Learn How Movement Will Change Low Back Pain

Last week we posted an article discussing some of the research around the clinical guidelines of low back pain.

There are several modalities commonly used that aren’t recommended like Tens, laser therapy, imaging, and corticosteroids,  but when we look at what is recommended we have an opportunity to make a real difference for those suffering from back pain.

One of the big things recommended is a biopsychosocial approach along with education. In order to start this kind of approach, patient reassurance is critical in order to help the patient feel safe (as we talked about last week).

In addition to reassurance, supervised exercise is also a crucial part of helping patients deal with their back pain. However, these two go hand in hand as it will quite often take a considerable amount of reassurance to convince a patient that it is okay to move.

One way to help is by looking at what the research says for exercise and low back pain, which you can use as a tool to convince (and reassure) patients this is the best course of action.

Exercise For Low Back Pain

Remember the old days when bed rest was the main prescription for low back pain?

Well, now bed rest is actually discouraged unless the pain is too severe, then only two days of bed rest are chosen. In contrast to this, we now understand that staying active has far better outcomes than the way we used to manage this.

And I know many of you might be saying “exercise is out of my scope of practice” and while this may be true, active and passive range of motion probably is within your scope, so there is no reason you can’t incorporate some of this into your treatments. 

I know there is probably some concern over being able to recommend “specific” exercises (or movements) but don’t worry it doesn’t have to be all that complicated…in fact, it shouldn’t be! Supervised movement without the use of expensive equipment is one of the specific recommendations, so you can do this right in your treatment room.

This is especially true in the acute stage, where strengthening, extension, and specific exercises are not recommended. Rather, in this case, we want to use graded exposure to physical activity. Graded exposure is essentially getting a patient to move (gradually) into a feared or painful movement (we’ve had articles about this before which you can read HERE for a more detailed description).

For example, when it comes to acute low back pain, if your patient is scared, or experiencing pain with a certain movement like standing forward flexion, have them change the plane of movement and try flexion again. Try having them sit comfortably in a chair, then lean forward. This is still spinal flexion, it’s just in a more supportive position. When they can move in this position comfortably, point out how capable they are of the movement and reassure them that flexion is safe. You can then gradually work up to standing flexion until this feels safe again.

There are many ways to do this, it just takes a little experimentation on your part.

When it comes to chronic low back pain there is no evidence that one exercise is superior to another.

However, recommendations show that remaining as physically active as possible along with an early return to work is well supported by evidence (probably why some workplaces have a gradual return to work program). While there are no specific exercises highlighted as more effective than others, the exercises that work are simply the ones your patient will do. Find out what’s important to them and encourage them to do it. Whether it is strength training, going for a walk, playing with their kids, or playing hockey, the intent is to build confidence in their bodies as opposed to fixing a problem.

Inevitably the question of dosage comes up and the research shows that too much, or too little exercise with some patients can run the risk of developing persistent pain. This is where it’s important to experiment a little to see what works best for the patient, we don’t want them to overdo it, but also want to avoid not doing enough (one of the reasons bed rest has been eliminated).

Overall since we know a biopsychosocial approach is most effective, encourage things like movement in general, getting back to work, staying connected with the things and the people they enjoy. Just make sure these things are done gradually. If we can address peoples fear of movement by using graded exposure early on, we have a better chance of avoiding prolonged pain and disability. So, don’t stress about ‘specific’ exercises, the overall goal is to get our patients moving and keep them moving. Movement along with some education and reassurance can go a long way in not only improving low back pain but also the patients quality of life.


Altered Skin Colour And Circulation, Result Of Massage Or Nervous System?


This is one of those topics that inevitably comes up on a regular basis.

The last time I taught our course on pain science and therapeutic exercise, there was some resistance to the idea that massage therapy does not increase circulation and last week there were some big discussions on the topic on one of the massage groups on facebook.

This was a harsh reality for me when I realized we don’t have any effect on circulation and I remember the day in college when I started to question it (I’d love to say it was because I was some sort of forward-thinking genius, but I digress). I was working with a hockey team and one of the players had an episode in the summer which required him to be on blood thinners. I was super worried that if I did any massage I’d have an adverse effect on him, so I approached one of my teachers to ask if massage was contraindicated and what I should do as I was worried about the increase of circulation with his condition.

My teacher simply looked at me and said: “you’re not going to increase his circulation any more than him playing hockey!”

