Acute Back Injury – what to do & what not to

I decided to write this blog as I am frequently contacted by clients and members of the public who have ‘put their back out’ and are looking for advice on what they should/shouldn’t do, plus effective treatment ASAP. I was keen to gather all the required information in a helpful blog, which I could share with clients and the public.

It should be considered that when you injure your back, there are three distinct stages of tissue healing; the inflammatory, proliferation and remodelling stage. These stages overlap and can vary in length according to tissue/s injured, severity of the injury (i.e. more severe injuries take longer to heal) and blood supply to the tissue (i.e. less bloody supply = longer healing time). For the purpose of this blog I do not need to explain these stages in detail, but if you’re interested you can find more information on these, plus various tissue/injury healing times, on the link below:

https://theprehabguys.com/tissue-healing-timelines/

For the purpose of post back injury advice I have divided my advice into FOUR phases, as the appropriate advice for the first part of the inflammatory phase is different to the second part:

First 2 Days – the acute (Inflammatory) phase

The acute phase is when the tissue damage is fresh and particularly inflamed; this may cause heat, swelling and more intense pain. This phase usually lasts about 2 days, but may last up to 4 days in more severe injuries.

Do…

Use PRICE treatment (Protect, Rest, Ice, Compression, Elevation).
PROTECT the area from physical stress, excessive activity (i.e.overuse, bending & twisting, sports, lifting, quick movements, unnecessary weight bearing, etc). Move carefully using your core muscles to support your injured back; bend using the hips/knees (not back – keep this relatively straight).
REST the area by avoiding work, sport, housework and physical activity. The neutral spine ‘resting’ position/s (see below) can be useful at this stage. Lie on a (firm) surface with a pillow under your head and a pillow/support under your knees. You may find putting your lower legs up on a padded chair more comfortable, so your hips & knees are at right angles.

ICE the area regularly (if required), up to five times per day (using dry-fabric covered cold pack/s, crushed ice or frozen peas – for 20 minutes). This doesn’t actually help healing, but is more for comfort/symptom management (as it helps calm the inflamed tissue and reduce associated pain/muscle spasm).
COMPRESSION: Lying on an ice pack or leaning against one provides some compression of the injury (which should not be too heavy or prolonged). Elevation not relevant for back pain.
Take anti-inflammatory drugs (e.g. Ibuprofen, naproxen, diclofenac) for symptomatic relief (with your doctor/pharmacists approval) with food – only if required. If the pain is severe you can alternate anti-inflamatories with regular analgesics (e.g. Paracetamol, Co-codamol, Tramadol), ensuring the anti-inflamatories are taken after your main meals – speak to your doctor for advice or an indicated prescription. Tumeric or devil’s claw supplements are a great herbal alternative to anti-inflammatory drugs.
If your back injury is causing severe muscle spasm your doctor may prescribe a short course of muscle relaxant medication such as Diazepam or Baclofen, to reduce spasm and related pain. Like opiate analgesics, some of these medications are addictive so long term use may be unwise. Cramp Bark is a great herbal alternative!
Book a treatment for ASAP after the acute phase has passed! Get your slot booked in for day 3-5 post injury, depending on the injury severity (i.e. more severe – leave it longer).

Don’t…

Apply a heat pack, or have a hot bath: Heat increases inflammation, which will increase pain and muscle spasm (even if it feels soothing while applied). Heat is great for chronic (non-inflammatory) pain, NOT acute pain!
Have a treatment on the day of injury, or day after. You might be eager to ‘get it sorted’ ASAP, however, it is better to leave your body to do its thing for the first 2-3 days! Getting treated too early may interfere with your bodies initial healing processes, and further aggravate the acutely inflamed tissue. While massage and mobilisation are countraindicated at this stage, acupuncture, ultrasound and gentle ice massage can be used if you’re determined to have some treatment.
Go to work: Time to call in sick for 2-3 days. If you work through it you will further inflame your back, interfere with the initial healing processes and might feel ill from the excessive inflammation. You might also need longer off in the medium-long term!
Do sport, housework or excessive physical activity: It doesn’t matter if you have ‘paid for your class’ or are letting down your mate/team – cancel the sports! Also, leave the housework for a couple of days, or get others to do it.
Do stretches, self massage, rehab exercise or foam rollering: Its too early for such interventions, you may do more harm than good, and will probably aggravate the inflamed tissue!

Day 3>6 – sub-acute Repair Phase 1 (Inflammation/proliferation)

Do…

At this stage use MICE treatment (Movement, Ice, Compression, Elevation)
MOVEMENT: Once the acute stage is passing its important to regularly move the injured area while the injured tissue is being replaced and repaired (this helps tissue healing, functional scar tissue formation and good range of movement). Take the injured area through its full range of movements regularly, ensuring you don’t overstretch it or cause pain (discomfort is ok). 20 movements, 3 x day is recommended at this stage.
ICE: You can continue to ice the injured area if its feeling particularly painful or hot/inflamed, but reduce this to 2 x per day (or after aggravating activity).
Compression and elevation are not indicated.
Stretching: AFTER the initial acute phase of 2-4 days is when you should start to stretch the injured area. However, these stretched should initially be light, so as not to further tear/aggravate injured tissue. 15 second stretches (x 2) are good at this stage.
Have a ‘hands on’ treatment: Book an appointment with a Clinical Massage Therapist, Sports Therapist or Osteopath to assess and treat you’re injury (preferably one with an ultrasound machine or therapeutic laser – to aid tissue repair).
Book a rehab exercise appointment with a Sports Therapist, Physio or Rehab PT for about a week after the injury, or look up suitable exercises online (bear in mind, its better to have someone check you are doing them correctly, and that they are suitable for your needs!).
Take longer off work if you need it. Listen to your body/doctor/therapist; if your back is still too painful/inflamed you may need longer off, to be able to work safely without consequences.

