If you have had an episode of back pain, getting rid of pain may be the least important issue. Several forms of treatment have shown to be effective in reducing pain. Other studies show that low back pain will go away with no treatment at all.
The real issue is to make sure it doesn’t come back.
Studies show the rate of recurrence of low back pain within a year can range from 33% to 84%. (Hancock MJ, Maher CM, Petocz P et al. , Risk factors for a recurrence of low back pain Spine J 2015; Pengel LH, Herbert RD, Maher CG, Refshauge KM Acute low back pain: systematic review of its prognosis BMJ 2003)
And if you have had multiple prior episodes of back pain, you have more than three times the risk of having another episode on low back pain in the next year. (Gustavo C. Machado, Chris G. Maher, Paulo H. Ferreira, Jane Latimer, Bart W. Koes, Daniel Steffens, Manuela L. Ferreira, Can Recurrence After an Acute Episode of Low Back Pain Be Predicted?, Physical Therapy, September 2017)
Clearly, the problem is more than getting rid of the pain, it’s to keep it from coming back.
So what do we do to keep low back pain from coming back?
Based on my experience, you need to first identify the nature of your specific type of back pain, as there are many types of back pain. Then, identify and fix the causes.
The research shows that the most effective intervention for preventing a reoccurrence of low back pain is exercise. A landmark study showed the risk of low back pain reoccurrence can be reduced by 45% with an exercise program. (D. Steffens, C.G. Maher, L.S. Pereira, M.L. Stevens, V.C. Oliveira, M. Chapple, et al. Prevention of low back pain: a systematic review and meta-analysis JAMA Intern Med, 2016) This is in line with expert consensus and a thorough research review that found exercise, along with behavior modification and education, was the most successful intervention for treating low back pain (Foster, NE et al. Lancet 2018).
So, we know that exercise is critical for preventing a reoccurrence.
The real issue is getting people to do it.
Fortunately, recent research gives us some insight into this issue. Giovanni E Ferreira Kirsten Howard Joshua R Zadro Mary O’Keeffe Chung-Wei Christine Lin Chris G Maher People considering exercise to prevent low back pain recurrence prefer exercise programs that differ from programs known to be effective: a discrete choice experiment Journal of Physiotherapy, October 2020.
Researchers presented a large group of individuals with back pain, and showed them options for preventing back pain. They subjects were shown the research regarding the effectiveness of exercise in reducing the rates of reoccurrence. Then they asked them which exercise programs they would be willing to do. Each exercise program varied based on duration, frequency, cost, amongst other factors.
Fortunately, they found that the majority of folks preferred to do exercise over not doing exercise at all in order to reduce their chances of another episode of back pain.
Unfortunately, people preferred brief and infrequent workouts that were below the amounts demonstrated in prior studies to be sufficient for reducing back pain severity.
So is something really better than nothing?
The authors concluded that this may indicate that clinicians should consider the fact that most people will not do the optimal dose of exercise. This insinuates that we should instead focus on teaching more brief, less frequent exercise prescriptions. While acknowledging that this may not be a proper dose, at least it will encourage people to be active.
But I see things a little differently.
This research does tell us something interesting: many people are willing to exercise, but not as much as often prescribed by clinicians. This isn’t too surprising. But I don’t think clinicians should simply take this information to mean that they should prescribe shorter exercise programs.
MED Max ROI Method
Too many people are concerned about the optimal dose, but most of us lack the ability and will to follow the optimal dose. Furthermore, there isn’t enough evidence to convincingly tell us what the optimal dose is when it comes to exercise. To add to the complexity, there are so many individual variables that determine the optimal dose.
Accordingly, there should be more focus on determining the M.E.D.: minimum effective dose. For example, many studies show that training a muscle 3 times a week is superior to training once a week. But more inexperienced people can see excellent gains in training just 1 time a week, if the movement trained is a simple movement. Similarly, training with one set per exercise is very effective in increasing strength in beginners, but 3 sets is more effective. Again, more advanced trainers will need more sets to see improvements compared to beginners. However, training once every 2 weeks or 3 weeks is not effective. Thus, training 1 time with one set per muscle group is the minimally effective dose for a beginner. Please keep in mind these are grossly simplified generalities used merely to describe the concept of minimal effective dose. For your individual situation, age, goals, nutrition, activity levels, and a host of other factors that need to be taken into account. But the key take away here, in combination with the results of this study, is that if we are looking to determine how to make sure people actually do a program that will help reduce the incidence of back pain, we all should be heavily invested in finding the minimal effective dose.
