Low
back pain is most prevalent during our young and middle
adult lives, between the ages of twenty-five and fifty-five.
Eighty percent of the population will experience an episode
of
low back pain during their lifetime, and once an episode
is experienced, there is a likelihood that the back pain
may become episodic. For this reason, it is important to
understand some of the activities that may exacerbate or
prolong an episode of back pain, and what to expect when
you seek conservative medical management and physical therapy.
There
is a belief by most patients that back pain occurs as a
result of a traumatic event, for example, as a result of
some sport activity or lifting something heavy. Most often,
however, low back pain begins for no specific reason. Often,
a patient may relate an event that occurred several days
before the low back pain actually began. With further investigation,
it can be determined that it is the poor postures and positions
in which the person is engaged after the activity that aggravates
or causes the back pain, not the physical activity itself.
For that reason, it is important to learn proper postures
during sitting, lifting and bending, and methods to minimize
the likelihood of experiencing low back pain.
A
Typical Example:
A patient, a 40 year-old male, who comes to PT with a
complaint of low back pain for about two weeks that began
for no apparent reason. The patient states that he was sitting
at his office and noticed his back was starting to bother
him. He reports that his pain is worsened with prolonged
sitting or driving and feels better when walking. He states
he has been unable to garden due to the pain, but when he
works out at the gym or plays basketball, he feels good.
During the week, he has much more pain than on the weekend.
He has no complaints of pain when sleeping and wakes up
feeling good. He finds that toward the end of his workday
where he primarily sits at a computer, his pain is worsened.
During the PT
Exam, the therapist may have identified specific movements
that help to decrease the back pain. Given the history described
above, activities that cause the low back to flex, or bend
forward, increase this patient's pain. That includes sitting
for long periods of time (the low back is flexed when you
sit, especially when slouched) and when gardening, where
the back is also bending forward. When this patient walks
or plays basketball, he feels good, indicating that activities
where the low back is erect and moving toward extension
(bending "backwards") decrease the pain. Therefore, extension
movements were most likely found to decrease this patient's
pain during the PT exam, while flexion movements aggravated
his symptoms.
The
patient would then be instructed in specific exercises that
require the back to bend backwards, in order to alleviate
the pain. The patient would be instructed to perform these
regularly throughout the day to prevent the onset of pain
and also to alleviate the back pain should it develop. This
patient would also be instructed to temporarily avoid those
activities that aggravate his symptoms, which are primarily
flexion activities, like slouched sitting or gardening.
Correcting
Sitting Posture and Instruction in Proper Lifting Techniques
The therapist may have identified poor, or slouched
sitting posture during the initial examination, which is
most often the case, especially with a patient history as
described above. The PT can instruct this patient in proper
sitting posture using a lumbar roll, which is a special
pillow designed to maintain the "lordotic curve," or hollow,
in the low back. This correction of sitting posture assists
in minimizing the onset of pain. The instruction would also
include applying the concept of posture correction to sitting
in a car, at the office, and any other place specific to
the patient's daily routine. Interrupting prolonged sitting
posture with breaks to walk to the fax machine or to the
copier on a regular basis would also be appropriate.
Instruction
in proper bending and lifting should also be provided. With
a history as described above, activities that require repetitive
or sustained bending, like gardening, aggravate the patient's
symptoms. These activities should be temporarily avoided
until the pain is under control. As the person is able to
resume bending, education in proper bending and lifting
techniques should be provided in order to prevent the onset
of low back pain during this episode as well as to prevent
future episodes.
Even
though there are specific activities this patient should
avoid, there are a multitude of activities in which this
patient could participate pain free. Since this patient
feels good while playing basketball and when working out
at the gym, these activities should continue. However, it
is critical that AFTER the patient exercises, the patient
should be cautious to maintain good sitting posture, as
it is often the case that a patient will feel good while
exercising, but develop low back pain a few hours later
when sedentary.
Aerobic
Conditioning
Once pain-control techniques are well understood, a patient
should quickly progress to an aerobic conditioning program.
It has been found that aerobic activity assists in bringing
nutrients to structures in the spine. Some of these structures,
like the disc, have a relatively poor blood supply and rely
on body movements and aerobic activity to circulate nutrients
to these structures. When a person is sedentary, less of
these nutrients are able to get to the structures in the
spine to keep them healthy.
Aerobic-conditioning
activities should be chosen based on a patient's interest,
availability, and coincide with the type of problem that
the person has. Generally, a walking program, elliptical
trainer, and upright bicycle are good choices. The program
should be performed at least three times a week for thirty
to forty minutes each session.
Strengthening
and Flexibility Exercises
Once the pain is under control, spine and lower extremity
flexibility exercises should be initiated. In the above
example, this patient needed to avoid activities that required
him to bend forward because they aggravated his pain. Once
the pain is stabilized, however, his ability to bend forward
may be limited and stiff due to avoidance of this activity.
Therefore, restoring flexion movement is critical to return
the patient to full activities. Additionally, any limitation
of flexibility of the legs should also be addressed, as
tightness in these muscles may inhibit a person's ability
to maintain certain postures and positions necessary to
control back pain.
As
the pain in the back stabilizes, strengthening exercises
should also be incorporated into the PT program. The trunk
muscles themselves, the abdominals and spine extensors,
should be directly strengthened. Additionally, activities
that require the trunk to maintain a stable position, while
strengthening the upper and lower body, should also be included.
Leg strengthening is important as well, so that a person
can properly lift objects from the floor using their legs
muscles rather than those of the back. A home program of
strengthening exercises should also be included that are
easy to do and require minimal equipment.
Minimizing
"Bed Rest"
Gone are the days of prolonged bed rest. Most often, even
with acute back pain, engaging in proper movements and postures
as well as a progressive return to activities has been found
to be much more successful in terms of controlling low back
pain and allowing a return to normal activities more quickly.
Use
of Passive Modalities
Although the emphasis of a good back rehab program is returning
to function and activity while learning to control the symptoms
of low back pain, there are instances where the use of "passive
modalities" is indicated. In most cases, passive modalities
should be used in conjunction with other, more active forms
of physical therapy during treatment. Modalities can be
utilized early in the course of physical therapy care to
help control pain. However, as the physical therapy program
progresses, the focus should move away from the use of modalities
and include a progressive increase in activity and exercise
and instruction in self-treatment techniques.
Passive
modalities are described as the application of some form
of cold, heat, or electricity to the body to assist in pain
management. These modalities are referred to as "passive,"
as the recipient does not have to actively participate.
The modality is applied while the patient is at rest. The
most common forms of heat include moist hot packs and ultrasound.
Cold treatments, or cryotherapy, can be used to minimize
pain as well. This can be administered in the form of cold
packs and ice massage to the low back. Fluoromethane is
a spray that can also be applied to the skin by the therapist,
and is usually followed by a series of therapist-assisted
stretches.
Electric
stimulation can also be used to control pain. Some specific
types include TENS (transcutaneous electric nerve stimulation)
and microcurrent. In cases where TENS has been found to
be helpful in controlling pain, especially chronic pain,
a portable TENS unit can be obtained for home use.
Conclusion
Although this discussion is by no means exhaustive of the
type of physical therapy treatments available for low back
pain, a program that is active in nature and geared toward
instructing the patient in self care techniques and back
injury prevention are key ingredients in returning a person
to a pain-free, active and healthy lifestyle.
Reprinted with Permission
Rothman Institute
925 Chestnut Street, Philadelphia PA 19107-4216
(215) 955-3458
Last Updated: 03/24/2008
