By Larry Grine, DPT, Virginia Therapy and Fitness Center
The prevalence of low back pain is staggering. Approximately four out of five people will experience low back pain during their lives. It is one of the most common reasons for healthcare visits in the United States. What causes low back pain, why is this such a widespread problem, and can physical therapy for low back pain help?
Low Back Basics
The spinal column has 24 vertebrae that move and are located above the fused segments of the sacrum and tailbone, which do not move. Lower back pain (LBP) is generated from the lowest five motion segments between the lowest rib down to the pelvis/tailbone region, called the lumbar spine. Segmental nerves related to this area of the spine will innervate the back, buttocks, hips, and legs. As a result, pain can be referred into these areas.
Injury to the low back region can cause abrupt mechanical or chemical damage/irritation to the intervertebral discs and/or vertebrae, compression of nerve roots, and poor movement of the spinal joints. The intervertebral disc is round-shaped, made of fibrocartilaginous material, and located between the vertebral bones of each segment. The disc will absorb compressive, rotational, and shearing forces based on the type of movements, postures, and positions a person moves in and out of each day. Discogenic low back pain refers specifically to pain coming from one or more of the intervertebral discs in the lumbar spine.
The normal aging process will cause gradual changes to our bodies. For many, these are gradual changes to their spinal structure, spinal alignment, intervertebral discs, and/or surrounding muscular system. Symptoms related to discogenic pain are often associated with postures, positions, and movements that increase pressure inside the intervertebral disc which include: sitting, squatting, bending forward from the waist, and coughing or sneezing. Disc degeneration does not usually cause significant pain in the early stages. However, LBP and other symptoms may occur in more advanced stages of disc degeneration.
Physical Therapy for Low Back Pain
The symptom of discogenic LBP is simply localized pain in the low back region, and primarily does not radiate down the leg(s) until the degeneration advances to the point that it causes compression to the spinal nerves. Some degeneration to the intervertebral disc can be caused by poor movement patterns when compensating for changes in another area of the body. For example, a stiff hip will often cause patients to walk with a limp. The abnormal gait pattern can increase stresses throughout the body and cause accelerated degeneration of the intervertebral disc. This highlights the importance of a whole body evaluation and approach, which good physical therapy will accomplish.
What does ‘good’ physical therapy look like for the low back? The most successful physical therapy routines for discogenic LBP should include:
Early intervention — from the time of injury or onset of pain.
A full body biomechanical examination — to accurately identify pain triggers and identify dysfunctional movement patterns, postures, and positions. Also to identify any muscle imbalances caused by weakness or overactive muscles.
Tailored Treatments — to meet the needs of each individual, including:
- To eliminate pain triggers
- To reduce inflammation
- To provide the body with an optimal healing environment
- Comprehensive Treatments — the most successful treatments use a combination of modalities:
- Manual therapy
- Targeted exercise
- Strengthening
- Functional restoration
Lifestyle modification coaching to maintain good spinal hygiene, such as:
- Weight loss to achieve a “back-friendly” weight
- Smoking cessation
- Daily home physical activity
- Timing Makes a Difference
Oftentimes, patients with lower back pain face significant delays in getting to a physical therapist, which slows the recovery process. These delays are often related to a patient self-treating or seeking treatment from providers that do not specialize in spinal healthcare, and 6-10 weeks quickly pass with continuing or worsening symptoms. This delay may cause a reduction in the ability to remedy LBP quickly and can make compensatory patterns more difficult to resolve once proper spine physical therapy is initiated.
The Research
A study titled “Physical Therapy as the First Point of Care to Treat Low Back Pain” was published in the Health Services Research Journal in December 2018. They found that patients who worked with a physical therapist as the first treatment approach had a lower probability of needing:
- Opioid prescriptions
- Advanced imaging services
- Emergency room visits
Patients included in this research were also found to have significantly lower out-of-pocket costs. This article reviewed data from 150,000 insurance claims and concluded that patients with low back pain are better off seeing a physical therapist first.
Many articles highlight effective treatment of lower back conditions from treating areas adjacent to the lower back, called regional interdependence. Regional interdependence is simply the cross interactions that occur between different regions of the body that connect to one another, such as the lower back and hips, knees, ankles, and feet. Research has shown that inflamed discs can result from an overload of biomechanical stresses from other areas of the body and increase the rate of disc degeneration.
Conclusion
There will always be cases where physical therapy alone does not resolve the problem, and the need for additional treatments is warranted. It takes an excellent team approach of physical therapists and spinal specialists who see patients frequently and work collaboratively to identify and prescribe the proper treatment. The largest hurdle to a quicker recovery might be the easiest to overcome. The solution is simple…evidence shows that patients need to get to a good therapist as early as possible after a low back injury or the onset of significant pain without an obvious injury. A good recommendation is to also have an excellent spinal surgeon in mind in case your LBP doesn’t improve with conservative care.
References
- Bianca K Frogner, Kenneth Harwood, C Holly A Andrilla, Malaika Schwartz, Jesse M Pines. Health Serv Res. 2018 Dec;53(6):4629-4646. doi: 10.1111/1475-6773.12984. Epub 2018 May 23. Physical Therapy as the First Point of Care to Treat Low Back Pain: An Instrumental Variables Approach to Estimate Impact on Opioid Prescription, Health Care Utilization, and Costs
- Airaksinen O, Brox JI, Cedraschi C, et al. Chapter 4 European guidelines for the management of chronic nonspecific low back pain. Eur Spine J Off Publ Eur Spine Soc Eur Spinal Deform Soc Eur Sect Cerv Spine Res Soc. 2006;15(suppl 2):S192–S300.
- Delitto A, George SZ, Van Dillen LR, et al. Low back pain. J Orthop Sports Phys Ther. 2012;42(4):A1–A57.
- Staal JB, Hlobil H, van Tulder MW, et al. Occupational health guidelines for the management of low back pain: an international comparison. Occup Environ Med. 2003;60(9): 618–626.
- Burns SA, Mintken PE, Austin GP, Cleland J. Short-term response of hip mobilizations and exercise in individuals with chronic low back pain: a case series. J Man Manip Ther. 2011;19:100–107.
- Cooper NA, Scavo KM, Strickland KJ, et al. Prevalence of gluteus medius weakness in people with chronic low back pain compared to healthy controls. Eur Spine J. 2016;25(4):1258–1265.