Similarly, we should also determine the optimal dose. Some may decide that they are willing to commit to whatever necessary to achieve the best result. Even if they realize putting forth 30% more effort will only yield 5% more improvement.
Most people will appreciate having both the MED and optimal dose programs. Perfect programs only work with perfect lives. So our programs should account for that. This means that some weeks things will go well and we can commit the time and effort to the ideal program. Other times, life gets in the way, so we need to gear down for the BTN program (better than nothing) to utilize the minimally effective dose.
While we can aspire for the optimal, we can fall back on MED to assure we stay on track. Sometimes victory simply means ”not losing ground” and “weathering the storm” until we are able to cruise forward again.
Designing such a program will take the combined efforts of the patient, clinician, and researchers to process the evidence and apply it to the unique situation. Don’t expect the researchers to spoon feed us the exact answer. There are too many variables to control to yield exact answers.
Related to this, we should also consider the Max ROI (return on investment) of our exercise programs. Effectiveness means different things to different people. Thus, what you may deem a positive return or result may be different than what I think is a positive return. Similarly, what you are willing to invest (time, effort, discomfort) may be different than what I am willing to invest). Thus, return on investment is related to the goals and desires of the individual we are helping. All clinicians would be well advised to take greater stock in considering the goals and needs of their clients and patients over pushing their perception of the optimal result. This requires a direct conversation as to what exactly success looks like to the patient and what are they realistically able to commit towards achieving this result. I am constantly surprised how rare it is to have this perspective. I can tell when my patients eyes light up when they hear me ask them such questions, as they remark that no one has asked them this before.
Using our prior example, while doing 3 sets of an exercise 3 times a week may be most effective, 2 sets performed once per week may be sufficiently effective given the personals relatively modest goals and lower investment (time) that they are willing to give. This is especially important given that the law of diminished returns often applies to many forms of exercise. For example, exercising 3 times a week isn’t always three time more effective than once a week. To make this clearer, training once a week might improve your strength by 50 pounds, whereas training 3 times a week may improve your strength by 65 lbs.
Thus, in addition to considering someone’s goals and unique situation when dosing exercise, we should discuss the concept of MED and Max ROI so a more optimal plan that people will stick to is developed. Researchers should focus on comparing various dosages and their relative effects so we can make more effective recommendations and thus better facilitate exercise adherence.
Are we underselling exercise by talking about prevention?
It really isn’t much of a surprise that researchers found that most people are not willing to commit to the optimal exercise dose when presented with information that proves exercise will greatly reduce the risk of another episode of back pain.
But what if they didn’t confine the proposed benefits to just preventing low back pain?
What if they also shared that it would facilitate fat loss, lower disease risk, improve performance, increase energy, and dozens of other well established benefits of exercise, while at the same time also reducing their risk of low back pain?
When calculating the return on investment, you would likely get more people who will invest more (time/effort) if the return is more (dozens of benefits beyond prevention).
This would likely encourage people to ramp up their commitment level to exercise.
In fact, it would likely increase the amount of people who are willing to exercise at all. Researchers in this study found that a significant amount of people decided that they should not exercise at all in order to reduce the risk of low back pain.
However, if other benefits were provided, with supporting evidence shared, it is likely that more people would have been willing to choose and stick with an exercise program as some may be more motivated by fat loss and performance enhancement than injury prevention.
4 simple ways to improve compliance with a low back injury prevention program
So let’s wrap up with 4 key strategies to make sure you stick with a proper low back pain injury prevention program
- Have a program that is individualized and multifactorial: a one size fits all generic program is not likely going to provide optimal results for you
- Find the minimally effective dose and optimal dose for your situation, and vacillate between those as life allows
- Design a program according to maximum ROI, taking into account your unique factors
- Don’t undersell your program as just prevention, reframe and adapt the routine to provide more benefits to improve the ROI.
I believe this will be critical to making sure more people choose, and stick to, proven strategies to reduce back pain, and more!
Of course, if you need help with this reach out here.