It was like a light bulb of astonishment went off, I wish I had a picture of my face.

Now, surely that story can be taken anecdotally if you choose to, so the question will remain: “what does the research say?”

Heart Rate And The SNS

I remember in college while working in the student clinic, part of each treatment we had to develop three goals prior to treatment to be reviewed by one of the clinic supervisors.

Most of the time my goals would look something like this (they got more specific as school progressed):

  1. Increase circulation.
  2. Decrease SNS firing.
  3. Patient education.

I think the reasoning behind “decreasing the sympathetic nervous system firing” was more to just a way of saying we calmed the patient’s stressors down and essentially helped them relax. As we know the SNS is responsible for our “fight or flight” response, which is essentially used when we are scared because we’re being chased by a bear or something. In order to have a “fight or flight” response, it would require our heart to start pumping hard and feed blood to the necessary parts of our body to get us moving and run from the said bear.

One of the assessment tools we would use to prove whether we actually had an effect on the patients SNS was to check their pulse before and after treatment to see if there was a change. Inevitably their pulse rate would be slower post-treatment than it was prior to treatment, thus justifying how we “relaxed” our patient.

So how in the world did I think I could simultaneously increase circulation, while both decreasing sympathetic nervous system activity? My assessment was literally proving me wrong. The sad part is I only thought of this example last week, at no point during my education did I ever question this, I just habitually put them as goals.

One thing we know for sure (and we’ve written about it before, you can read it here), is that massage therapy can help with hypertension and actually decreasing blood pressure. Some articles argue this entirely depends on the type and depth of massage technique used. One study showed using trigger point therapy and sports massage actually increased BP, however, the article wisely ackn0wledged this was due to the pain caused during a trigger point treatment. In this case, the treatment would be causing a sympathetic nervous system reaction to withdraw from pain, thus temporarily increasing blood pressure.

With everything we know about modern pain science and the knowledge around old theory of trigger point therapy, I hope we aren’t going in and causing pain with our patients anymore, as we know it’s not effective. In turn, it’s also not a technique we should use to fight the argument about an increase in circulation. As far as sports massage causing an increase, we’ll get to that in a bit. 

Sport Massage 

In the sport massage world, there has been a long time practice of using tapotement techniques to help with warm-up and increase blood flow before a competition.

While this can be an effective way of helping an athlete warm-up, there is probably more of a psychological aspect to it than anything about bringing circulation to a specific body part or tissue (this may be part of the reason that a typical warm-up involving exercise is always recommended before seeing a therapist to assist with warmup).

There is also the argument about doing a “leg flush” post-competition to help clear out lactic acid as part of recovery.

While there are several studies showing that blood flow is increased with massage (to help prove the above theories), most of the methods used to try and prove this theory wasn’t very reliable. However, more recent studies have shown that massage has little effect on arterial blood flow.

There were theories that reported a 50% increase in circulation after a vigorous massage, but later studies (which used somewhat unreliable measurement tools) showed not only smaller increases, but some showed no increase at all.

The above-cited study actually did tests post-exercise to see if massage would still have any effect when it comes to circulation. They used one group who would take regular rest post-exercise and one group who would receive massage. There was no significant difference between the two groups on femoral artery blood flow and massage performed on the quadriceps.

So what does this tell us? The only real way to increase blood flow is through movement and exercise. As our friend Alice Sanvito stated in a forum not too long ago: “If we mean there is more blood to an area, we run into another problem. The circulatory system is a closed-loop. There is a relatively fixed amount of blood. If more blood is shunted to one area, then there must be less blood somewhere else.”

The body would not let this happen, so we cannot actually alter circulation to bring more or less to any area of the body, without significant injury, which would result in shock, or blood loss.

Changes In Skin Colour

The question came up, “if we don’t increase circulation why does the skin go red!?”

Great question!, so I had to do some research on that as well.

We have all seen it in our clinic, we work on a specific area of the body and the skin changes color and gets a little bit pink, or maybe even red. Well, there are two possible mechanisms at work here, either the friction created doing, say, an effleurage stroke is irritating the skin, or a change in temperature from touch is the culprit. What about the clients you treat where the skin doesn’t change colour? Does this mean the massage is having less of an effect on them?

Well, studies show that skin friction can increase heating which causes hyperemia in the local massaged area. But the same thing happens when I put a cold pack on my arm and isn’t cold actually supposed to cause vasodilation and a decrease in circulation?

