Physiotherapy and Lower Back pain
Lower back pain is one of the most common conditions we see in the clinic every week. Lower back pain is an issue that affects up to 80% of us at some point during our lifetime (NINDS, 2014). It can be a debilitating and painful experience and can leave us fearful of completing our normal everyday tasks at work and at home. At any one time, up to a quarter of adults report experiencing lower back pain in the past 3 months (NINDS, 2014). There are several factors that increases our risk of developing lower back pain, which include but are not limited to, advancing age, being unfit, being pregnant, weight gain, certain genetics, having a heavy occupation and mental health problems (NINDS, 2014). Some of these risks we can manage and alter but some unavoidable.
What is the Cause of my Back Pain?
Any pain producing structures of the lumbar spine may cause lower back pain (Brukner and Khan, 2006). Pain can vary from mild discomfort to severe pain with radiating symptoms also known as radicular pain or radiculopathy. Lower back pain at times can be associated with numbness and/or pins and needles. Lower back pain can be caused by a variety of conditions. For most patients no clear-cut diagnosis can be confirmed. Nonspecific or unknown causes, including strains or sprains, account for over two-thirds of chronic low back pain. A further quarter of chronic low back pain is related to mechanical causes such as nerve root-related conditions (radiculopathies), degenerative conditions or herniated or ruptured discs (National Health Committee, 2015).
Most episodes of back pain are acute, which mean most of the symptoms resolve within six weeks of the start of the episode of back pain. If pain lingers and reoccurs up to 12 weeks this is referred to as sub-acute pain. If the episode of lower back pain lasts more than 3 months, the pain is described as chronic. This does not mean you will always have it, but these episodes usually require more intensive pain management and therapy to resolve the symptoms. The good news is that there's often nothing to fear, and with time and a gradual loading or exercise program, you can make a full recovery from your lower back pain episode. In fact, research shows that 90% of people with a lower back pain episode recover within 6 weeks (vanTulder et al, 2006).
Lower Back Anatomy & Causes of Back Pain
The lower back is made up of 5 vertebrae or back bones, the sacrum and coccyx bone. There are fibrous ligament structures, called discs, that sit in between the bones, vertebrae to help provide shock absorption and transmit forces. The discs can be injured with rotational movements and, or compression forces (Brukner and Khan, 2006). The bones are connected to each other via joints and surrounding ligaments which also can be sprained, and which can contribute to lower back pain. Local surrounding muscles are connected by tendons to the bones and at times myofascial trigger points can also contribute to lower back pain (Brukner and Khan, 2006).
The spinal cord runs through the middle of each vertebrae and gives off a pair of nerves at each level of the spine which innervates different parts of the limbs. These can be a source of pain if they are compressed. An acute compressed nerve root can be caused by prolapsed discs or in an older patient can be a result of bone thickening around the nerve root (Brukner and Khan, 2006).
How Can Physios Help?
When you first present to physiotherapy, with lower back pain, we will discuss the cause of your injury and rule out any sinister causes for your back pain with a few simple questions. Three percent of lower back pain that presents for physiotherapy is due to organ pain or some sinister cause, so it is important for us to rule these out (National Health Committee, 2015). The Physio will then complete a full assessment of your spine and discuss an appropriate management plan with you. Assessment includes looking at mobility, flexibility and strength around your spine and hips. We palpate different structures around the spine to try and identify the cause of your discomfort. Often imaging is not warranted, but if required your physio can refer you for an X-ray. If more advanced imaging is required, such as an MRI or CT scan, a referral can be made for you to a specialist.
Management of your back pain will depend on the symptoms you present with. The first line of treatment is pain management and get you moving again. Everybody is different so we try to individualize a treatment plan to you and your condition.
The use of heat or cold packs, although limited evidence, may help provide pain relief (NINDS, 2014). Most people prefer the use of heat packs or hot water bottles for up to 10 minutes at a time. Utilizing a spa pool or sauna can also be beneficial.
Short term use of over the counter pain relief medication may also be useful to control the pain and get you moving again. Recommendations include using paracetamol and non-steroidal anti-inflammatory medications as a first line of treatment (National Health Committee, 2015). The recommendation is also for regular use of these medications initially rather than as required use. If pain is limiting your ability to complete your normal activities and workload then taking pain relief can help to return to these which in turn will help to get you moving again and reduce your stiffness. If these fail to control your pain, we may advise you to see the GP to discuss further adequate pain relief options.
What to Expect With Physiotherapy
Use of manual therapy and acupuncture has been shown to provide short term relief which in turn allows you to increase your activity levels and get you back on your feet. We utilize these in clinic to try and reduce your discomfort and get you moving again. Bed rest should be minimized and gentle activity that you can manage and tolerate is highly recommended. Your physiotherapist can provide you with a tailored mobility and strengthening program which gradually load the spine. There's now a lot of evidence to suggest that an inability to use your stabilizing muscles including your transverse abdominis and multifidus muscles are important to address, and your physiotherapist can provide you with suitable exercises to target these regions (Brukner and Khan, 2006). Overall, the best approach is to gradually get back to exercising in a way that you can manage and tolerate. There are several ways we can adjust and exercise to make it tolerable to you which include coaching to optimize technique, adjusting dosage and load. We can also review your manual handling skills and discuss your workstation set up at work to ensure these are optimal. Our aim is to gradually get you back to your sporting and everyday activities in a pain free manner.
