A Modern Approach to Low Back Pain with Dr. Greg Lehman
Low back pain (LBP) is an all too common musculoskeletal complaint worldwide and the number one cause of disability (1). Here, we’ll explore updating LBP treatment models with Dr. Greg Lehman. Dr. Lehman is a world renowned physiotherapist, chiropractor, and strength and conditioning specialist who treats musculoskeletal disorders through a biopsychosocial lens. The insights here are from his appearance on episode 14 of our podcast Physio Explained (where you can learn from the best in 20 minutes or less).
How did “Core Stability” become a major focus in LBP?
Early research in LBP led to the concept of stability. This research proposed that passive structures, muscles, and the nervous system act together to control motion of the spine, making it more stable (2) (3) (4). The reasoning at the time was that if the spine was not stable, back pain would ensue. Then, the idea of transverse abdominis timing emerged, where people with LBP were thought to have delayed firing of their transverse abdominis when lifting the arm (5). Treatment models were developed based on these two key ideas:
- That we need to control spinal motion by improving the endurance of trunk muscles.
- That we need to correct the timing of trunk muscles like the transverse abdominis.
However, does “dysfunctional” muscle timing need to be corrected? Or perhaps it simply occurs in parallel to the onset of LBP? Recent research has shown that improving muscle timing does not correlate with clinical improvements or reduced pain (6) (7). Training motor control is still recommended by the American Physical Therapy Association’s (APTA) clinical practice guidelines and is shown to be effective (however, not necessarily more so than other forms of exercise) (8) (9). So core stability training can work, but we should integrate it with our modern understanding of low back pain.
A modern, integrative approach
Older treatments can work, but we should use updated narratives
While older narratives of core stability training may not be accurate, these treatments can still be effective. For example, Dr. Lehman still uses bird-dogs as a treatment for certain patients. However, his intention is not to improve spinal stiffness or muscle timing, but rather to load the spine, because movement and load are therapeutic when dosed properly. Personally, I had a phase in clinical practice where I rejected exercises like bird-dogs simply because the narrative didn’t square well with our current understanding of back pain. I now know that a variety of treatments may work, through a variety of mechanisms.
Balance avoidance and exposure to painful movements and positions
Another modern approach is to initially avoid and then expose the back to aggravating movements/positions. Some movements may need to be temporarily avoided in order to decrease pain. But eventually we need to reload affected areas and build tolerance to certain positions. This concept is referred to as “poking the bear”. For example, if low back extension is painful for someone, we could initially use flexion to decrease their pain. Then we would gradually expose the spine to extension. In this case, an exercise like the bird-dog could be therapeutic to build tolerance to extension.
Acknowledge the multifactorial nature of back pain
Some interpretations of the biopsychosocial model lead people to disregard imaging findings. However, Dr. Lehman reminds us that the word “biopsychosocial” includes the root “bio”- we just cannot be sure how much that biological, tissue-level pathology matters in each patient. For example, if an MRI shows a disc herniation, this tissue damage can contribute to low back pain. So we should acknowledge this when patients are concerned about imaging findings. I align with Dr. Lehman’s approach of acknowledging the potential contributions of tissue damage seen on imaging, yet focusing on factors we can control to improve recovery.
To help patients understand these factors, Dr. Lehman offers the analogy of our body being like a cup, with the water poured in representing contributors to pain. When the cup overflows we experience pain. These contributors can be tissue specific stress (e.g. compression of a facet joint in the back), poor sleep, psychological stress, etc. Thus in rehab, we want to cast a wide net and address all relevant factors to optimize recovery. This cup analogy acknowledges the biological reality of a patient’s pain experience, while empowering them to address the factors they can change.
Lastly, due to the multifactorial nature of pain and rehab, Dr. Lehman suggests being candid with patients about prognosis. Typically, persistent pain will take some time to recover from. However, occasionally we get lucky and pain resolves quickly. Thus, when communicating a prognosis for low back pain it is best to be “cautiously optimistic”.