While there is a minor increase in blood flow to the capillaries of the skin, the increase in blood flow has been measured and shows that the amount is so arbitrary, there is no way it is being diverted away from local musculature. So, while this is p0ssibly a minor increase to the skin, we can’t assume we are increasing circulation to the muscle because the skin is changing colour.

As we mentioned before, what about those clients whose skin colour doesn’t change? Does this mean there is something wrong with their circulatory system, and we aren’t influencing circulation to that area? I’d venture to say no, it probably has more to do with skin sensitivity, or it’s a true measure of how minimal the circulation increase actually is.

Our friend Alice Sanvito also made a stellar point about this:

“What were we taught about the sympathetic and parasympathetic nervous systems? The sympathetic “fight or flight” nervous system diverts blood away from the skin and internal organs and towards the muscles. The parasympathetic “rest and digest” nervous system diverts blood away from the muscles and towards the internal organs and the skin. Since massage tends to relax people, it is probably safe to assume it is downregulating the sympathetic nervous system.”

Like it has been with so many other things in our career, we really have to take a step back sometimes and critically look at the things we were taught. This has been a huge learning curve for me during my career, but there is also a refreshing side to being able to give honest and logical answers to patients. While we may encounter arguments from others on these points, it’s important to keep educating ourselves and others to stay on top of current research and evidence-based practice. We’ve said it before on this blog in regards to circulation, there’s more of an increase happening by your patient walking into your clinic and getting on your table than from anything that happens during the treatment. And you know what? That’s okay because what you are doing for them on the table is FAR more important than worrying about increasing their circulation. 


Using Movement To Teach Resilience, Not Fragility

Movement is a very important component in the treatment of painful problems. 

It makes sense that if someone has a movement problem that movement will be key to their recovery. 

Pain is very effective at taking things like movement away from us. And it often leads to a search for “good” movements to be encouraged and “bad” movements to be avoided. 

It can seem sensible, especially when the pain seemed to originate with a particular movement or activity, and many a well-meaning provider is all too happy to help a person identify them. But let me tell you that one of my biggest frustrations is when I get people who have become scared of movements and actively avoid them because they’ve been told to!

 “My PT said that my lumbar degenerative disc disease is probably related to all of the bending that I’ve done in my life. So, now I avoid bending whenever I can.” 

This, folks, is avoidant behavior, one of the biggest indicators of poor prognosis, that was ENCOURAGED by something a person was told. 

We can do better than this. Much better!

Movement Is Education. Teach Resilience, Not Fragility.

It can be tempting to separate the things we do into divisions such as manual therapy, education, exercise, motor control movements, etc.

Certainly there are plenty of examples out there of “making sure to include education into your treatment.”

I would submit that you can’t avoid educating your patient even if you try.

Everything that we do informs the patient in some way or another. Even the timing and body language used when we take notes or make eye contact informs the patient about what we consider to be important about their case.

“He looked concerned and started taking notes when I mentioned my old auto accident. That must be important!”

Our tests, screens and the way we react to the findings provides education. When we apply our hands to the patient we are educating them about their condition.

“He looked at my spine and when he pushed on it I noticed stiffness.”

Movement is no different.

When we discourage certain movements we are sending a message that those movements are a threat and may create harm. When we encourage other movements, we are providing education as to what may be “good” or “helpful.”

Sometimes this may be appropriate but we must be careful because, if on one hand we tell the patient that “pain is an output of the brain” and that their problem is not explained by an orthopedic “issue in the tissue” but then on the other hand dispense movements based on tissue strain principles then we are sending a mixed message.

Or, worse we may be sending a consistent message of threat that implies fragility.

Be careful of passing on themes of fragility through movement programs.

Use movement as a way to demonstrate resilience, build confidence, and regain lost territory of function.

People Don’t Look For Explanations, They Look For Confirmation

If we are going to educate and communicate with people effectively we need to have some understanding of behavior.

One of the most important aspects of human behavior that we must always keep in mind is called confirmation bias.

It is the tendency to look for things that support the position that we already hold and we ALL do it.

What this means for us is that people 1) tend to come in with some idea of the problem already and 2) are looking for confirmation of this idea.

This is scary for us because it means that these messages of fragility may be getting passed on without our even knowing it! You may have no intention of passing on the “poor posture” message, but they may find validation in something you’ve said or done anyway!

