How to (efficiently) treat low back pain in Hong Kong
Lower-back pain is the worldwide leading cause of activity limitation and absence from work. Hong Kong is no exception. Medical and economic costs associated with the pathology are very high and tend to increase every year.
At Hong Kong Sports Clinic, we strive to incorporate the latest evidence available, in order to increase treatment efficiency, while lowering the overall cost to both our patients and society.
We hope that you enjoy reading the following essential, evidence-based facts about low back pain.
1.What is low back pain?
"Understanding the complexity of lower back pain is essential to treat it efficiently"
A general definition of low back pain
Let’s start with defining the lower back anatomical area. To keep it simple, it runs from the lowest set of ribs, down to the start of the gluteal fold.
Low back pain can be either acute or chronic.
- An acute low back pain episode can last from just a couple of days, and stay up to 6 weeks. It usually resolves by itself within that timeframe. In Hong Kong, like in most countries around the world, the most common first line of treatment would include rest and painkillers - which in most cases will not help a lot. While drugs like anti-inflammatory pills can give some sort of symptoms relief, bed rest is not advised for more than two days. Our Instagram feed has a selection of exercises you can safely perform even during a very acute episode.
- Chronic low back pain is defined as lasting more than 3 months and is a real therapeutical challenge. The pain usually does not solely come from damage or irritation of our soft tissues anymore. We now need to have a more global bio-psycho-social approach to pain.
Different types of low back pain
We can classify the different types of low-back pain as follow.
- Discogenic: the pain is most likely coming from the intervertebral disc. A lot of patients are afraid that something “doesn’t work properly” or that a vertebra is “out of place”. This often creates unnecessary fear-avoidance patterns. People become scared of moving or exercising. Let’s just remember that the spine is a very stable structure, that sometimes gets irritated. In the vast majority of cases, nothing is structurally wrong with our spine. This type of pain can be with or without radiating pain in the butt/groin/leg.
- Joint-related: the pain comes from the part of the facets - where the joints touch each other -, or the surrounding capsule.
- Musculoskeletal/myofascial: the pain comes from soft tissues, and is often related to repetitive strain or trauma. Some specific tender spots - trigger points - can be found.
- Non-specific back pain: the most common type of low-back pain is a symptom of abnormalities or other conditions, which often remain unidentifiable.
2.What are the predictive factors of low back pain?
“Our sedentary lifestyle appears to be one of the leading contributing factors to low back pain”
The most common risk factors for low back pain
Some people are more at risk of developing back pain than others. The list includes, but is not limited to, the following:
- Obesity: more weight equals more load on our joints.
- Motorization: the vibrations coming from sitting in a car seat may lead to accelerated disc degeneration.
- Sedentary lifestyle: lack of physical activity prevents the optimal functioning of our body.
- Overuse: just like not enough sport is detrimental, too much sport can also have a negative impact on our body.
- Gender: women are more affected than men.
- Age: getting older implies normal and progressive wear and tear of our bones, ligaments, tendons, and muscles. Arthritis consists of normal, age-related degeneration of the cartilage, which can lead to some form of bone deformation. Sometimes it will pinch a nerve, or trigger inflammation, leading to a painful back episode.
- Prolonged sitting: People who sit for more than 5 hours a day are at a higher risk of triggering back pain.
- Smoking: heavy smokers are more at risk of developing low back pain.
- Recent episodes of low back pain: multiple studies have shown the “vicious circle” aspect of low back pain.
3.Presentation and symptoms of a typical low back pain episode
"Most back pain episodes are benign, but some cases require your attention"
Physical and functional aspects of low back pain
Back pain episodes can have a mix of physical and psycho-emotional causes.
- For a lot of people, a typical painful episode starts with a “false movement”. It may involve lifting, twisting, forward-bending, or any combination of the above. Pain can start immediately, or be delayed until the next morning.
- The usual presentation can vary from one individual to the other, with some people getting movement-related pain, while others would mostly complain at night. Pain can be centered or one-sided, triggered by our spine’s flexion or extension. Referred pain in the leg may or may not be present.
Red flags and more serious causes of low back pain
In rare circumstances, some signs point to a more serious condition that requires immediate attention. While 99% of low back pain cases are benign, there are some conditions that call for specific attention and advice from a qualified general practitioner. These "red-flags" can be ruled-out during the initial assessment.
Serious causes of low back pain include a history of:
- Malignancy: when there is a previously treated cancer.
- Fractures: when a physical trauma/fall/accident is described. Pain is almost constant, regardless of the movement or position of the body.
- Infection: fever could be a sign of an infectious disease.
- Chronic inflammatory disorder: associated with the HLA-B27 gene, often with a family history.
- Acute nerve compression: associated with urinary retention, loss of bowel control, or a sudden loss of strength in a group of muscles.
4.Why are there so many different treatments available for lower back pain in Hong Kong?
“What we see on X-rays and MRIs does not always match the intensity of pain”
The plurality of existing options indicates that to this day, there are no gold standards for the treatment of low-back pain. Ineffective treatments based on image findings or tunnel-vision focus on the low-back area are common reasons for treatments with a poor outcome.
- Imagery and low back pain: X-ray or MRI findings may not necessarily match the symptoms. Therefore, their prescription should remain specific to certain conditions, involving severe referred pain in the lower limb. Recent worldwide guidelines do not recommend routine imaging anymore.
- The hip-pelvis-back complex: the lower back does not function independently of other areas. The closest key anatomical structures include the hip and the pelvis. One of the reasons so many treatments are inefficient might be the sole focus of said approaches to the lower back area, focusing on symptoms instead of the root cause.
