By Dr Peter Selvaratnam A/C Professor and Specialist Musculoskeletal Physiotherapist

The COVID-19 pandemic has resulted in more people working from home in un-ergonomic positions resulting in the increased incidence of low back pain and/or sciatica. Some have become DIY (Do It Yourself) specialists by painting, renovating their home, gardening, and others have commenced a new hobby of walking long distances or running and suffered low back injuries.

What is the incidence of low back pain?

Medical researchers state that eighty percent (80%) of people in Western countries suffer from mild to moderate low back pain at some stage in their life. The cost of low back pain to the community and individuals is enormous.

What is the cause?

There are different causes to low back pain. Prolonged sitting especially with the advent of the computer, internet, e-mail and social media have increased the duration and frequency of sitting. The recent increase in zoom chats in poor postures and sitting like a couch potato while watching television have also contributed to low back pain.

Professor Alf Nachemson reported in 1963 in the Journal of Bone and Joint Surgery that the sitting position increases the pressure within the lumbar intervertebral disc by 6.5 times one’s body weight. The intradiscal pressure increases by eight (8) times while standing and bending over a wash basin, and more so while lifting an object.

Low back pain therefore can be triggered while bending and/or twisting to pick up light or heavy objects. Similarly gardening, vacuuming, prolonged cooking, motor vehicle accidents and sporting injuries can cause low back pain. Very often back pain occurs following repeated activities over many months (cumulative trauma).

Hyperextension injuries in cricketers (for example, in bowlers), gymnasts, javelin throwers and repeated impact while running can lead to a condition called spondylolysis or spondylolisthesis. In the latter, the 4th or 5th lumbar vertebra can be displaced forward by 1-2 millimetres and in some by 10 millimetres. In some cases the displacement of the 5th lumbar vertebra can be congenital. Very often pain is experienced while standing or walking and eased by sitting.

Other causes of low back pain?

In rare instances, low back pain and sciatic pain can be caused by endometriosis, gut issues, prostate problems, and abdominal aortic calcification and in very rare instances by certain tumours. Lifestyle stresses, pandemics, financial pressures, negative thought processes, post-traumatic stress disorder (PTSD), anger and carrying bitterness can also exacerbate one’s low back pain.

Can degenerative changes cause spinal canal stenosis?

As people become more mature, osteoarthrosis (degenerative change) of the lumbar facet joints can cause narrowing of the spinal canal and the foramen through which nerves exit. These changes may lead to pain while standing or walking. Spinal canal stenosis can cause pain while walking and needs to be differentiated from vascular stenosis.

However, researchers state that not all pain is due to degenerative changes. Some patients with severe osteoarthrosis have minimal or no pain and other with mild osteoarthrosis report of more pain. Hence, the individual’s functional activities, personality and response to life stressors influences their threshold of pain.

What is at fault?

The lumbar intervertebral discs can move ‘back’ or back and to ‘one side’ causing the lumbar disc to bulge, herniate or prolapse. It is a misconception that the lumbar intervertebral disc is the only cause of low back pain. The lumbar facet joints which are on either side of the vertebra can also cause pain in addition to spinal ligaments, and deconditioning of spinal muscles and the influence of one’s spinal biomechanics.

The lower lumbar intervertebral discs and facet joints may compress and irritate the adjacent spinal nerves and can cause pain in the sciatic nerve distribution. The low back muscles (erector spinae) can sometimes cause as much pain as the lumbar discs.

Prolonged lumbar pain and related anxiety can cause the nervous system to be ‘switched on’ and continually fire and lead to tense the muscles.

It is important to be assessed by your medical practitioner or a Specialist Musculoskeletal Physiotherapist if your pain persists. They can arrange appropriate X-rays or MRI scans and your medical practitioner can rule out other causes of low back pain.

What are some strategies to overcome pain?

