Low back pain, back pain, lumbar pain, spinal pain, all are names for the troublesome and very common problem which affects many of us at certain times in our lives. Physiotherapists assess and treat large number of back pain patients every day and have various treatment techniques to help this condition.
Back pain is rarely an indication of serious underlying medical condition such as cancer, infection or arthritic disease but the physiotherapist needs to be sure he or she is dealing with a non-serious back pain. Standard exclusion questions are asked by the physio to rule out loss of weight, loss of appetite, previous cancer history, bowel and bladder control, rheumatoid arthritis, diabetes, epilepsy, particular pain problems at night and generally feeling ill.
This subjective history tells the physio that the back problem is mechanical, i.e. it is related to the stresses and strains on the spinal joints now and in the past. They can then move on to the objective examination, looking at the patient with their clothes off. Initial examination starts with the patient walking in and with how they sit for the questioning, and posture is noted next. Many postural changes are not of great significance but some fit the overall picture and increase the confidence in the correct therapeutic diagnosis.
Spinal pain usually reduces the normal movements the patient is able to perform and this pattern of movement loss gives an indication of the kind of lumbar problem. The range of lumbar flexion is often reduced with the lumbar spine staying stiff and with pain during the movement or at the end of the available range. The other spinal movements are also tested, with the physio also checking the muscle reflexes, muscle strength, hip ranges of movement, sacro-iliac joints and the skin sensibility. The physiotherapist will palpate the spinal joints, gathering information about the stiffness or pain reactions of the lumbar segments.
The treatment goals and plan will be formulated with references to the findings during the examination e.g. a joint, disc or postural problem. A painful spinal joint will need careful treatment with gentle exercises, pacing, reduction in aggravating factors and pain-killers. A stiff spinal joint can cope with stronger manual techniques and exercises to stretch out the stiff tissues.
One of the most common therapies for athletes, gym attenders and those undergoing rehabilitation after injury or illness is to perform core stability work. Many Pilates classes are available using this approach to holding a mid-range spinal posture while performing activities. Initial technique is taught on a plinth until the patient has good control then progressed to keeping their stability control whilst performing harder and harder activities, finishing off with relevant functional work
Spinal joints do not appreciate being at end of their range for too long such as remaining slumped in sitting for a long period. This stretches the ligaments and can cause and maintain a pain problem. Physios teach patients to understand the new strange posture they are being asked to perform is the norm and that they need to perform it regularly until they do it naturally.
Many back pain physios use the McKenzie technique which uses repetitive movement to change the forces which the disc nucleus exerts on the walls of the disc, the annulus fibrosus. An increase in pressure against the posterior disc wall can worsen symptoms while a decrease can improve pain. Repeated movements in one plane establish a "directional preference", a direction of movement which improves the presenting symptom. McKenzie therapists treat patients depending on whether they have postural syndrome, dysfunction syndrome or derangement syndrome. McKenzie therapy is a popular technique, based on the idea that the disc nucleus exerts a force on the walls of the disc and can cause pain problems.
Once the symptoms are under control, the patient is taught to pace their activities appropriately so as not to overstress their spinal joints at any one time and to work on their overall fitness. It is embarrassing that there isn't good evidence for any particular therapy for low back pain. However there is good evidence that increasing our overall fitness, both aerobic and muscular, improves back pain symptoms and makes it less likely that we will have further episodes.
