The New (and Improved) Guidelines on Low Back Pain

The New (and Improved) Guidelines on Low Back Pain

Low back pain is a very common thing in the United States, and is considered to be one of the most common reasons for physician visits in the country. While most Americans have experienced low back pain at some point in their life, approximately 25% of the adult population has experienced it at some point in the last three months. Low back pain isn’t cheap either, as a 2006 article from the Journal of Bone & Joint Surgery found “The total costs of low-back pain in the United States exceed $100 billion per year. Two-thirds of these costs are indirect, due to lost wages and reduced productivity.” That’s a lot of money to spend on a problem that can be managed much more effectively, and fortunately it looks like things are about to change for the better.

The Wall Street Journal recently wrote an informative article about the new medical guidelines for low back pain, which was just published by the American College of Physicians (ACP). The article from the WSJ does a nice job of putting the recommendations from the ACP article into plain English, highlighting the importance of non-invasive therapies and discouraging the use of over the counter and prescription drugs as a primary or even secondary option. Alternative, natural and psychological therapies are now the primary recommendations for all clinicians in treating low back pain. Be sure to read the article from the WSJ, as the article you’re reading now breaks it all down further.

These new guidelines not only highlight the efficacy of non-invasive treatments, they discourage the use of long-term opioids, which are prescription drugs that have effects similar to heroin. Long term opioid use often leads to addiction of both opioid prescriptions and even heroin, and according to the CDC, killed over 33,000 people in the United States last year. Nearly half of these deaths were from a prescription opioid. In cases of chronic pain that aren’t alleviated by natural methods, according to the guidelines, these drugs can still be warranted. We all have the right to live without pain and have a better quality of life, but the recognition that pushing such harmful drugs before exhausting every other option is a bad idea is not only going to save lives, but help to greatly lower healthcare costs. The new guidelines do well by encouraging doctors to emphasize the extremely negative side effects of opioids, and how they should only be used on a short term basis. Even Tylenol is no longer recommended, as it has been shown to be no more effective than a placebo.

Low back pain usually develops over time, from common issues such as bad posture and poor biomechanics. The onset of low back pain in these situations is referred to as repetitive stress injury, and it is much more common than an acute injury that comes on as a result of something like lifting a heavy object too quickly or getting in a car accident. Low back pain most commonly occurs in people between the ages of 30-50. Why is that? Many people in that age group that are high risk for low back pain are overweight and don’t exercise properly (or exercise at all), and often sit too much most of the day. The weekend warriors – those that have poor movement most of the week but exercise vigorously when they have the time – are more likely to pull a muscle or strain a joint because their bodies are unprepared. Making sure you have good posture and the right movement patterns is crucial in making sure you avoid injury when it’s time to get back into the gym.

Acute and subacute low back pain should follow the guidelines that were described, but there is still more that could have been added here. A good physical therapist has the knowledge to apply to various non-invasive therapies that can reduce pain, swelling and inflammation from the acute (injury) phase all the way through maintenance care. The same goes for a good acupuncturist, and many in that field specialize in acute injury. Even a great chiropractor can get the healing started with the right adjustments, soft tissue therapies, and education on how to correct the movement patterns that created these problems in the first place.

Exercise is probably the most important recommendation in this new set of guidelines, considering that many people that exercise with low back pain are likely exercising the wrong way. Crossfit is an industry in particular that falls under scrutiny when it comes to people getting injured from working out. It’s not that Crossfit is necessarily a harmful workout, but many people that suffer injuries from the routines go into them unprepared and deconditioned, which is a big problem that reaches far beyond this exercise system. The problem is that intense exercise on people that are not prepared for it is a problem waiting to happen, and many people that want to get in shape are better suited in doing something that is customized to them as an individual in the early stages of improving their strength, coordination and balance. Once they develop the right movement patterns, only then do they truly reduce their risk of injury by doing more vigorous workouts.

To take these guidelines a little further, it would be wise to recognize where exactly you are in the injury cycle to know where to start when it comes to getting back to 100%. If you are in the acute phase, which is right after the injury or flare up occurs and where pain and swelling are at their worst, the focus should be on pain reduction, light mobilization if the area is stable, and controlling inflammation. Ice should be applied to areas of inflammation, gentle motion or joint mobility can be effective in activating the lymph system which helps to clear the body of byproducts left over from an injury, and if the pain is too intense, then the drugs that are discouraged from initial consideration begin to enter the conversation. While seeing your medical doctor to rule out something more serious is recommended in many situations, most people ultimately see the best results from other doctors such as chiropractors or physical therapists, practitioners such as acupuncturists and massage therapists, or highly trained functional trainers and yoga therapists. The acute phase only lasts 2-4 days unless the injury is re-aggravated (which it often is in repetitive stress injuries), but the point here is that there are even more ways to approach an acute injury than listed in these guidelines.

In the subacute phase, it’s important to focus on restoring strength, balance, and neural awareness (proprioception) to help shape the way tissue is being laid down as new scar tissue begins to form and strengthen. Our brain is the most important part of how and why we move, so we need to feed it with good information. Z-Health is a particularly effective training system that gives personal trainers the tools to help their clients regain their neuromotor senses through functional neural training. Vision training, balance and joint mobility drills, nerve flossing… these are only a few of the various effective approaches in helping to retrain the brain after an injury. Neuromuscular Reeducation is a long word that doesn’t mean anything to many of you, but it is basically the way that a doctor will walk you a series of therapies to help you to regain the movement patterns that your body needs not only to overcome an injury, but to eliminate the bad posture or movement patterns that got you there in the first place. The subacute phase usually lasts up to six weeks, further evidence that the “quick-fix” solutions are not going to get you back to where you want to be.

