Back pain is one of the most common pain issues we (as humans) will face – it is the No.1 cause of pain and disability in developed nations… but as the report on low back pain that came out in The Lancet in 2018 pointed out – often the specific tissue to blame is impossible to discover. for 90-95% of people with low back pain, it will fall under the category of ‘non-specific low back pain’ – meaning that it isn’t radicular (or nerve root driven, which makes up 5-10% of all back pain) or from a specific spinal pathology, like problems with the cauda equina or a fracture (these issues make up less than 1% of cases of low back pain) Taking a good history is vital – especially for ruling in or out those issues that will need imaging (most back pain doesn’t require imaging…it rarely shows useful information and most asymptomatic people will have signs of wear and tear)

But…is back pain different for women? Perhaps…

Now, in the spirit of full disclosure, I am very fond of commenting that the pelvic floor is responsible for everything…or at least, it thinks it is…. It’s a very psychologically sensitive part of our bodies, prone to tightening up into potentially painful over-activity in times of stress or threat (like, perhaps, a cancer diagnosis…but more of that later). Restricted pelvic floor muscle coordination can also be a major driver for constipation, and potentially diminished diaphragm excursion and decreased bladder control – all of which are linked to back pain specifically in women. It is also in an area of the body – the pelvis – that is very sensitive to hormonal changes. Oestrogen, in particular, the Queen of our hormonal system, has over 300 functions in the female body – affecting not only the body, our pelvic health but also our mind and changing levels of hormones can also affect stress management and pain perception. A study that came out recently by my friend and colleague, Sinead Dufour et al, showed that over 90% of women with back pain had pelvic floor dysfunction…but how many women are routinely asked about their pelvic health when they seek medical advice for back pain?

So, in general, for women with back pain, a strategy that rules out red flags like osteoporotic fractures, cauda equina problems or cancer, should not focus on imaging, bed rest or strong medication but on using the breath as a gateway to calm the nervous system and improve coordination to the pelvic floor and restore ‘confident fearless movement’ (yes, I am using the Louis Gifford quote again, as I love it so much!)

But…what if the woman has had breast cancer?

This is actually a scenario where imaging IS a good idea – depending on her age, bone health, breast cancer treatment and the success of that treatment, it is important to rule out osteoporotic fractures or metastasis to the spine before proceeding on a strengthening programme. Even if there are spinal mets, strengthening may be indicated…but spinal stability baseline needs to be assessed first, and malignant spinal cord compression needs to be ruled out. It’s really important that if you are working with women with Breast Cancer in a rehab context that you are aware of the short, medium AND long term effects – not only of the breast cancer itself but also for the implications of breast cancer treatment.

Once the imaging has been done in this scenario, then treatment can proceed along the usual lines of breath work, pelvic health, education around pain science …and of course MOVEMENT! Whether we are working with women at midlife or during/after breast cancer treatment though, we do need to be respectful of the effects of oestrogen levels being lower – not only on bone health but also on muscles and tendons – tendinopathies of the hip and shoulder particularly but don’t forget the feet either (Posterior Tibial Tendon – I’m talking to you!)

If you’d like to learn more about working with women at midlife, I’ll invite you to check out our 3rd Age programme – this course has a whole module on musculo-skeletal health at midlife, covering back pain, shoulder, hips and feet issues with guest interviews and exercise prescription strategies. If you’re looking to help women live well during and after Breast Cancer (including learning about what to do, what not to do, spotting red flags and marketing your Breast Cancer Rehab practice…) then head on over here to learn more about the online Breast Cancer Rehab course and its closed Facebook support group.

I’m going to leave you with an excerpt from the course on breathing strategies, to not only calm the nervous system but optimise the lymphatic system too.

Until next time,