5.What treatments work and what are not working for lower back pain?
“There is a need to stop wasting resources on ineffective treatments”
In 2019, over 200 different treatment methods have been reported by US insurances. Lower back pain is very common, but still poorly understood and treated.
Common treatments that do not work
- Here is a short-list of common approaches to low-back pain that have been described as ineffective, or not significantly better than a placebo. Following these treatments for your lower back pain may result in sub-optimal use of your time and resources.
- Steroid injections
- Electrical nerve stimulation
- Opioid drugs
- Bed rest
- Shock-wave therapy
- Low-level laser therapy
- And probably many more...
There is some evidence for efficient treatments
- The following approaches have been studied and proven to provide at least short-term relief. Combining exercises with some type of manual therapy seems to provide the best long-term results.
- Exercise: moving more is the best remedy for low-back pain, both for prevention and treatment. While a specific, better set of exercises has not been identified yet, many different approaches show a significant positive impact on patients suffering from low back pain.
- Drugs: non-steroidal anti-inflammatory drugs can give some initial short-term relief. We advise you to try the lowest effective dose and shortest duration, first. Muscle relaxants can help, too. Beware of potential side-effects with both medications.
- Manual therapy: physiotherapy, osteopathy, and chiropractic demonstrate both short and long-term benefits on acute low back pain.
- Cognitive-behavioral therapy: some studies have described a positive short-term impact on pain, disability, and relaxation.
- Multidisciplinary approach: combining different fields may give a greater overall outcome.
- Heat and ice packs: both may help with symptoms control.
- Dry needling: seems to reduce pain intensity and functional disability. It may work even better in association with other treatment modalities.
- Massage: can give a short-term relief - from a few days up to a week - for both acute and chronic low back pain. Usually pretty harmless, but better avoid it during the onset - first few days - of an episode.
- Surgery: the following advice from Wikipedia is correct: “surgery is useful in those with a herniated disc that is causing significant pain radiating into the leg, significant leg weakness, bladder problems, or loss of bowel control. It may also be useful in those with spinal stenosis. In the absence of these issues, there is no clear evidence of a benefit from surgery”.
6.Tips and advice for the prevention of low-back pain
“A few changes to your lifestyle will contribute greatly to live a pain-free life”
Several of the predictors/risk factors for low back pain are in fact modifiable lifestyle components. Here is a list of simple - but not always easy to apply - advice to consider if you want to sustain less intense and frequent back pain episodes.
- Manage your stress: a high level of stress and/or anxiety has often been associated with both higher intensity and frequency of low back pain episodes.
- Increase your level of physical activity: sedentary and obesity often go hand in hand, especially in high-income countries like Hong Kong. We ideally want to sleep for at least 7 hours a day, so what we do for the remaining 17 hours matters the most. Try to find a sport that you enjoy and conveniently fits your hectic schedule. Make it easy to attend, and fun!
- Sit less: this advice seems logical in regards to the previous one, but we can’t emphasize enough how bad sitting is for our general health.
Office workers sustain more musculoskeletal injuries than any other industry sector workers. Sitting for as little as 2 continuous hours increases the risk of heart disease, diabetes, metabolic syndrome, cancer, back and neck pain.
- Sleep more: getting these 7 hours of sleep instead of 6 (or less) has a huge impact on several aspects of our lives, including lower back pain.
Attention to posture and ergonomics
- At our clinic, we see many office workers from various Hong Kong-based companies. One question that we keep hearing is: “What is the best posture I should adopt when sitting at my desk?”. While there are better postures than others, the best posture maintained for 10 hours per day will still hurt you.
- The advice here is to add some variety to the sitting position. Try to use a standing desk or alternate between sitting and standing throughout the day. When you sit, change the position of your legs often. Extend them, bring one foot on the opposite knee, bring your ankles together while pushing the knees out, sit at the edge of your chair… Be creative with your legs!
7.Why do patients book Hong Kong Sports Clinic for their low-back problems?
“Learn the right movements first, then repeat them a lot. This will promote your physical health”
We are back experts
Every practitioner at our clinic is capable of helping you with your low back pain. We will always do our best to give you some substantial and fast short-term relief through hands-on therapy while guiding you towards the best long-term changes.
We have an active approach to pain
We believe that a purely manual approach to low back pain has its limits. For that reason, exercises are almost always on the menu. We want you to feel in control, and understand that what you do outside of the clinic is just as important, if not more, than the time you spend with us. Of course, we will do our best to ease up your pain, but there is a limit to the “magic” our hands can provide.
We keep an honest and open-minded vision of your pain
Lower back pain is complex. There is a lot we still don’t know about it. While we understand how pain works, we do see that sometimes patients get better and that sometimes they do not. We keep educating ourselves to deliver the most adequate and up-to-date advice. And as a team, we trust each-others. So if needed, we will not hesitate to refer you to one of our colleagues, for a second opinion, or a different approach to your pain.
8.How to experiment with Hong Kong Sports Clinic approach to low back pain
“Contact us to guide you through your journey towards a pain-free back”
Simply call our reception - 37092846 - for more information, or to book an appointment. You can also use the Whatsapp button on the bottom right corner of the page.
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Shaw, B., Kinsella, R., Henschke, N., Walby, A. and Cowan, S., 2020. Back pain “red flags”: which are most predictive of serious pathology in the Emergency Department?. European Spine Journal, 29(8), pp.1870-1878.
Wu, A., March, L., Zheng, X., Huang, J., Wang, X., Zhao, J., Blyth, F., Smith, E., Buchbinder, R. and 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), pp.299-299.