Over the decades, a lot of work has been done in an attempt to reduce the negative impact of low back pain (LBP), and help patients recover and maintain a better quality of life. After the first episode of Low Back Pain, the risk of further episodes is quite high, with one-year recurrences ranging from 24% to 80%. The occurence of back pain is lowest in the youngest individuals, tends to increase between 30 and 60 years of age
What is Low back pain?
There are different definitions of low back pain depending on the source. According to the European Guidelines for prevention of low back pain, low back pain is defined as “pain and discomfort, localized below the costal margin and above the inferior gluteal folds, with or without leg pain”
there are 3 basic different categories of low back pain based on duration:-
- Acute:- Episode of low back pain for less than 6 weeks.
- Subacute:- Low back pain between 6 and 12 weeks.
- Chronic:- Low back pain for 12 weeks or more.
Nearly a third of people seeking treatment for low back pain will have persistent moderate pain for one year after an acute episode.
Understanding Lower back anatomy (Lumbar Spine):-
The lowest part of the spine is called the lumbar spine. This area has five vertebrae. However, sometimes people are born with a sixth vertebra in the lumbar region. The lumbar spine’s shape has what is called a lordotic curve. The lordotic shape is like a backward “C”.
Physiotherapists sometimes look at a spinal segment to understand and explain how the whole spine works. A spinal segment is made up of two vertebrae attached together by ligaments, with a soft disc separating them. Each spinal segment is like a well-tuned part of a machine. All of the parts should work together to allow weight-bearing, movement, and support.
The paraspinal muscles refer to the muscles next to the spine. They support the spine and are the motor for movement of the spine. Your joints allow flexibility and your muscles allow mobility. When you experience a muscle spasm, it is because your muscle tightens up and will not relax. These spasms usually occur as a reflex – meaning that you cannot control the contraction of these muscles. When any part of the spine is injured including a disc, ligaments, bones, or muscles, the muscles automatically go into spasm to reduce the motion around the area. This protective mechanism is designed to protect the injured area.
The nerves of the lumbar spine then reach to your legs, bowel, and bladder. These nerves coordinate and control all the body’s organs and parts, and let you control your muscles. Damage to the nerves themselves can cause pain, tingling, or numbness in the area where the nerve travels.
Causes of Low back pain:-
Depending on various factors like age, gender, lifestyle, nutrition there are numerous causes of LBP:-
- Bad posture
- Overweight/ obesity
- Sedentary lifestyle
- Poor general fitness
- Stress
- Long working hours
- Sudden injury/accident/trauma
Back pain in children:-
The impact of LBP on children and adolescents is significant with up to 94% of those with pain experiencing some degree of disability. Furthermore, it has been suggested that LBP experienced during childhood and adolescence increases the risk of LBP in adulthood, possibly through the development of maladaptive beliefs, behaviors, and attitudes related to the earlier pain events.
The spine of a child and adolescent is physiologically different from the adult spine (i.e. ligamentous laxity, bone composition, muscle mass) and therefore potentially responds differently to various interventions, movements, and loading. Although measures like back-related education and promotion programs have been tried other than traditional treatment, research says that they are not effective in reducing LBP prevalence in children.
Low back pain in pregnancy:-
These are known facts that approximately 50% of women experience low back or pelvic girdle pain during pregnancy; 25% continue to experience pain 1 year after delivery. Pelvic girdle pain is associated with a decrease in regular physical activity during pregnancy. But there is a wave of prenatal yoga, exercise programs for prevention and reduction of low back pain during pregnancy. Well here are the research findings
Research says:-
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- Being physically active during pregnancy did not reduce the odds of developing low back, pelvic, or lumbopelvic pain either during pregnancy or in the postpartum period.
- Physical activity performed in various formats during pregnancy decreased the severity of low back, pelvic, and lumbopelvic pain during pregnancy and the early postpartum period.
