Strategies for Acute Low Back Pain

We’ve all seen it before. Someone comes in saying that their “back locked up” on them!

They are in a lot of pain, guarded with their movement, and not sure what to do.

Here’s how we approach this and some pearls to help them get out of pain and spasm and back into their activities without setbacks.

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#AskMikeReinold Episode 334: Strategies for Acute Low Back Pain

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Show Notes

Working with Fitness Athletes and Low Back Pain with Dan Pope


Brady Cannon:
All right, we got Tim from Maryland asked, “I work in an athletic orthopedic clinic. I often see fairly young athletic people with acute low back pain that they describe as just locking up on them, and then pain for days. Sometimes they have mild neurological symptoms down their leg, but oftentimes they don’t. Why do you think that is? And what’s your treatment strategy?”

Mike Reinold:
Nice. Good job, Brady Cannon. Love it.

Lenny Macrina:

Mike Reinold:
Boom, cannonball. Yeah, you just nailed it. Anyway, yeah, I feel like this is three of my patients right now that I’m rehabbing for other extremities too. So I hope Diwesh and Jonah don’t take that the wrong way. I’m sure it wasn’t what they were doing in the gym. It was them. It was definitely them. But this happens all the time, right? I’m sure Dan and Dave, probably you guys see a ton of these here too. But the younger, the healthier person, it’s not necessarily neurologic, or maybe it’s the beginning of something. Who knows, right? It’s not like they’re shooting pain down their leg, but they just have that acute lock up in their back, and they almost can’t even move.

And man, the apprehension and… Fear may be the wrong word, but they’re nervous. They’re like, “What the heck just happened? What is this?” I’ve heard people recently that are like, “I had to have somebody drive me home because I was nervous.” That sort of thing. So who wants to start with this one? Because this is a good one. And I’d actually like to know the answer because I need help with this. I have three people right now. So who wants to start? Kev, what do you think?

Kevin Coughlin:
Yeah, I’ll just start by saying that it can definitely be challenging, and the patient can appear super, super nervous and worked up. I think generally the first thing I try to do with that person is, as we’re going through the assessment, just educating them and letting them know that, “I know this is horrible right now, but luckily most cases of acute back pain tend to get better pretty quickly. So this is obviously horrible, and I’m here to help you, and we’re going to find any strategy we can to bring your pain down. But just thinking over the next four or six weeks, this is going to progress relatively quickly.” I think what I tend to see is that debilitating period can be a couple days long. And then it transitions to a more achy, uncomfortable back pain, but one where they’re totally able to function with that.

So I think the first thing I try to do is just talk them off a ledge. And as long as we’re screening for red flags, and they’re not presenting with any, just letting them know that this will subside likely in the next few weeks. And then I would say from there, going through, if we can do any type of movement assessment. It depends. Sometimes they’re so painful, a movement assessment’s not worth it. We’re not going to get any good information. If we can, I try to find if they’re appearing to be flexion or extension-based. So one position where we can just have them lay in, whether it’s supine with legs elevated on a ball or something to keep them in a little bit of flexion, if they’re presenting as flexion tolerant. Or laying on their stomach if they’re preferring extension. And then from there, whatever I can do to help alleviate some pain.

The question was asking about locking up. I think sometimes, if you’re treating a younger population, this could be more of a bony issue. If it’s like an extension rotation athlete, maybe you’re getting some spasming of the muscles in the area. In that case, maybe I’ll give them a little heat and see if that helps. I’ll do a little massage stuff and see if that helps. Sometimes gentle joint mobilizations can be helpful. And then after that, maybe just some light breathing, positional breathing techniques, and then very gentle exercise if they can tolerate it. But throughout that whole process, just educating them on, “All right, we’re finding that you feel a little better in a flex position. Let’s try some of these flexion-based stretches, see how you tolerate them.” And encouraging them to move as much as they feel like they can in the coming days. Because that tends to help them get better as well. But I think a lot of education, and screening for red flags, obviously, and then trying to provide any relief that we can, based on what we’re finding and what they’re telling us.