Back pain is a common, multifactorial challenge we see as physiotherapists. Here are the clinical pearls from this talk with Dr. Greg Lehman to help you approach back pain today:
- Older treatments (e.g. motor control training) can work, however we should frame them with updated, modern narratives such as increasing movement and therapeutically stressing the back.
- “Poke the bear” – we may need to avoid certain positions temporarily, but eventually we must expose the spine to uncomfortable positions.
- Use the “cup analogy” to communicate the multifactorial nature of low back pain. A lot of factors (including tissue-level pathology) can contribute to pain, so we should cast a big net to address all relevant factors.
To hear insights from experts like Dr. Greg Lehman and other rehab experts, listen to our podcast Physio Explained!
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- Wu, A., March, L., Zheng, X., Huang, J., Wang, X., Zhao, J., Blyth, F. M., Smith, E., Buchbinder, R., & Hoy, D. (2020). Global low back pain prevalence and years lived with disability from 1990 to 2017: estimates from the Global Burden of Disease Study 2017. Annals of translational medicine, 8(6), 299. https://doi.org/10.21037/atm.2020.02.175
- Bergmark A. (1989). Stability of the lumbar spine. A study in mechanical engineering. Acta orthopaedica Scandinavica. Supplementum, 230, 1–54. https://doi.org/10.3109/17453678909154177
- Panjabi M. M. (1992). The stabilizing system of the spine. Part I. Function, dysfunction, adaptation, and enhancement. Journal of spinal disorders, 5(4), 383–397. https://doi.org/10.1097/00002517-199212000-00001
- Panjabi M. M. (1992). The stabilizing system of the spine. Part II. Neutral zone and instability hypothesis. Journal of spinal disorders, 5(4), 390–397. https://doi.org/10.1097/00002517-199212000-00002
- Hodges, P. W., & Richardson, C. A. (1998). Delayed postural contraction of transversus abdominis in low back pain associated with movement of the lower limb. Journal of spinal disorders, 11(1), 46–56.
- Wong, A. Y., Parent, E. C., Funabashi, M., & Kawchuk, G. N. (2014). Do changes in transversus abdominis and lumbar multifidus during conservative treatment explain changes in clinical outcomes related to nonspecific low back pain? A systematic review. The journal of pain, 15(4), . https://doi.org/10.1016/j.jpain.2013.10.008
- Mannion, A. F., Caporaso, F., Pulkovski, N., & Sprott, H. (2012). Spine stabilisation exercises in the treatment of chronic low back pain: a good clinical outcome is not associated with improved abdominal muscle function. European spine journal : official publication of the European Spine Society, the European Spinal Deformity Society, and the European Section of the Cervical Spine Research Society, 21(7), 1301–1310. https://doi.org/10.1007/s00586-012-2155-9
- George, S. Z., Fritz, J. M., Silfies, S. P., Schneider, M. J., Beneciuk, J. M., Lentz, T. A., Gilliam, J. R., Hendren, S., & Norman, K. S. (2021). Interventions for the Management of Acute and Chronic Low Back Pain: Revision 2021. The Journal of orthopaedic and sports physical therapy, 51(11), CPG1–CPG60. https://doi.org/10.2519/jospt.2021.0304
- Smrcina, Z., Woelfel, S., & Burcal, C. (2022). A Systematic Review of the Effectiveness of Core Stability Exercises in Patients with Non-Specific Low Back Pain. International journal of sports physical therapy, 17(5), 766–774. https://doi.org/10.26603/001c.37251
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Great summary. Nothing on our modern approach to manual therapy though? I’m a little surprised by the use of the word “damage” when describing a disc herniation when we know they have quite good potential to resolve, and probably more important, when we know the narrative we use when describing scan results can heavily influenced patient outcomes.
i like the cup analogy!