However, compared with other cost-effective non-pharmacological treatments, such as interdisciplinary rehabilitation, acupuncture, spinal manipulation, or cognitive behavioral therapy, exercise is easily accessible as part of a self-management strategy, can require minimal equipment, and can be performed at home
Conclusion: Exercise appears to reduce the risk of low back pain in pregnant women, and sick leave because of lumbopelvic pain, but there is no clear evidence for an effect on pelvic girdle pain.
Low back pain in athletes:-
There is a relationship between back pain and physical activity. it is essential to prevent back pain but when the amount of physical activity is very high it can be the reason for developing back pain.
Elite athletes have a higher grade of physical activity and thus might have a higher risk of developing back pain. They spend much time in training and competition, which subjects their bodies to a great deal of mechanical strain and, thus, a high level of stress on the musculoskeletal system. Depending on the sports discipline, this stress is exceedingly high especially in the years from adolescence (14 years of age), in which elite competitive sports begin, until peak competitive performance at ages of up to 40 years.
As in the general population, back pain in athletes can lead to high costs of treatment, dropping out of training and competition, decreased quality of life, and limitations to performance. Research says “High physical loads, repetitive mechanical strain, and static or dynamic extreme body positions increase the risk of spinal overload and overuse” are the causative factors of back pain in athletes.”
In some sports disciplines, contact with an opponent and the resulting strain on the spine might be an additional risk factor for back pain. Traumatic spinal injury is more frequent (e.g., gymnastics, wrestling), in sports involving repetitive loading of the spine during motion or load extremes (e.g., gymnastics, cricket, weightlifting, rowing), and in sports in which the spine is subject to high-impact loads with sometimes unpredictable landing forces (e.g., horseback riding, volleyball). Due to the nature of these sports, it is not surprising that the incidence of intervertebral disc or spine abnormal
ties is higher.
A commonly encountered question is, can athletes play through pain? There is no simple answer to this question. For example, an athlete with suspected spondylolysis is generally advised that he or she should not play through pain, while athletes with chronic low back pain from muscular or ligamentous strain may continue to practice, exercise, and compete. However, there is little evidence to support either of these approaches. These athletes should always be monitored for their safety.
Hyperlordosis (lordotic low back pain) is the second most common cause of adolescent low back pain. This condition is related to adolescent growth spurts when the axial skeleton grows faster than the surrounding soft tissue, resulting in muscular pain. Other causes of low back pain unique to children are vertebral endplate fractures and bacterial infection of the vertebral disk.
Examination of Low back pain:-
The main aim of physiotherapy examination is to understand where the symptoms arise from and which movements tend to aggravate the pain. As the client walks into the clinic out examination begins with the observation of the way he/she walked in, he/she able to sit properly, what are the facial expressions.
A detailed history is taken understanding how the back pain started and what all has been done about it. followed by that the client’s movements are examined in standing and lying down and special test if required are carried out.
90% of the clients who walk in have been diagnosed with non-specific low back pain. only a few people fall in the specific diagnosis of low back pain.
Is it important to get an x-ray or MRI done before visiting a physio?
the answer is NO. Evidence confirms that clinicians should refrain from routine, immediate lumbar imaging in primary care patients with nonspecific, acute, or subacute LBP and no indications of underlying serious conditions.
Do you need to go to an orthopedic before visiting a physio?
A physiotherapist will examine your movements as well as your pain and is fully competent in diagnosing your low back pain. It’s ok to contact a physio directly for all your low back pain-related queries.
Management of low back pain:-
There are several treatment options available for back pain. the physiotherapy management is mainly aimed at improving the structures around the low back by treatment and movements and get the clients going back to normalcy. As more and more research goes into movement therapy, older approaches of using machines for low back pain have taken a back seat. there are newer exercise regimes available to cure low back pain.
Individualized physiotherapy has the potential of being more effective for people with LBP. Using the STOPS individualized physiotherapy protocol including manual therapy, directional preference management, postural re-education, motor control training, and graded functional exercise we have been able to treat more than 5000 patients successfully over the past decade. not only there has been a high level of patient satisfaction with this kind of approach but it is cost-effective as well.
