Nonspecific low back pain

Nonspecific low back pain

Low back pain (LBP) is tension soreness and or stiffness in the back, between the bottom of the ribcage and top of the leg, that can be triggered by physical factors (e.g., lifting awkwardly) or psychosocial factors (e.g., being fatigued or tired), or by a combination of the two (e.g., being distracted while lifting). It can often get worse with movement of back, coughing, or sneezing.`

Low back pain is one of the most common causes for seeking medical treatment and it is estimated that one in two people will experience low back pain at some point during their lifetimes. LPB is the leading chronic health problem that causes activity limitation and work absence (Kent PMKJ 2005, Chiropractice and Osteopathy), and forcing older workers to retire prematurely. It keeps more people out of the workplace than heart disease, diabetes, hypertension, neoplasm, respiratory disease, and asthma combined. (Schofi Eld DJ, 2008). Also, individuals who have experienced activity limiting LPB often experience reoccurring episodes with estimates ranging between 24–33%. (Stanton T. et al, spine 2008; Wasiak R, spine 2003)

LPB is a symptom rather than a disease. Like other symptoms, such as headache and dizziness, it can have many causes. It is thought that in some cases the cause may be a sprain (an over-stretch) of a ligament or muscle. In other cases the cause may be a minor problem with the disc between two vertebrae, or a minor problem with a small ‘facet’ joint between two vertebrae. There may be other minor problems in the structures and tissues of the lower back that result in pain. (Chris Maher, The Lancet, 2016)
Interestingly sometimes LPB can develop even in the absence of any associated change in radiographic appearance of the spine. Studies have reported that, 32% of asymptomatic subjects had ‘abnormal’ lumbar spines and only 47% of subjects who were experiencing low back pain had an abnormality identified. (Savage et al 1997)

Non-specific low back pain means that the pain is not due to any specific or underlying disease that can be found. It is the most common type of back pain. About 19 in 20 cases of acute (sudden onset) low back pain are classed as ‘non-specific’. (Chris Maher, The Lancet, 2016)

Patients who suffer from chronic low back pain often have impaired quality of life and also suffer from depression. Depressive symptoms can appear because back pain limits patients’ ability to work and engage in their usual social activities because of their disability. (Kristallia Vitoula 2018)
Low back pain is a self limiting condition. Most people with a bout of non-specific low back pain improve quickly, usually within a week or so, even without treatment. Sometimes it takes a bit longer time to recover. Although the pain may go away, the re-occurrence rate of LBP is extremely high and these individuals are likely to experience another episode of LBP within 3-6 months. Re-occurrence is a major problem with the re-occurrence rate being approximately 60%.

The temporal evolution of symptoms divides low back pain into acute (symptoms lasting \ 4 weeks), sub-acute (symptoms lasting 4–12 weeks) or chronic (symptoms lasting at least 3 months). Chronic LBP will affect at least 10% of low back pain sufferers. (Meucci RD 2015)
It is believed that early physical therapy intervention can help reduce the risk of conversion
of patients with acute low back pain to patients with chronic symptoms. A study by Linton
demonstrated that early active physical therapy intervention for patients with the first
episode of acute musculoskeletal pain significantly decreased the incidence of chronic
pain. (Linton SJ, Pain 1993)

Management of LPB:
There is a substantial amount of medical literature supporting specific physical therapy exercises for the treatment of low back pain. While most episodes of low back pain are self limiting and will get better on their own, active exercise plays an important role in helping reduce the patient’s pain and improving subsequent function in patients with low back pain.