Mike Reinold:
Yeah, I think that’s a good way to frame this too, Kevin, which I took from Tim’s question, to be honest. But assume you didn’t find anything like a huge red flag, because I think that’s the point here… This is just to add on, but I love what you kind of broke down there at the beginning here. The first process here is to break that pain spasm cycle. They’re having that spasm, and sometimes I even try to educate them like, “I don’t even think the symptoms you’re having right now maybe even related to whatever the pathology or whatever it might be. It’s the secondary spasm that’s occurring to help try to protect that is really the symptom that’s driving you crazy.” So that leads our early phase stuff. But I don’t know. Who else wants to jump in? What do you think on this topic? This is pretty common, right? I mean, I know I want to hear a little bit from Dan Pope, to be honest with you, but I don’t want to put him on the spot. Does anybody else want to jump in?

Dave Tilley:
Get him, Dan.

Dan Pope:
I mean, I can say a thing or two, I guess.

Lenny Macrina:
Dan, Dan, Dan, Dan.

Mike Reinold:
This is Dan’s world. I mean, he’s great at this. So I’m going to sit back and just get ready to be educated here.

Dan Pope:
I don’t know if there’s anything good that’s coming for me. I see a lot, just because we see a lot of people who lift weights. Low back is one of the most common injuries. Happens pretty frequently. A lot of lifters have this, and it’s something they deal with on a pretty regular basis. Back feels good one day, next day it feels like garbage, following day feels pretty good again. I think Kevin really nailed it there. When you have low back pain, especially for the first time, it’s so debilitating and so scary, you think something really, really bad is going on. And it’s kind of a hilarious issue. It doesn’t really make a lot of sense to me, but compared to a lot of other injuries, it just seems to get better so fast. And it’s so odd that someone could be so debilitated one day, and the next day, like, “Yeah, I’m feeling pretty good.” And you hear this story all the time that things lock up. And “I’ll have a couple bad days,” and then they’re completely fine after that. Which you don’t really see with other tendinopathies or something along those lines.

It just behaves differently. So I think that is number one. Educating patients that, “This is terrible, but there’s a good chance you’ll feel awesome tomorrow. So don’t feel like you have to change everything.” And I think moving from that place, and I think this is also where you’re talking about with your patient right now, we want to try to maintain their fitness and keep on exercise as much as possible. But there’s also that likelihood, I kind of see it as a hamstring strain injury, that’s just going to occur in the next few weeks unless you’re careful. So I think it’s twofold. Making sure that you’re backing up enough that you’re not continually irritating it, but also trying to maintain their fitness as much as possible. So let’s say it was like a Romanian deadlift or something along those lines that aggravated someone’s spine. If they feel pretty good the next week after having a flare-up after that, maybe we have to modify that to something different.

And I often will use the words tolerable. If something feels tolerable, that’s a good thing. You might have to be a little more cautious with those repeat offenders. Some folks, they feel like they’re pushing probably a good amount, and it’s not going to be too much, but the next day they’re right back in the same place so you have to pull back a little bit more. So I think a lot of it is this balancing act of trying to figure out what can we continue pushing without that risk. And just like that hamstring, it’s the same issue. It’s like we can probably return quicker, but we just have that increased risk of flaring things up again.

So it probably depends on how important, because I think for an athlete we were talking about, it’s like, “Well, do you really need to load that deadlift heavy for your goals?” Probably not. Why do we need to keep on pushing this? We can probably back off a little bit more so. But if I have a powerlifter that’s six weeks out from nationals or something like that, it’s like we probably have to push it a bit, but we’re going to assume a little more risk. Just like if someone is preparing for, I don’t know, some big soccer competition in three weeks and has an acute strain. It’s like, well, we’re going to have to push it probably a little bit, but a risk goes up for that reason.

Mike Reinold:
Yeah, I love it, Dan. And I think that between you and Kevin putting that together, I mean that really covers to me the first two big phases. The first phase is break that spasm cycle. That was what Kevin kind of mentioned. Break the pain spasm cycle, get them, move them. Make sure they realize that. They’re not going to cause damage by moving, so just get them moving a little bit, and let that subside. And sometimes I think… I almost say it’s like a muscle, right? You overdo a muscle or you work a muscle that you haven’t used a while in the gym, it’s three to five days that you’re going to have almost delayed onset muscle soreness. Because all those little muscles in your back were spasming at 25% max intensity, whatever it was, for 24 hours. Of course that muscle is going to be sore.

But it’s funny. I like how you said that, Dan, because I think that next phase, and I try not to tell this, I don’t mean to tell this to the person. I almost consider it the fragile phase. I don’t want to tell them that, because I don’t want them to think they’re fragile. That’s the opposite of what we want. But in my mind, I like how you said there’s a few weeks where it’s almost a… You know, It can spasm up again. And why do you think that is, Dan? I’ve wondered myself. Was it because their endurance wasn’t quite there for the stabilizers in there? And It’s almost like if you go a little bit too much, it can spasm again. What do you think that is, Dan? Do you have any idea?