Don’t…

Apply a heat pack – unless the area is no longer hot/inflamed, and is no longer intensely painful.
Take anti-inflammatories long term: If you are in allot of pain its fine to take them for a little longer for symptomatic relief. However, they may begin to impede tissue repair and regeneration, so it is better to drop these and stick to regular analgesics (if required) for pain relief, in the sub-acute/remodelling phases.
Do foam rolling, strong self massage or strong stretching. If you are going to self massage then do it LIGHTLY, and only treat painful trigger points around the injured area. Strong massage & pressure is not helpful at this stage and will aggravate the tissues!
Do sports/exercise, unless it is light, low impact and does not heavily involve the back. You will aggravate it and may re-injure it; it not worth it.
Have manipulative therapy: While manipulative therapy can be helpful in getting your back healthy and functional, it is still too early for manipulation or stronger spinal mobilisations.

Day 7>24 – Sub-acute repair phase 2 (Proliferation)

Do…

Stop icing the injury at this stage, unless it is particularly inflamed (i.e. hot, swollen, sharper pain) or you have done something to aggravate/re-injure it (then ice is still appropriate).
Contrast bathing (alternating hot-cold-hot-cold) will help healing at this time. Start with a 5 minutes of a covered heat pack on the area, then 2 mins of a covered ice pack > 2 mins heat > 2 mins cold > 2 mins heat > finish with 2 mins cold.
A heat pack will also be beneficial for pain, muscle spasm & tissue repair at this stage, providing the area is not too hot/inflamed/bruised (then opt for ice!).
Make time to do your rehab exercises every other day!
Stretch and move the area daily to encourage healthy scar tissue and stimulate repair. You can apply moderate intensity stretches now, and hold them for longer (i.e. 30 secs x 2) as the area heals & calms!
Rest the area if it is reacting to overuse – listen to your body and don’t overdoo it!
Foam roller & and apply moderate intensity stretching & self massage. If the injury is severe then postpone the foam rollering for another week or so, and go lighter on the self-massage/stretching! If applying self massage try to use cross fibre friction, smoothing the tissues in one direction only (i.e. light return).Treat painful trigger points using 8-20 seconds of pressure with a tennis ball (i.e lie on it).
Return to sports which are not high impact, and are not too intense on your back (unless injury severe).
Take care in your movements, especially bending, turning and lifting. Make sure you don’t overstretch for things, that you bend with your hips/knees (not back). Keep loads close to your body, central and not above chest height.
Have a hands-on treatment at least weekly.

Don’t…

Forget about stretching, movement and rehab exercises now its hurting less – it is now the provisional matrix is replaced with granulation tissue which will form your scar tissue. You want this to be healthy and flexible – this requires movement and stretching!
Take antiinflamatories constantly as they will interfere with tissue healing. They can be used to help stop the area getting overly inflamed for work/sport, but should only be used sporadically.
Overdo it on the foam rollering or self massage. This should me MODERATE intensity and only 1-2 times per day.

Day 25>90 – Remodelling (maturation) Phase

Do…

Use heat packs to sooth your back/promote blood circulation/healing.
Get back to a fully active/mobile life. Don’t avoid physical activity or limit your mobility – activity and movement are both essential for back health!
Have a hands on treatment at least fortnightly.
Keep stretching & moving the injury/tight areas daily.You can apply stronger stretches now (30 secs x 2), but wait for the body to ‘let go’ and allow the tissue to lengthen. Stronger stretching and foam rollering is ok now, but only 1-2 times per day.
Do your rehab exercises at least twice a week.

Don’t…

Ice the area, unless its re-injured or inflamed from treatment.
Get complacent about the need for movement and stretching of the area, the scar tissue is remodelling and needs movement & stretching!

It is very important to keep the back moving, and stretch it (and other areas which may have tightened up in response to the injury), post the acute phase, while it heals. This will help avoid stiff/stuck scar tissue and unhealthy compensations likely to cause pain, stiffness and poor spine/joint movement. Remember moderate injuries may take 3 months to fully heal, more serious injuries 6 months or longer – it’s your responsibility to ensure the tissue is moved and stretched over this timescale! It’s also wise to have a monthly/bi-monthly maintenance treatment, especially on back injury’s. Back injuries have a tendency for the scar tissue to tighten, trigger points develop and facet joints to lock up, causing pain and function issues – stay ahead of the game with an occasional tune-up.

Exercises to aid back injury healing

Here are some exercises which will help your back injury heal in a functional, healthy manner. Start these after the ‘acute phase’ (i.e. on day 3-5 post injury) and ensure you do these daily. Also ensure you take the injured area through its full range of movements for a 2 minutes at least a couple of times per day, on top of the rehab exercises below. Avoid any movements which cause pain, though some discomfort is to be expected exercising/moving an injury (you can always do a smaller movement, or go less far in the painful direction, to enable some essential movement/exercise!). If the pain is still severe a week after the injury, get the injury assessed medically.

Cat-Cow x 20: sshttps://www.youtube.com/watch?v=mTPClIWOU9w

Back chair rotation mobilisation x 20: https://www.youtube.com/watch?v=BlNhowQbyA8

Back side bend exercise x 20: https://www.youtube.com/watch?v=J8JqxQYUUro

Gentle core control x 10: https://www.youtube.com/watch?v=7ZojRzIro2I

Supine lumbar twist stretch x 2: https://www.youtube.com/watch?v=BzYBkAvdCJY

Childs pose stretch x 2: https://www.youtube.com/watch?v=7zsKsz4uQe4