Low back pain is one the most pervasive and costly conditions in medicine today. Approximately 80% of Americans will experience a significant episode of low back pain at some point in their lives. Even worse is the fact that the peak incidence occurs between the third and fifth decades-one of the most productive periods in life. Low back pain consistently ranks in the top 10 list of reasons people seek medical care, and cost estimates range in the billions annually. LBP accounts for 1/3 of Workman’s compensation claims, which average $8,000.00 per claim.
Despite the frequency, disability and cost to the public a 1994 government funded committee determined that there was insufficient reliable data on which to base treatment recommendations. At this time, national guidelines for the treatment of chronic low back pain still do not exist. The good news in all of this is that 80% of the time insidious low back pain will resolve on its own without intervention within two weeks. It is the other 20% of these cases that do not show dramatic improvement in two weeks that account for the majority of treatment resources and time.
In a more recent visit to this problem Dr.’s Atlas and Nardin incorporated recent findings in an attempt to develop an evidence-based approach to the evaluation and treatment of Low Back Pain.
1. History and physical exam provide clues to uncommon but serious sources of LBP.
2. Diagnostic tests should not be a routine part of the initial evaluation, but should be used selectively based on history, exam, and response to treatment.
3. Patients without neurologic impairment should receive activity modification, education, and nonnarcotic analgesics.
4. Patients who do not recover in 2-4 weeks should be referred for physical treatments. Patients with or without radicular symptoms and no neurological deficit should receive conservative care.
A Few Words About Diagnostic Imaging
We live in a world with amazing technology and this is no exception when it comes to medical imaging tests (xray, CAT scan, MRI…). More often than not patients presenting with low back pain have either had some sort of imaging done and/or have questions about the influence of these results or the necessity of more expensive testing (MRI, CAT scan etc..) The interesting thing about diagnostic testing is that blinded studies of these images alone do not allow physicians to predict who has pain or dysfunction. In fact, studies indicate upwards of 30% of populations have positive findings on standard diagnostic tests yet have no symptoms or dysfunction. So patients age 30-55 with diagnostic findings of osteoarthritis, degenerative disc disease and even disc involvement would be incorrect assuming that these findings are the source of their pain or that these findings sentence them to a life of pain or dysfunction. Having said that, it is imperative that the decision to have testing done and the interpretation of any results is made by a physician, who has evaluated the patient to rule out serious disease processes and orthopedic/neurologic concerns. It is for these reasons in part that the evidence-based approach does not recommend routine diagnostic testing (see point #2).
Treatment Options in Physical Therapy
Despite these ugly truths the good news is that major progress is being made in our understanding of low back pain and its rehabilitation, although sorting through the immense varieties in treatment approaches and providers is often frustrating. With this in mind, I have evaluated numerous models and approaches for treatment. I have decided to focus on approaches that emphasize a Postural/Structural model. Below are brief reviews of four of the best approaches for mechanical management of low back pain available in conservative care today.
McKenzie Mechanical Diagnosis &Therapy
The McKenzie approach was developed by Robin McKenzie a few decades ago. The McKenzie Institute is an International Organization that certifies clinicians in mechanical diagnosis and treatment of spine dysfunction. This approach is commonly misunderstood as only extension exercise. In reality, the approach is based on a mechanical movement exam designed to determine directional bias for restoring motion and centralizing symptoms. The result of this exam is a treatment and exercise strategy that may include flexion (forward bending exercises), extension (backward bending exercises), sidebending or rotation. Studies on centralization indicate it is consistently one of only a few good predictors of a good outcome. This type of evaluation may be helpful in decisions regarding the need for diagnostic testing or more invasive procedures. Robin McKenzie has authored two books designed for self treatment of neck and low back pain.
Manual therapy has a long history and involves a large spectrum of techniques ranging from high velocity to indirect myofascial. A 2003 study in Spine found significantly larger improvements in pain, disability and return to work both short and long term with manipulation versus exercise alone. The use of manipulation is recommended for patients with acute low back pain in the first month of symptoms according to the US department of Health and Human Services. The term manipulation is used here to include osteopaths, physical therapists and chiropractors, all of whom provide these services albeit under differing philosophies.
Dynamic Core Stabilization
Recent studies on lumbar function have identified key patterns of muscle activation, and more importantly found differences in these patterns between subjects with and without low back pain. This information has led to implementation of new exercise strategies to ensure that the patient is able to activate these mechanisms. This is particularly beneficial in postoperative patients or patients with hypermobility. Assessment and implementation of these exercises should be done under the care of a physical therapist. People often find that starting core/abdominal exercises that they have heard or read about only aggravates their symptoms, which leads to unnecessary frustration and pain. The reason for this is that existing muscle imbalances require specific strategies and cueing to be resolved.
Traditional Adjunctive Modalities
Moist heat, ice, massage, ultrasound, electrical stimulation, traction, and topical lotions all fall into the category of passive treatment modalities. While these treatments often feel good and provide short-term decreases in pain they are insufficient as stand alone treatements in chronic back pain. Despite the lack of high quality research for these modalities, they can often be helpful to the patient when part of a complete mechanical treatment program.