In the remodeling phase, the healing continues. Have you heard about fascia yet? More and more of you have, but it’s still kind of depressing how little it’s talked about. Fascia runs through our entire body and helps to reinforce our strength and flexibility. Healing is a continuum, just as health is in general. If your rehabilitation stops after six weeks and you go back to the couch, that injury that you thought you got over will remind you that it wasn’t done yet. Maybe it will remind you gently at first, but those reminders may not be so kind to you down the road. We have to impose the right kind of stress to new tissue for it to become as strong and malleable as possible, meaning we have to move it the right way or suffer the consequences. Muscles tendons, ligaments and fascia will grow back the way you hope if you keep your body moving in a healthy way. Myofascial release is particularly effective, and can be taught proficiently by many different doctors, practitioners and trainers.

Nothing is more important for remodeling new tissue than the balance of strengthening and mobilizing the affected area. Pick your favorite workout, movement therapy, or whatever else makes you tick to keep these tissues healthy. This is where your physical therapist, chiropractor, or acupuncturist have done the bulk of their job, and now must pass the torch to the providers that get you moving more in a way that you truly enjoy. If you’re a cyclist, make sure your hip flexors and glutes are firing properly. For the yogis out there, be sure you are strong enough this time around to go into that aggressive pose without straining the ligaments too much. And for you weight lifters, if your hands are rolled in over your thighs from too much bench-pressing, start releasing your pecs and shoulders with a lacrosse ball after you work out, and take yoga classes to add in some flexibility. The best athletes in the world work hard to strike a balance between flexibility and strength to prevent injury and perform at the highest level, and we should all take a page out of their book, regardless of where we fall on the athletic spectrum.

Stress management is another important factor listed in the ACP guidelines. The link between anxiety, depression and other stress disorders and low back pain is very important to recognize, as many of the non-invasive techniques used to manage low back pain can also positively affect these psychological disorders. Yoga therapy is a particularly useful tool in managing both stress and low back pain, as the focus on breathing, mindfulness and movement is a great technique in addressing both of these issues at once. Shallow breathing can stimulate cortisol production, our body’s stress hormone, and our body associates that with the fight-or-flight response. Too much cortisol production lowers the immune system response, which makes you more susceptible to much more than just low back pain. It makes sense then that people dealing with chronic stress and pain are more susceptible to getting sick on a more frequent basis.

Other top quality functional training systems such as Tac Fit incorporate breathing techniques into their teaching, as they recognize the importance of a healthy immune system, proper oxygen saturation, and the ability to expand the rib cage and diaphragm. If training isn’t your thing, then there are plenty of options out there to keep your mind healthy. From smartphone apps that guide you through daily meditations to psychologists that focus on natural approaches to help get your mind healthy, there are a plethora of natural ways to curtail your chronic stress. Think of your brain as a big muscle that needs more training than any other part of your body. Treat chronic stress, anxiety and depression as an injury that you can go out and fix. By taking a guided approach by an experienced provider to help lower and eliminate these types of psychological issues, you will find that the problem is much more manageable than you ever thought before.

80% of adults experience back pain at some point. It’s the most common cause of job-related disability and leading contributor to missed work days. Many companies have begun to incorporate wellness programs, or have even hired a chiropractor, yoga instructor, trainer, or massage therapist to help improve the health and wellbeing of their employees and in turn reducing the costs associated with low back pain. Large companies such as Facebook and Google have wellness centers on their campuses, but even small companies can hire the right provider to help guide the health of their company.

Generally, you just need to move more. More specifically though, you need to know more about how you sit and how you move. Take care of yourself first by being preventative. See a chiropractor or physical therapist, they will give you better joint mobility and teach you how to move better. Get a massage, and try acupuncture. Work out with guidance initially, and always learn new ways to move better. Be good to your brain, body, and spirit.

Our company, True Motion, was designed to walk people through all phases of healing through various methods. We focus on prevention of injury with healthy clients, and if you come to us in an already injured state, we will get you to the remodeling phase as quickly and efficiently as possible. We make sure that our clients focus on a regaining mobility quickly and carefully, always remembering to be good to your brain in the process. Getting people out of pain is always the initial focus, while keeping an eye on teaching our clients how to permanently train the brain and body how to move better for the long haul. Being both the founder of True Motion and a chiropractor that focuses on correcting biomechanics, I always make sure that I am able to quickly get my patients to a place where they can work one on one with one of our skilled trainers, take our effective yoga classes, and see our massage therapists and acupuncturists at the right intervals to keep their bodies healthy.

If you are already dealing with low back pain, these guidelines will steer you in the right direction. There is no single answer on what to do about low back pain, and that’s the way it should be. It’s not a breakthrough pill, a single miracle treatment, or some other garbage like that. There are many answers, and many of them are good for you. The world is full of very proficient people that have been saying this for a long time, so go out there find some new guidance. Or just take these new guidelines to heart, the American College of Physicians got them right this time.


Dr. Eric Bender, D.C., C.C.S.P.

True Motion Human Performance


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