Dan Pope:
I don’t know. I think you can kind of approach it from a few different perspectives, like a biomechanical approach where, yeah, maybe they didn’t have the strength and endurance they need, there’s a little too much motion, overstretched one of those ligaments in the spine, and you have a big nociceptive response. Goes up to your brain. Body’s like, “I don’t like this. Let’s make it really painful.” So I think building that strength and that endurance is probably more important for the athlete. Maybe not as much for a sedentary person. But the other thing I had tell my patients is that the body keeps the score. And that was actually a book, I think its guy’s name was Bessel van der Kolf or something along those lines. And it was a book on PTSD, but I think it’s actually very relevant.

It’s like your body’s trying to keep you safe. It’s trying to protect you. So one of the reasons when, after you have an injury, things get really sensitive is because your body’s just trying to protect you. And over the course of the time, at least really close to the injury, I think your body is more likely to resensitize the area because it’s like, “Hey, idiot, don’t hurt yourself in the same exact way that you did a week ago.” And as you start to build some strength, some capacity, some trust with your brain, whatever it is, that sensitivity is probably going to go down again.

Because we’ve seen this before. We’ve seen these athletes. We had someone before, a champion was squatting heavy. She felt kind of a pop in her spine. And then she was laying on the floor literally for two hours in tremendous pain. Had to have two people walk her to the car to go to the emergency room, which took like 45 minutes. Then we go to the emergency room, do some imaging, and there’s nothing. Which blows my mind that that can happen. But for whatever reason, this body mounts this tremendous protective mechanism. So I think we’re really trying to just be cautious, and try to respect that.

Mike Reinold:
Yeah, what a great example too. That was a fun day.

Dan Pope:
Oh, yeah.

Mike Reinold:
That was a fun day. She called me. I’m like, “Hey, what’s going on?” She’s like, “Nothing.” I’m like, “Okay.” She’s like, “I’m lying on the floor at the squat rack.” She called me. I’m like, you guys are all around. I’m like, “All right, I’ll be right there.” That was a crazy day. But I think that’s the best way of saying it there, Dan, is the body is trying to do its job. Now, as a PT… Remember, in this phase there’s tons of stuff we can do. We do want to slowly apply load, but take a step back and think, what are some of the variables that may have put them in a position to be more susceptible to this? Maybe there wasn’t any. But work on their hip range of motion, work on their T-spot, work on a little bit more core control, or education during the movements at slower speed and less force. So that way maybe when they get there again, they can do it.

But I think we see that a lot, and you can really capitalize on that. Dan alluded to one guy that I think I know who you’re talking about, that we were kind of talking about right now. But I think that’s another good example of an athlete where this happens, where we’re getting later in the off-season for his sport. He’s a baseball player, so he’s doing a ton. He’s in the gym, he’s doing some rehab, he’s throwing, he’s doing a ton. And if he keeps loading and loading and loading with things like a deadlift, like Dan kind of mentioned him, at some point in time, you have to say, “Look, your objective right now is to get ready to pitch. So you’re long tossing, you’re throwing bullpens, you’re doing all these things. That’s endurance of your back and your core, and your hips, and stuff like that.”

So if you’re doing that and you’re still trying to keep going up in weight with certain things, just sometimes it’s just an endurance issue. You just overloaded it. So you try to deadlift, but you’re exhausted and your dynamic stabilizers aren’t there. Maybe that’s part of it. So again, I think everything else we tend to talk about, especially on this podcast, is that the answer depends. It depends on the person in front of you and what they have going on. There’s so many different variables that go into it. But I think that’s a good approach. A phase one, phase two approach right there. Decrease the spasm, and then phase two is like when they’re building back up, is make sure we really educate, but keep moving. And then slowly get them back to where they were. And then hopefully this doesn’t happen again.

And I think that’s the key to us, for this. If you go back to last episode where we talked about how do you know when to push or back off a little bit, I think those principles apply here. So good question, Tim. I think a lot of people deal with that. So I’m glad you asked. I’m glad we got to answer that. But if you have something like that, just head to the website, ask away. And please head to Apple Podcasts, Spotify, subscribe, rate, and review us, and we’ll keep doing this. We really appreciate it. Thanks so much. See you on the next episode.


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