Author: Stuart McGill
There is no such thing as "non-specific back pain" (PDF)
Non-specific back pain, ideopathic back pain and lumbosacral strain, are terms used to label patients with back pain. There is no shortage of studies performed on groups that have non-specific back pain but they lack helpful recommendations for a pained individual. These studies found that everything, or nothing, worked in terms of treatment approaches because back pain is not a homogenious condition. It has many causes and treatment approaches. If there are two patients with different causes of pain, one approach may be very effective for one but may hurt the other. On average there is no effect, but as individuals there may be a massive effect when the treatment is matched to the specific disorder. Proper assessment can categorize people with back pain into specific groups to identify specific prevention and rehabilitation approaches. Trying to diagnose painful back disorders based on anatomical structure is possible but difficult. Some studies have shown specific tissues cause pain in individuals using local anesthesia approaches but these don’t have a high concordance with troublesome “features” seen on MRI or CT scans. Conversely, features seen in medical images associated with pathology and pain are often seen in asymptomatic workers. Even if the structure causing pain is known, this knowledge provides little guidance in reaching a cure. Back pain is almost always exacerbated by a particular motion, posture or load. Motions, postures or loads that exacerbate the back pain together with those that are tolerated can be identified. A prevention plan can be designed to eliminate the specific causes (motions, postures and loads identified through provocative testing – known as pain triggers) and a rehabilitation plan can be designed to enhance tolerance to these triggers. Back patients can therefore be categorized based on their intolerances. For example, workers with “spine flexion bending intolerance” will probably be exacerbated by sitting, tying shoes etc., yet very high load tolerance is found if the spine is not bent but kept in a neutral posture. Assessment to properly classify back pain sufferers in terms of painful motions, postures, and loads, provides clear clinical direction and eliminates the unhelpful non-diagnosis of “non-specific back pain.”
What
causes
back
troubles?
There
are
many
causes
of
back
troubles
with
the
strongest
scientific
literature
evidence
for
mechanical
causes.
These
include
loads
on
the
back
tissues
that
exceed
their
tolerance
in
terms
of
load
magnitude,
repetition
and
duration.
For
example,
the
spinal
discs
have
a
fatigue
life
for
the
number
of
bends
that
they
can
withstand
before
they
fail.
Yet
this
relationship
is
modulated
by
variables
such
as
hydration
(time
of
day),
the
corresponding
load
at
the
time
of
the
bending
motion,
and
the
direction
of
the
bending
axis,
to
name
a
few.
If
the
individual
continues
to
bend
the
painful
disc
(i.e.
continue
to
flexion-stretch
their
back),
they
will
most
likely
experience
worse
symptoms
–
or
a
recurrent
aggravated
situation.
The
same
mechanism
is
exacerbated
by
sitting
–
here
the
spine
(particularly
the
lowest
lumbar
disc)
is
flexion
bent.
Strangely,
these
patients
are
sometimes
told
to
pull
their
knees
to
their
chest
to
obtain
relief.
This
activates
the
stretch
receptors
in
the
back-extensor
muscles
resulting
in
short
term
analgesia
for
about
15
minutes,
but
this
bending
has
caused
further
damage
and/or
sensitization
of
the
underlying
pain
mechanism.
While
these
types
of
patients
are
relieved
by
frequent
posture
change,
and
even
fast
walking,
they
simply
cannot
tolerate
sitting.
Sitting
posture
can
be
assisted
with
lumbar
support
to
prevent
lumbar
flexion.
Special
exercises
designed
to
combat
the
cumulative
stresses
from
sitting
are
also
usually
helpful.
Encoding
the
“hip
hinge”
movement
pattern
to
replace
the
spine
bending
pattern
is
important.
Testing
and
classification
of
the
back
pain
sufferer
results
in
better
prevention
and
rehabilitation
approaches.
There
are
many
other
sub-categories
where
the
specific
strategies
to
avoid
the
cause
and
create
a
pain-free
foundation
will
differ.
Interestingly,
ergonomic
job
layout
change
and
design
may
be
helpful
but
the
worker
must
also
enhance
their
use
of
back
sparing
body
mechanics.
Assessment
and
Provocative
testing:
Motions,
Postures,
Loads
The
typical
orthopaedic
exam
determines
the
range
of
spine
motion,
some
neurological
measures
such
strength
of
reflexes,
and
some
qualitative
measures
of
muscle
strength.
These
measures
provide
little
guidance
for
designing
prevention
and
rehabilitation
programs.
In
a
study
where
we
tracked
back
pain
patients
in
a
pain
clinic1,
scores
of
patients
obtained
from
the
assessment
had
very
little
relation
as
to
who
recovered
and
returned
to
work.
