New research challenges established hands-on treatments for back pain. The most effective therapy, experts tell, is to exercise.
Our battle with back pain is an uphill struggle and possibly even more so since we’ve started to work from home to help delay the spread of coronavirus.
Latest estimates suggest that 80% of people worldwide will suffer from its debilitating effects and according to the World Health Organisation low back pain is the leading cause of disability and of work absence worldwide.
Surveys have shown that back pain accounts for over one-quarter of all doctor visits in Ireland and statistics from the 2016 National Health Survey found that 19% of Irish people reported suffering from lower back pain during the previous 12 months. All of this makes it the most commonly reported health condition, more widespread than high blood pressure, asthma, heart disease, depression, and diabetes. Previous research found that disability payments for back pain amounted to €348m.
You might think, for a condition so widespread, we would be adept at dealing with it. Yet for around 85% of chronic sufferers, their back pain is dubbed “non-specific” by doctors, meaning there is no precise cause which makes it even more tricky to treat.
The common approaches we take to tackle back pain, from pills to heat pads, posture-correcting shoes to anatomically designed office chairs, have proven largely ineffective for many. Now a new study has found that other treatments such as massage, acupuncture and electrotherapy are unlikely to have much effect on reducing pain.
In a meta-analysis of 89 studies British Journal of Sports Medicine recently Daniel Belavy, an associate professor from the Institute of Physical Activity and Nutrition at Deakin University in Australia, and a team of scientists reviewed available evidence for a range of popular back pain therapies and found the “hands-on” treatments that are often perceived as saviours of back pain were largely ineffective.
What does work, they found, is exercise, with activities ranging from walking to Pilates and swimming to jogging and resistance exercise all found to reduce pain and boost the mood of back pain sufferers.
Fiona Wilson, associate professor of physiotherapy at Trinity College Dublin and a contributing editor of the BJSM, says the paper outlines a sea change in thinking that now underpins the treatment of back problems.
“We have come a long way from blaming poor posture and overuse of technology for low back pain problems and recommending passive therapies or rest as a treatment for it,” Wilson says.
“Science has confirmed that a sedentary lifestyle and a general lack of movement are the main reasons so many people have back pain and it follows that becoming more active and adopting a range of different exercise approaches is the best way to deal with it.”
So what can we do to improve the state of our back? If you already have back pain, the key is to reintroduce exercise gradually, guided by a trainer or physiotherapist. But we should cast aside all notion of aiming for postural perfection, to put our bodies through as wide a range of movement as possible with a range of activities.
“The new paper stressed there is no single exercise form that is better than another and that there is no right or wrong way to exercise, but that a combination of things like walking, stretching, yoga and Pilates, weight training and swimming — a sort of cross-training approach — is vital for a healthy back and spine,” Wilson says.
Find something that works for you.
Opt for massage, acupuncture or manual therapy
Belavy says previous studies have found ultrasound, hot and cold therapies, and massage all fail to reduce low back pain. But even so-called hands-on treatments — manual therapy, chiropractic, osteopathic, massage or acupuncture — he found to be less effective than exercise-based options.
Does that mean we should avoid them? Not necessarily — just don’t expect miracles. However, we should cast aside the misconception that the body needs “realigning” and that muscle knots need to be worked out with the thumbs to improve back pain symptoms, neither of which is true.
Try a supplement or gadget
A review of evidence published in the journal JAMA Internal Medicine  revealed that many popular back pain gadgets — from back belts to orthotics used to correct posture — simply don’t work. “There is no supplement you can take and no gadget you can use to cure back pain,” Wilson says. “People with the condition are vulnerable and often clutching at straws, but my advice is not to pay for any of these things, but to seek specialist advice.”
Walking, jogging and swimming
Mental health issues, such as depression and anxiety, are seen in around one third of people with low back pain, says Belavy, and the most effective way of dealing with it is through aerobic exercise which provides a healthy boost of endorphins, the body’s natural painkillers and mood elevators. “Aerobic exercise included walking, cycling and jogging, but any land-based activity that improves the efficiency and capacity of your cardiorespiratory system is beneficial,” says Belavy.