  1. To avoid prolonged sitting. It is important to get up every 15 minutes for 2 minutes, and after an hour to walk around your work place or home for 5 minutes.
  2. Spread your work over a few days – such as paper work, housework and gardening.
  3. Avoid taking each task as an emergency or performing two days’ work in one day.
  4. Walking 30-60 minutes each day has been researched to benefit patients. If walking causes pain, cycling, using a cross-trainer and/or deep water walking provide aerobic fitness and re-condition the spinal muscles.
  5. Retraining of the abdominal ‘core’ muscles and low back multifidus muscles to improve lumbar muscle stability.
  6. Gentle lumbar exercises to improve spinal and pelvic mobility. These exercises must be performed within pain free limits. In the initial stages perform one exercise each week and later you can combine the exercises. Be directed by your highly trained registered Physiotherapist or a Specialist Musculoskeletal Physiotherapist.
    • Lie on your back on a firm surface or bed with the knees bent and the feet on the floor. Following which rock your knees to the left for 5 seconds and to the right for 5 seconds. Perform the movement within pain free limits. Repeat this movement 5 times. If the movement is comfortable you can then increase the repetition by one (1) each week up to 10 repetitions.
    • Lie on your back. Then lift your left knee within your pain free range towards your left hip for 5 seconds. Following this, lift your right knee towards your right hip for 5 seconds within your pain free range. Repeat this movement 5 times.
    • Lie on your back with your knees slightly bent with a pillow under your knees. Then lengthen and shorten the legs from the hip region. Hold for 5 seconds, perform 10 repetitions within your pain free range.
    • Feldenkrais movement: In the sitting position, move your trunk gently from side to side. Perform 5 repetitions every hour while sitting. This movement is ideal while sitting in front of a computer or during a meeting (especially if it is boring).
  7. Other strategies that can help are treatment when indicated of:
    • gentle spinal mobilization to improve spinal joint mobility and muscle function
    • nerve mobilization
    • trigger point therapy
    • dry needling with acupuncture needles and
    • Thor Cold Laser Therapy to name a few.

For patients with severe pain, nerve root sleeve injections, epidurals, radiofrequency nerve treatment and trigger point injections may be beneficial. Only 1% of patients require lumbar surgery but a few of them rush into early surgery due to frustration caused by slow recovery.

In most cases patients require medication to control their initial inflammatory process but in the long term a low back rehabilitation exercise programme tailor made for you with ergonomic modifications, good nutritional management and mineral supplement will assist in recovery and reduce the requirement for intervention.

What research has been performed on low back pain patients?

There have been many research programmes conducted by clinical and research Physiotherapists on low back conditions. The research conducted at the Department of Physiotherapy at the University of Queensland by Professor Jull and colleagues has demonstrated that patients with low back pain have reduced cross-sectional area of the low back muscle called the multifidus muscle.

The investigation conducted by leading research Physiotherapists at the University demonstrated (with an ultrasound) that the cross-sectional area (size) of the multifidus could be increased by specific abdominal stabilizing exercises. More heartening was that performing this particular abdominal programme reduced the recurrence of low back pain by 70% compared to traditional sit-up exercises for the abdominals.

The Professor Jull programme is a four stage programme conducted by Musculoskeletal Physiotherapists.

In stage one, patients are instructed to breathe out first in either the sitting, standing or lying positions. As they breathe out they are requested to ‘visualise’ as if they are passing water in the toilet and the action of trying to stop the flow. The contraction is held for 5 seconds while relaxed breathing is continued. This action is performed 10 times in the morning and evening. Avoid performing this exercise while passing water in the toilet.

You can also perform this movement once or twice each time you hear the phone ring, in any position – sitting/lying/standing (i.e. at least once every 2 hours) or when you experience pain, to maintain the endurance of the abdominal and multifidus muscles.

The other stages of the programme need to be instructed by registered Physiotherapists who have participated in Professor Jull’s training programme.

The Melbourne Spinal and Sports Medicine Clinic conducts a Biomechanical programme to help people with acute and ongoing low back and neck pain. Please contact the clinic on +613 9866 8010 or email: info@backtolife.com.au

Dr Peter Selvaratnam is a Doctor of Medical Anatomy and a Specialist in Musculoskeletal Physiotherapist in Melbourne. He is an A/C Professor at The University of Melbourne, Australia