a skilled examination your physiotherapist can make modifications to your exercise to improve its effectiveness. Treatment may also involve hands-on, manual therapy to help restore your spinal range of motion, and may also include pain-relieving techniques. Some patients find a reduction in pain with acupuncture, which can be used as an adjunct to other treatments.
After the pain has settled down, a skilled physiotherapist will help you discover how the problem began and which changes to make, including:
- An ergonomic assessment of your workstation to ensure good posture or eliminate occupational risks
- Education on proper lifting and squatting mechanics
- Core muscle strength training (if weakness is an issue)
- Strengthening or stretching abnormally weak or tight hip muscles
- Spinal mobility exercises
2. EXTENSION DOMINANT
Extension Dominant pain is often described in terms of the joints at the back of the spine called the zygapophyseal joints (or Z-joints). Again, this is often part of the problem, but not always. Extension Dominant pain has a tendency to follow an identifiable pattern:
SIGNS AND SYMPTOMS
- Pain after standing for long periods
- Temporary relief from sitting or bending
- Range of motion is typically stable and does not change in short periods of time. The back may be stiff, but it is always stiff in the same way
- Pain after high impact activities (running or gymnastics movements)
- Usually includes localized spinal pain
- May include leg pain, tingling, or even numbness in severe cases
Care for Extension Dominant pain is guided by finding ways to reduce pressure on the spine in extension, as people who suffer this type of pain often stand with their low backs arched. Gentle stabilizing abdominal exercises and hip mobility stretches (specifically hip flexor stretches) can be effective. Intermittently using flexed postures to relieve pain is also helpful. Pain relieving treatment techniques such as acupuncture or manual therapy may also play a temporary role.
Longer term care focuses on spinal/core stability and hip mobility. Once your pain is under control, the treatment program can be more aggressive, and will be aimed at building muscle around the spine while gaining length in shortened hip muscles.
3. NEUROGENIC CLAUDICATION
Neurogenic Claudication is a specific type of Extension Dominant back pain that tends to affect older individuals (60+). It’s caused by the nerves being compressed when the patient is standing and walking, and can significantly limit a patient’s ability to walk for longer distances.
SIGNS AND SYMPTOMS
- Typically no symptoms when sitting
- Upon rising and walking: pain, numbness or weakness in the legs begins after a predictable amount of time (length of time depends upon severity)
- Many of these patients have no local spine pain
- After symptoms begin, the patient must sit or bend forward to reduce symptoms
- Some patients are seen leaning over a shopping cart, for example, so they can walk without leg symptoms
When patients with Neurogenic Claudication have an acute flare-up, their walking tolerance is greatly reduced and they must take frequent breaks to allow their nerves to recover. These patients should be given a variety of flexion-based stretches and strategies to use frequently throughout the day, and temporarily reduce walking distances. As symptoms decrease, training and exercises to reduce pelvic anterior tilt in standing may be effective. These patients should not try to ‘fight through the pain’ or ‘train’ themselves to walk further, which tends to be like throwing fuel on the fire.
Restorative care for someone suffering from intermittent bouts of Neurogenic Claudication should be aimed at two main priorities: First, abdominal strength must be adequate so the individual can walk without the spine falling into an arched or extended position; second the patient’s hips must be mobile enough that the pelvis isn’t pulled into an anterior tilt in standing/walking. The stronger and more mobile a patient can keep themselves the more likely they are to avoid a decompression surgery to make room for the nerves. A physiotherapist well trained in spinal care can put together an exercise program to reduce sustained lumbar extension when walking.
4. INFLAMMATORY BACK PAIN
Inflammatory back pain is less common than mechanical back pain, but is often misdiagnosed. This type of pain is caused by excessive inflammation in the spinal joints, secondary to a medical condition causing the immune system to attack the joints of the spine. An example of a condition that causes inflammatory back pain is ankylosing spondylitis. However, there are a number of conditions that can result in inflammatory back pain. The physiotherapist’s job is to recognize the pain as inflammatory and refer the patient back for medical evaluation (often by a rheumatologist) and for more testing. However, once the diagnosis is made and medical management is in place, the physiotherapist will help with symptom management.
SIGNS AND SYMPTOMS
- Onset of pain is usually in patients under 35 years of age, and not due to trauma
- Pain persists for more than three months
- The back pain and stiffness worsen with immobility, especially at night and in early morning
- The back pain and stiffness tend to ease with physical activity and gentle exercise
- Anti-inflammatory medications (NSAIDs, such as ibuprofen or Naproxen) are very effective in relieving pain and stiffness in most patients
Patients should be given a management plan that teaches them positions of relief, as well as activities to avoid when experiencing a flare up. Unfortunately there’s no way to alter the natural path of this condition with physiotherapy, but a gentle exercise program is useful to maintain mobility and reduce pain. When symptoms are well controlled and pain levels low, a patient can use a more aggressive restorative program, designed by a skilled physiotherapist. In addition, some low impact functional strength training can be helpful.
5. PAIN DISORDERS
A Pain Disorder involving back pain is one of the more challenging conditions for medical professionals to treat. This patient’s nervous system is interpreting stimuli not normally painful or harmful to the body as dangerous, which the brain then treats as painful. It’s a complex issue requiring a profound understanding of the patient, and what has led him or her to this place; it can be incredibly frustrating for patients when medical professionals repeatedly tell them they see no organic cause for their pain. It’s important to note the pain these patients feel is just as physically real as it is for those suffering from a mechanical injury. The usual treatments don’t help this subset of patients, and so they are best served by working with a muti-disciplinary healthcare team, including a physiotherapist with a strong understanding of pain science.
SIGNS AND SYMPTOMS
- Vary widely
- Pain does not follow typical anatomic boundaries
- Location of pain may migrate to include other parts of the body
- Pain can be made worse by a state of anxiety or depression
- Increases and decreases in pain are not necessarily linked to mechanical trauma or physically stressful events
Patients suffering from a pain disorder will often experiment with pain relieving techniques to find a combination that works for them. Physiotherapists should help these patients understand their pain and guide them to maintain physical fitness and function. It’s also important to screen for any complicating factors, like anxiety or depression, that can contribute to the problem, and ensure these issues are addressed by a trained professional. Pain disorders of this nature are not common.
Within each type of back pain there is no ‘one size fits all’ treatment approach. Even after establishing the correct diagnosis, a skilled physiotherapist will work with the patient on a treatment plan focusing on factors driving the specific issue. If you’re suffering from back pain and are struggling to get answers, an experienced physiotherapist with training in spinal disorders can be an enormous help. If you’re unsure of where to find a physiotherapist, please call us at Cornerstone Physiotherapy. We help over 5,000 people every year to find solutions to complex conditions, including back pain, and we’re happy to offer our services so you can feel better, faster.
Adam Brown MClScPT
Adam is a well-respected physiotherapist known for successfully treating complex spinal patients throughout the Greater Toronto Area. He helped launch the Inter-Professional Spine Assessment and Education Centre (ISAEC) program and provides mentorship to orthopaedic physiotherapists.
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