Adopt perfect posture at your desk
“We have moved away from thinking that there is such a thing as a perfect posture we should all adopt at our desk or when standing and walking,” says Wilson.
“Get up, move around, slouch at your desk. Don’t sit in the same position for too long. I often advise patients to sit on the most uncomfortable wooden chair they can find because it means they constantly fidget which is the best news for their backs.”
Stop looking at your phone
Contrary to popular belief, there is no proof that craning over your smartphone or iPad is a root cause of neck and back pain. According to physiotherapists, our overuse of small screens is little different to reading a book for hours and likely to be incidental to the development problems.
Wilson says technology is nowhere near as big a risk factor as being sedentary. “Focus on more movement and forget technology,” she says.
Strengthen your abdominal muscles
“A lack of trunk muscle strength and endurance are known risk factors for future back pain,” Belavy says. Any activities that helps to strengthen the abdominal and core muscles are a good idea — core workout, Pilates and stabilisation exercises that subtly target specific trunk muscles such as the transversus abdominis and multifidus in order to improve control and coordination of the spine and pelvis.
“A basic example of stabilisation exercise is a specific task to teach the patient to contract their transversus abdominis — drawing in the lower part of their stomach without tensing up the stomach as a whole,” says Belavy. “This might then be progressed into activating the muscle in specific activities.”
Being overweight or obese is a significant risk factor for low back pain and it follows that losing excess weight is a step towards improving symptoms.
“Being overweight affects your movement patterns and likely means you are less active than you should be so that your muscle mass decreases,” says Wilson. “Body fat is metabolically active and the more of it you have, the more inflamed your body and inflammation, in itself, contributes to back pain.”
A study published in the American Journal of Epidemiology  found that overweight and obese men who began exercising for an hour each week reduced their risk of back pain by 20% — a consequence, suspected the researchers, of reduced inflammation in their bodies.
Losing weight also means there’s less pressure on your spinal discs. A study at the University of Hong Kong involving 2,599 participants, published in Arthritis & Rheumatism  found that overweight or obese adults were significantly more likely to have disc degeneration than those of normal weight.
According to Belavy’s team there was some evidence that general stretching didn’t do much to improve for pain or physical function in people with low back pain. But what about yoga? Provided it is carefully guided, the ancient exercise regimen might be helpful to some people. One study of 320 people with back pain, published in the Annals of Internal Medicine , showed how a yoga class designed specifically for back pain proved an effective way to improve symptoms.
“A lot depends on how well a yoga programme is structured,” Wilson says.
“It will improve important components of fitness for back pain, such as range of movement, but it does need to be specific and a person needs to be guided gradually through appropriate postures.”
Pilates is often the first port of call for people with back pain and, in Belavy’s review, it scored well in terms of reducing pain and improving back pain symptoms.
But it is not a cure-all — “it won’t work for everyone,” Wilson says, adding it should form one part of an exercise approach for people who finds it helps them.
“It’s important to state that Pilates didn’t turn out better than other active forms of exercise, such as stabilisation exercises, aerobic activity and resistance exercise”, Belavy says.
Ditch your heavy bag
It used to be thought that hauling around a heavy bag every day caused untold damage, Yet the consensus now is that, provided you are strong enough to carry it, even the heaviest bag will do no harm to your back.
In a 2018 review published in the British Journal of Sports Medicine, a panel of Australian researchers found no evidence to associate the carrying of heavy backpacks with back pain in children and adolescents. The take-home message was that moderately loaded and even heavier backpacks and bags are not detrimental to back health.
Strength and resistance training is among the best steps you can take to improve back health. In the recent BJSM study, resistance exercise was reportedly beneficial for boosting physical function and emotional health of people with low back pain.
“Our spines are designed to withstand strenuous lifting, including of weights, twisting and pushing movements,” says Wilson. “They are all movements that strengthen human tissue.