Asymmetries
of
both
strength
and
movement
(particularly
in
the
hips)
have
been
shown
to
be
associated
with,
and
predictive
of,
back
troubles.
Imbalance
in
torso
muscle
endurance
around
the
torso
has
been
shown
to
be
predictive
of
future
back
disorders.
Thus,
correction
of
asymmetries
with
corrective
and
therapeutic
exercise
should
be
the
first
stage
of
any
rehabilitation
program.
However,
provocative
testing
to
intentionally
provoke
discomfort
is
essential
in
determining
which
postures,
motions,
and
loads
are
exacerbating
the
pain
and
which
ones
are
well
tolerated.
Simply
having
a
pained
patient
sit
upright
on
a
stool
and
pull
upright
on
the
stool
seat
pan
to
compress
the
spine
usually
causes
no
discomfort.
However,
slouching
with
the
spine
causing
flexion,
and
repeating
the
pull
often
causes
pain
and
identifies
the
person
who
is
intolerant
of
flexion2.
Avoidance
of
spine
flexion
removes
the
cause,
and
specific
exercises
performed
with
a
neutral
spine
have
been
shown
to
be
most
effective
for
this
category
of
back
pain.
What
every
patient/worker
needs
to
know
Every
back
pained
worker
needs
to
know
the
following
to
facilitate
their
recovery:
a)
Exam
results
–
their
current
scores
give
context
to
the
future
goals;
b)Natural
history
and
prognosis
–
there
is
no
evidence
that
back
disorders
last
into
retirement
and
in
fact
are
often
addressed
with
appropriate
classification
and
treatment
plans;
c)
Causes
of
pain
–
the
way
one
moves
and
activate
muscles
can
eliminate
pain;
d)
What
they
must
avoid
–
removing
the
cause
of
the
disorders
this
allows
the
therapy
to
be
more
effective
via
two
mechanisms;
e)
Pain
sensitivity
is
reduced
by
winding
down
central
sensitization;
f)
Allowing
the
tissue
to
heal;
g)
Recovery
plan
–
a
progression
that
begins
by
addressing
movement
disorders
with
corrective
and
therapeutic
exercise,
stabilizing
those
body
areas
needing
stabilization
and
mobilizing
those
which
need
mobilization,
enhancing
endurance
so
that
joint
sparing
movement
patterns
can
be
repeated
even
when
fatigued,
building
some
strength
and
possibly
some
power
generating
ability
at
the
hips
and
shoulders
if
the
occupational
demand
is
present3 are
key
to
building
a
foundation
for
pain-free
activity.
Implications
of
the
tests
Provocative
testing,
when
combined
with
movement
screens
for
joint
symmetry
of
motion,
strength,
and
endurance,
underpins
a
powerful
classification
for
back
pained
individuals.
Classification
enhances
the
therapy
plan
and
identifies
what
to
avoid.
The
process
is
continued
throughout
the
recovery
to
define
tolerable
levels
of
load
in
specific
postures
and
movements
so
that
the
“dosage”
of
therapeutic
exercise
can
be
tuned
to
the
individual.
Conclusion
There is no such thing as “non-specific back pain” - there are only those individuals who have not had a thorough assessment. There should be no further studies of people with non-specific back pain, as they do not provide any insight into prevention or treatment programs for the individual. Classification of back pained workers into subcategories based in intolerance to specific motions, postures and loads directs targeted prevention and treatment.
Key messages
- A thorough assessment will identify the cause of pain in terms of offending motions, postures and loads.
- Studies on non-specific back pain are not helpful just as studies on non-specific head pain would not be helpful, nor tolerated.
- A specific diagnosis will guide each person on what to not do and what to do.
Implications for the prevention of MSD
- Remove cause of the disorder; wind down central sensitization, allow tissue to heal
- Put corrective and therapeutic exercise in place
- Stabilize and mobilize targeted areas
- Enhance endurance, strength and some power generating ability at the hips and shoulders if occupational demand is present
References
- Parks KA, Crichton KS, Goldford RJ, McGill SM (2003). On the validity of ratings of impairment for low back disorders. SPINE. 28(4):380-384.
- McGill, S.M., Back Mechanic: The step-by-step McGill method to fix back pain. (backfitpro.com), 2015.
- McGill, S.M. Low back disorders: Evidence based prevention and rehabilitation, Human Kinetics Publishers, Champaign, IL, U.S.A., 2002. ISBN 0-7360-4241-5, Third Edition, 2016
Last updated: 2016
Disclaimer: Position papers are funded by the Centre of Research Expertise for the Prevention of Musculoskeletal Disorders, which receives funding through a grant provided by the Ontario Ministry of Labour. The views expressed are those of the authors and do not necessarily reflect those of the Centre nor of the Province.