Physiotherapy Treatment of Low Back Pain

By: Jonathan Blood-Smyth

Low back pain is very common and most people have some experience of a back pain episode at some time of life. Attendances at physiotherapy clinics for low back pain are very high so physios have a variety of assessment and treatment techniques to manage spinal pain and improve patients' function.
Many people self refer for their back pain and so the physio has a responsibility to ensure the patient has not got a serious underlying condition. The physiotherapist goes through the patient's presenting condition and asks specific questions to rule out medically serious matters. Typical questions include a history of cancer, control of bladder and bowel, arthritic disease, epilepsy, diabetes, appetite loss, weight loss, sleep problems and night pain.
The physio is looking for the patient to react as if they have mechanical spinal pain, a condition where normal physical stresses such as sitting or walking have a worsening or easing affect on the pain. The examination starts by observing the posture and movement of the patient during the questioning and the physio follows this by examining the spinal posture and ranges of movement. Abnormalities of posture are common and not always important, with leg length differences, a reduction or increase in the back curves and a scoliosis being common findings.
Next the physiotherapy examination moves on to active movements. Lumbar flexion is bending over forwards as if the hands are to touch the toes, and the range of movement and any pain is noted. This is repeated for extension and perhaps side flexions and side gliding, all adding to the picture forming in the physio's mind. The physio may test the hip joints, the sacro-iliac joints, the sensibility, the reflexes and muscle power. Palpation of the spinal joints can tell a skilled physiotherapist about the stiffness and reaction of individual spinal segments, thus localising a problem to a specific level.
Once the therapeutic diagnosis is made the physio will set the treatment goals and plan of treatment. If stiffness is a problem, mobilisation techniques can be used and the patient taught mobilising exercises as a home programme. If pain is the main issue then analgesia might be recommended with gentle mobilising and exercise techniques to ease the joints.
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.
Apart from treatment the patient needs to consider changing some aspects of their behaviour if the treatment is going to get the best result. Pacing activity to avoid overdoing activities and suffering afterwards is important, allowing the problem to ease. Aerobic and muscle fitness in the gym or pool has good scientific evidence behind it for reducing the number and severity of back pain episodes, while many back pain treatments have little evidence to prove their effectiveness.

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Jonathan Blood-Smyth is a Superintendent Physiotherapist at a large NHS teaching hospital in South-West England. He publishes articles on injuries and mishaps in periodicals and on his website for physiotherapists. If you are looking for local physiotherapy after an mishap or injury, visit his website for physiotherapy practitioners around the United Kingdom.

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