Beyond this is another related behavior known as the backfire effect.

If you try to talk someone out of a position that they already hold it is very likely that it will only cause them to entrench in the very belief you are trying to discourage.

This means that if you were to make the effort to tell your patient the many reasons why their pain likely has nothing to do with their posture, there is a very good chance that this will only make them even more confident in their notion of the poor posture problem!

C’mon now! What are we to do?! We need to take a third road.

One form of learning that is currently thought to be one of the more powerful mechanisms behind the success of exposure based approaches is that of inhibitory learning (here and here).

Think of someone who has a fear of being bitten by a dog.

They may think that if they sat in the same room as a dog for 10 minutes that their chances of being bitten would be 100%. So, if they sat in a room for 10 minutes and weren’t bitten, this finding would be surprising.

Evidence indicates the outcomes that drive lasting change are those that are unexpected.

It appears that the more surprising the result, the bigger the effect. When a person is confronted with a surprising result, they no longer look for a confirmation but instead look for an explanation. This is good timing to apply verbal education.

We can easily apply this principle to movement.

When they can demonstrate to themselves resilience they did not expect, the surprising result offers an opportunity to refute the notion of fragility.

Reassurance Is One Of Our Most Powerful Allies

“To live a year without a memorable bout of back pain is abnormal” ~Nortin Hadler MD

Why is this so important?

What is often implied in our approaches, either implicitly or explicitly, is that pain is never normal.

This is just not true. Pain happens and has a role.

The average person will experience a memorable bout of back pain every 1-2 years (here, here, here, and here).

When we imply that the presence of pain is by default abnormal we may validate the presence of threat implying that something is wrong. Pain appears to be based on the perception of bodily threat. So, in that case, when our treatments work it is likely through a process of convincing that the threat has been removed or resolved.

In certain cases, like fractures and lacerations, that is certainly appropriate.

However, in the absence of a true threat, we should be careful about potentially validating the abnormality of pain.

Encouraging the avoidance of certain movements can drive fear and confirm that scary things exist along that continuum of movement.

This gives us a valuable role in re-assurance.

What is typical and expected? What would we see if this were something more concerning?

Photo by: Roger Mommaerts

Photo by: Roger Mommaerts

Consider Yourself In The Role Of Contextual Architect

I have long considered that my primary role as a physical therapist is to set up scenarios in which people can come to certain conclusions.

We are architects of the context in which change occurs, at best (here). We are not responsible for the change itself, only the patient can bring change.

This is why I am no fan of the descriptors of “healers” and “fixers.”

We can set up and progress “experiments” which can refute fragility and encourage resilience. We can use movement in the form of exposures to first disconfirm the limitation and then use graded activities in varying contexts to consolidate and strengthen the disconfirmation.

It becomes a form of confidence building.

So, be mindful of the messages being sent by your interactions. Be aware that your patient is looking for any signs to confirm their worst fears, even if you are not purposefully sending that message.

Use your understanding to set up experiments in which they can demonstrate to themselves a surprising resilience.

When it occurs be ready for the opportunity to explain it. But…

Be Mindful Of The “Safety Signal”

Returning to the dog bite fear scenario, there are a few different ways that we could set up the experiment so as to bring about the surprising outcome.

But, not all options are equally good.

For example, we could put the dog on a chain. Or we could give the person a shield or a taser or something to use to defend themselves. We could stand there with them providing assurance that if the dog were to attack we would stop it.

These are examples of what are known as “safety signals.”

The safety or lack of the feared result is credited to something other than themselves: the chain, the defense, or the helper person. While these things may serve to give the person a sense of safety, it may not be a sense of safety that they will feel they brought about for themselves.

So it is not likely to last because it only serves to confirm that the threat was real in the first place.

The best outcome is when they feel as though they’ve successfully navigated the predicament of their own accord. The best outcome is when they feel that they have the resilience to be in the presence of the dog themselves.

In the case of movement treatments, we need to be mindful of this as well.

Did they feel that they navigated the steps successfully, or did they they do it because of the tape they were wearing protected them?

Were they able to successfully work in their garden or was it just because someone had “fixed their alignment.”

Again, look for opportunities to portray themes of resilience, not fragility and vulnerability.


Practice becomes a time when repetition gives reinforcement. Gradually increasing loads build confidence. Differing contexts and scenarios provides consolidation. And regaining of lost valued functions provides motivation.