Common techniques of physiotherapy include:

MANUAL THERAPY
Thrust and non-thrust mobilization/manipulation is a common intervention utilized for
acute, sub acute, and chronic low back pain. Studies suggest that, for patients with LBP a comprehensive treatment plan including thrust and non-thrust mobilization/manipulation directed at the lumbo-pelvic region is effective at decreasing pain and disability. (Whitman et al 2006)

EXERCISES THERAPY
Gentle exercise for mobility and stretching (especially the muscles of the legs and back) can help decrease the severity, duration and recurrence of low back pain. Exercises may vary in intensity, frequency, and duration. Exercise therapy when used in isolation or with additional interventions is effective at decreasing pain and disability related to nonspecific LBP. (Macedo et al Phys Ther 2009) In various researches exercise therapy was found to be effective in decreasing pain in the chronic population, graded activity improved absenteeism in the sub acute population. (Hayden JA 2005, Cavanaugh JM 1995, Aure OF 2006)

DIRECTIONAL PREFERENCE EXERCISES
Flexion based exercises have long been utilized to potentially relieving mechanical compression of the lumbar nerve roots and improving spinal flexibility. (Backstom et al, Manual Therapy 2011)
Some other studies also suggest that spinal extension exercises (McKenzie therapy) is more effective than comparison treatments like NSAIDS, educational booklet, etc. (Clare, et al, Aust J Physiother 2004)
Nerve mobilization: patients treated with end range nerve mobilization procedures (like passive slump) demonstrated marked reductions in pain. (George JOSPT 2002 and Cleland et al Manual Therapy 2004)
Flexion exercises in combined with other interventions such as manual therapy, strengthening exercises, nerve mobilization procedures, and progressive walking have shown significant reduction in pain and disability in older patients with chronic low back pain with radiating symptoms. (Anthony Delitto , Steven Z George JOSPT 2012)

PATIENT EDUCATION AND COUNSELING
Education and counselling about causes of back pain, prognosis, appropriate use of imaging studies and specialists, and activities for promoting recovery and preventing recurrences have been traditional used for patients with acute, sub-acute, and chronic low back pain.

PROGRESSIVE ENDURANCE EXERCISE AND FITNESS ACTIVITIES
Presently, most national guidelines for patients with chronic low back pain endorse progressive aerobic exercise with moderate to high recommendations. (Airaksinen O Et al, EUR Spine J 2006, Bekkering GE physiotherapy 2003, Chau R 2007, Mercer MK 2006, Pillastrini P. Spine 2011, Savigny P, 2009)
High intensity exercise has also been demonstrated to have a positive effect on patients with chronic low back pain. (Staal JB JOR 2005, Smith C 2010, Rainville, Spine 2002, Murtezani A 2011, Cohen I Spots Med 2002)

Modern approach for treating Chronic Low Back Pain
Chronic low back pain is no longer considered a purely structural, anatomical or biomechanical disorder of the lumbar spine. Instead, there is strong evidence that chronic low back pain is associated with a complex interaction of factors across the biopsychosocial spectrum. These not only involve structural or biomechanical factors, but also cognitive (e.g., unhelpful beliefs, catastrophising, maladaptive coping strategies, low self-efficacy), psychological (e.g., fear, anxiety, depression) and social (e.g., work and family issues) factors (Vibe Fersum , O’sullivan, Eur J Pain 2013).

How it works:
•Negative thoughts (e.g., “My back pain is uncontrollable” introduce Negative feelings (e.g., depression, anger) and bring maladaptive health behaviours (e.g., skipping treatment sessions) thereby reinforcing negative cycle.

If one negative thought can be changed or better understood, then it can break down this negative cycle. This can be addressed through education and Cognitive Behavioural Therapy (CBT)
CBT aims to shift attention from incorrect and erratic thoughts and fears to adaptive thought patterns. It modifies the overall pain experience, help restore functioning and improve the quality of life of patients who suffer from chronic pain.
There is a great evidence to support the effectiveness of various cognitive behavioural interventions for reducing pain intensity and improving a patient’s coping skills. They help the patient let go the struggle against pain and move toward achieving their most valued life goal. Medical management is also more effective if cognitive, psychological and social factors are addressed. (Mark Jensen PHD, Mansell G 2013, Smeets 2006).

At Ability Physiotherapy and Sports Injury Clinic, we choose the best approach for your low back pain and help you return to activity at the earliest.

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Dr. Amit Rana, PT

Author: Dr. Amit Rana, PT

MPT (Osteomyology)

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