Treating Lumbar Spinal Pain by Physiotherapy
The lifetime incidence of low back pain is very high, with most of us being affected to a lesser or greater extent at some point in our life. The very high numbers of lumbar pain sufferers means a large proportion of physiotherapy clients have this problem, and physios use many different techniques of treatment to assess and treat back pain.
Back pain is rarely an indication of serious underlying medical condition such as cancer, infection or arthritic disease but the physiotherapist needs to be sure he or she is dealing with a non-serious back pain. Standard exclusion questions are asked by the physio to rule out loss of weight, loss of appetite, previous cancer history, bowel and bladder control, rheumatoid arthritis, diabetes, epilepsy, particular pain problems at night and generally feeling ill.
This subjective history tells the physio that the back problem is mechanical, i.e. it is related to the stresses and strains on the spinal joints now and in the past. They can then move on to the objective examination, looking at the patient with their clothes off. Initial examination starts with the patient walking in and with how they sit for the questioning, and posture is noted next. Many postural changes are not of great significance but some fit the overall picture and increase the confidence in the correct therapeutic diagnosis.
The physiotherapy diagnosis is based on the changes in normal spinal movements. Limitation of spinal flexion (bending forward) is common with reduced range, guarding and some worsening of the pain during or at the end of this movement and other spinal movements. The physiotherapist may test the strength of the muscles and reflexes, the ability to feel sensations in the legs, hip movements and the sacro-iliac joints. Testing of the movements between the individual spinal joints can indicate where the pain, instability or stiffness might be produced.
The treatment goals and plan will be formulated with references to the findings during the examination e.g. a joint, disc or postural problem. A painful spinal joint will need careful treatment with gentle exercises, pacing, reduction in aggravating factors and pain-killers. A stiff spinal joint can cope with stronger manual techniques and exercises to stretch out the stiff tissues.
Lumbar stability has been a controversial and exciting development over the last 20 years with much research into the role of the abdominal and pelvic muscle groups in providing stability control to the lumbar spine. Patients are taught to maintain a neutral lumbar posture whilst recruiting their abdominal and spinal stabilisers and then move on to exercises with more resistance involved, eventually performing more functional exercises using the same principles.
Postural correction can be an important part of physiotherapy treatment as poor posture can hold vulnerable tissues near their end ranges, stressing them and reducing the blood supply to such tissues under stress. Moving the joints away from the end ranges and teaching a person to maintain that as a new “normal” posture can reduce the tissue stresses and help the overall picture to settle down.
McKenzie technique is followed by many spinal physiotherapists. This therapy holds that certain postures and movements affect the central disc material, the nucleus pulposus, either causing it to increase pressure on the posterior wall of the intervertebral disc or to reduce the pressure. The physiotherapist asks the patient to do repetitive movements in one direction to establish a “directional preference” which either worsens or improves the symptoms. From this the physio forms a treatment plan based on which direction of movement causes the desirable disc changes which alter the symptoms in the desired manner.
Once the symptoms are under control, the patient is taught to pace their activities appropriately so as not to overstress their spinal joints at any one time and to work on their overall fitness. It is embarrassing that there isn’t good evidence for any particular therapy for low back pain. However there is good evidence that increasing our overall fitness, both aerobic and muscular, improves back pain symptoms and makes it less likely that we will have further episodes.