"Many different forms of exercise seem to help lower back pain. This includes aerobic exercises like walking, cycling, swimming as well as exercises aimed at improving the posture, strength and mobility of the spine. It does not appear that any one of these is always better than the others. The most relevant factor is whether people continue with their exercise programme over time. Therefore, you should consider which form of exercise you enjoy most, and which you can do with little or no inconvenience. Remember that many hobbies and daily routines can be considered exercise also, for example gardening, cutting the lawn, and using the stairs instead of the lift (ISCP,2011).
Other Treatment Options
Corticosteroid epidural injections, which is an anti-inflammatory agent, can be beneficial in patients with radiculopathy or leg- dominant pain whose symptoms do not resolve withing 6 weeks (National Health Committee, 2015). The use of these injections with patients who have no referred pain are not generally recommended. These injections are usually provided by a pain specialist or musculoskeletal specialist. Your physiotherapist can refer you should you require this treatment.
Surgery is rarely warranted in the presence of lower back pain. Spinal surgery is not something to be undertaken lightly and is only advised for those with certain symptoms and where a comprehensive conservative treatment plan has failed to resolve your symptoms. Generally, surgery is not recommended for those with non-specific lower back pain and should only be undertaken when there is a strong chance that the surgery will resolve your symptoms (National Health Committee, 2015).
*In 2015 a study completed looked at over 3,100 people with no lower back pain and reviewed their spines on imaging. Interestingly, despite having no symptoms 37% of 20-year old had disc degeneration while up to 96% of 80year old had disc degeneration. 30% of 20year old and 84% of 80year old had some notable disc bulge. Majority of the time, findings on MRI are part of the bodies natural degeneration process (Brinjikji et al, 2015). This is not to say we just ignore MRI finding but it is important to manage the symptoms you are presenting with and not just the images.
* Lower back pain is the second most common reason for doctor's visits in the US.
* "From research we now know that amount of pain perceived by someone does not always indicate more damage. People with similar back problems can feel very different levels and types of pain. Amounts of pain felt can vary according to a number of factors, including the situation in which the pain occurs, previous pain experiences, your mood, fears, fitness, stress levels and coping style. Ultimately, two individuals with the same injury can feel different amounts and types of pain. Furthermore, the brain has the ability to ‘inhibit’ or turn down the volume and intensity of pain. How? Why? First it is important to remember that pain is interpreted and processed in the brain. The brain plays an important part in regulating if, and how much of, a given sensation, such as pain, a person feels at any given time" (ISCP,2011). Often understanding this and realizing you are not doing any further damage is enough for most people to start moving again.
Tips for Preventing and Caring for Your Lower Back Pain
- Manage your weight by exercising regularly and eating a healthy and balanced diet. Applications such as my fitness pal allow you to track your calorific intake which can give you a clear idea of how many calories you are consuming daily. If you are concerned about your diet, it is advisable to see a dietitian to discuss any concerns you may have.
- Being physically active regularly is important to maintaining strength and cardiovascular fitness. The World Health Organisation recommends that all adults aged between 18 and 64, should undertake 150 minutes of moderate intensity aerobic exercise a week with muscle strengthening activities on 2 or more days of the week (WHO, 2011).
- Avoiding too much rest is important in preventing lower back pain. Being active during the day, especially if you work within an sedentary role, is important.
- Warm up and stretch before undertaking strenuous exercise or even activities around the house or garden that require repetitive activity.
- Making sure your desk at work, work surfaces at home and car are set up appropriately for you.
National Institute of Neurological Disorders and Stroke (NINDS) (Dec 2014). Low Back Pain Fact Sheet. Retrieved from: https://www.ninds.nih.gov/Disorders/Patient-Caregiver-Education/Fact-Sheets/Low-Back-Pain-Fact-Sheet
National Health Committee (July, 2015). Lower Back Pain: A pathway to prioritization. Wellington: National Health Committee. Retrieved from: https://www.health.govt.nz/system/files/documents/publications/nhc-lbp-pathway-to-prioritisation.pdf
VanTulder M, Becker A et al. (2006). Chapter 3. European guidelines for the management of acute nonspecific low-back pain in primary care. Eur Spine Journal; 15: S169-91.
Brinjikji W et al (2015). Systematic literature review of imaging features of spinal degeneration in asymptomatic populations. AJNR AM J Neuroradiol. Apr 2015; 36 (4 811-816. Retrieved at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4464797/pdf/nihms-696022.pdf
World Health Organisation (2011) [Fact Sheet]. Retrieved from: https://www.who.int/dietphysicalactivity/factsheet_adults/en/
Irish Society of Chartered Physiotherapists (ISCP) (2011). Moving4Health challenging back pain myths. Move for Health Committee. Retrieved from: https://www.wcpt.org/sites/wcpt.org/files/files/Publicity_materials-ISCP-Booklet.pdf
Brukner P. and Khan K (2006). Clinical Sports Medicine, 3rd Edition. Australia; McGraw-Hill Professional.