Low Back Pain

Low back pain affects about 60 to 80% of people within their lifetime. It has been shown that 23% of the world's adult population suffer from chronic low back pain and have a re-occurrence rate of 24 to 80%.


One definition of low back pain can be described as symptoms such as pain and discomfort localised to the costal margin and above the inferior gluteal fold that can present with or without leg pain. It can also be described as someone getting symptoms that happen in area between the lower rib margin and the proximal thighs. The most common form of low back pain is one that is labelled as non-specific low back pain. Non-specific low back pain is defined as pain that is derived from the low back but is not attributed to a specific pathology.


Low back pain is categorised into 3 section which are acute, sub-acute and chronic low back pain. Acute low back pain is where symptoms are usually resolved within 6 weeks or less. Sub-acute low back pain is where symptoms are present between 6 to 12 weeks and chronic low back pain is when symptoms are persistent more than 12 weeks.


More than 80% of all health care costs go toward the management of chronic low back pain. Most individuals seeking treatment for their low back pain will have persistence symptoms one year after their acute episode and will have activity limitation.

Low Back Pain Examination

The first aim of the physiotherapy examination for an individual presenting with low back pain is to rule out serious conditions such as fractures, cancer, infection, ankylosing spondylitis or specific causes such as radiculopathy, caudal equina syndrome. These conditions are usually rare and only account for 1 to 10% of all cases.


90% of patients that present to primary care practitioner usually have non-specific low back pain and the physiotherapist will aim to identify impairments that may be contributing to symptoms. These impairments can include biological factors (e.g. weakness, stiffness), psychological factors (depression, fear of movement, catastrophising) and social factor (work, home situation). Diagnostic imaging is not recommended in the first month of symptoms and should only be used if symptoms do not respond to protocols.


Leg pain is a very common symptom that may come with low back pain and may be a result from an injury to the neural or musculoskeletal tissues of the lumbar spine.


Management Strategies

There has been a change on how we manage individuals with back pain and physiotherapists no longer aim to diagnose a specific structure at fault and aim treatment to that specific structure. Recent evidence suggests that it may not be possible or necessary to identify the specific tissue of the source of pain for the effective management of mechanical back pain. We now take a global approach to treat low back pain.


Recent guideline in treating low back pain suggest that advice, non-pharmacological management such as physiotherapy intervention which include exercise, manual therapy and dry needling are indicated for this condition. Recent studies have shown that exercises that target the diaphragm have improved and have an effect on the lumbar stabilising muscles. Diaphragm training has an effect on improving active stabilisers of the lumbar spine such as the transverse abdominis and lumbar multifidus which can help symptoms of low back pain.


An exercise program can be also beneficial for individual with low back pain. The exercise program should include a warmup session that may include pelvic tilts, lumbar rotations, arm movements, and whole-body movements in standing. It may also include exercises that target back extensors, abdominals, buttocks, trunk rotators, leg muscles and obliques. It may also finish with flexibility exercises.


Prevention of Low Back Pain

General guidelines for low back pain suggest that regular physical exercises can prevent low back pain or the re-occurrence of subsequent episodes of symptoms. The type of exercises that in use for preventative management should target back extensors and trunk flexors combined with some sort of aerobic activity. High intensity program is advised to patients with recurrent and long-lasting low back pain, but this type may not for an individual trying to prevent low back pain. But, individualised programs and interventions have a positive effect in preventative management in symptoms. Lumbar support or back belts have been shown to prevent low back pain and are not recommended.



References:

Casiano VE, De NK. Back Pain. InStatPearls [Internet] 2019 Feb 24. StatPearls Publishing. Available from:https://www.ncbi.nlm.nih.gov/books/NBK538173/ (last accessed 21.1.2020)


Burton AK. European guidelines for prevention in low back pain. COST B13 Working Group. 2004: 1-53.



Kinkade S. Evaluation and treatment of acute low back pain. Am Ac of Family Phys. 2007: 1182-1188.


Aure OF, Nilsen JH, Vasseljen O. Manual Therapy and Exercise Therapy in Patients With Chronic Low Back Pain: A Randomized, Controlled Trial With 1-Year Follow-Up. Spine. 2003;28(6):525-532.


Ferreira ML, Ferreira PH, Latimer J, Herbert RD, Hodges PW, Jennings MD, Maher CG, Refshuage KM. Comparison of General Exercise, Motor Control Exercise and Spinal Manipulative Therapy for Chronic Low Back Pain: A Randomized Trial. Pain. 2007;131:31-37.

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