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The treatment program is customized according to your symptoms, capacity, and goals. It may include a variety of treatment options like electrotherapy, dry needling, manual therapy, Kinesiotaping, or a clinical Pilates-based rehab program targeting your core muscles. Generally, the first session can extend for an hour or more, then onwards as the program is designed the session usually lasts 30- 45 minutes.
try these core exercises for your back strengthening
Exercise therapy for back pain:-
here is what research has to say “Exercise therapy using individualized regimens, supervision, stretching, and strengthening was associated with the best outcomes. The addition of exercise to other noninvasive therapies was associated with small improvements in pain and function.”
A systemic review found segmental stabilizing exercises more effective in reducing the recurrence of pain in acute low back pain; For chronic low back pain, segmental stabilizing exercises were more effective than treatment from general practitioners.
At Physiocure, we teach segmental stabilizing exercises which gradually help to reset the normalcy in the lower back region.
Manual therapy in back pain
There is moderate evidence of short-term pain relief with acute low back pain treated with SMT. Chronic low back pain showed moderate improvement with SMT, which is as effective as NSAIDs and more effective than physical therapy in the long term
Acupuncture and back pain
Acupuncture is often used for LBP. We found moderate evidence of the benefit of acupuncture in patients with NSLBP ((sub)acute and chronic), which was mostly observed post-treatment. Significant effects were demonstrated with respect to pain intensity but not function when compared with sham or placebo acupuncture
Pilates:-
Pilates is a system of exercises widely used in patients with low back pain. The practices based on this method have promoted the restoration of the function of muscles involved in lumbopelvic stabilisation, that is, transversus abdominis, multifidus, diaphragm, and pelvic floor muscles. During each exercise, specific principles of this method should be followed to restore or sustain the motor control of the lumbar spine and proper body posture. no conclusive evidence was found that Pilates is superior to other forms of exercise.
Contraindications comprise unstable fractures, with caution required in unstable spondylolisthesis and radiculopathy. Potential risks can include: increase in low back pain, aggravating pathology, excessive muscle tension, or even self-injury during exercises.
Pilates exercises should be administered more than two to three times a week, with a session lasting a minimum of 60 min, within at least 20 sessions (20 hours).
Bracing/Lumbar Supports
Braces are not effective in preventing back pain. However, there is conflicting evidence about whether braces are effective supplements to other preventive interventions. Bracing, in combination with activity restriction, is effective in the treatment of spondylolysis in adolescents. A meta-analysis of 15 observational spondylolysis and grade 1 spondylolisthesis treatment studies did not find a significant improvement in rates of healing with bracing when compared with conservative treatment without bracing. Most experts recommend surgical consultation for spondylolisthesis with 50% slippage or more (grade 3 and higher).
References:-
- Zaina F, Balagué F, Battié M, Karppinen J, Negrini S. Low back pain rehabilitation in 2020: new frontiers and old limits of our understanding. Eur J Phys Rehabil Med. 2020 Apr;56(2):212-219. doi: 10.23736/S1973-9087.20.06257-7. Epub 2020 Mar 25. PMID: 32214063.
- Evidence of efficacy of acupuncture in the management of low back pain: a systematic review and meta-analysis of randomised placebo- or sham-controlled trials.Yan Xiang*, Jin-yuan He, Huan-huan Tian, September 16, 2019.
- Is immediate imaging important in managing low back pain?
- Low back pain in children and adolescents: a systematic review and meta-analysis evaluating the effectiveness of conservative interventions.
- Exercise for the prevention and treatment of low back, pelvic girdle and lumbopelvic pain during pregnancy: a systematic review and meta-analysis.
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The timing of surgery in lumbar disc prolapse: A systematic review
- COST B13 Working Group on Guidelines for Prevention in Low Back Pain. Chapter 2. European guidelines for prevention in low back pain
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The Evolving Case Supporting Individualised Physiotherapy for Low Back Pain.
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Prevalence of Back Pain in Sports: A Systematic Review of the Literature.