The Role of Physical Therapy
Physical therapy with a trained professional may be useful if pain has not improved after 3 – 4 weeks. It is important for any person who has chronic low back pain to have an exercise program. Professionals who understand the limitations and special needs of back pain, and can address individual health conditions, should guide this program. One study indicated that patients who planned their own exercise program did worse than those in physical therapy or doctor-directed programs.
Physical therapy typically includes the following:
Education and training the patient in correct movement.
Exercises to help the patient keep the spine in neutral positions during all daily activities.
Incorrect movements or long-term high-impact exercise is often a cause of back pain in the first place. People vulnerable to back pain should avoid activities that put undue stress on the lower back or require sudden twisting movements, such as football, golf, ballet, and weight lifting.
Exercises performed after a simple diskectomy do not seem to provide much added benefit over time.
Specific and regular exercise under the guidance of a trained professional is important for reducing pain and improving function, although patients often find it difficult to maintain therapy.
Exercise and Acute or Subacute Back Pain
Exercise does not help acute back pain. In fact, overexertion may cause further harm. Beginning after 4 – 8 weeks of pain, however, a rehabilitation program may benefit the patient.
An incremental aerobic exercise program (such as walking, stationary biking, and swimming) may begin within 2 weeks of symptoms. Jogging is usually not recommended, at least not until the pain is gone and muscles are stronger.
Patients should avoid exercises that put the lower back under pressure until the back muscles are well toned. Such exercises include leg lifts done in a facedown position, straight leg sit-ups, and leg curls using exercise equipment.
In all cases, patients should never force themselves to exercise if, by doing so, the pain increases.
Exercise and Chronic Back Pain
Exercise plays a very beneficial role in chronic back pain. Repetition is the key to increasing flexibility, building endurance, and strengthening the specific muscles needed to support and neutralize the spine. Exercise should be considered as part of a broader program to return to normal home, work, and social activities. In this way, the positive benefits of exercise not only affect strength and flexibility but also alter and improve patients’ attitudes toward their disability and pain. Exercise may also be effective when combined with a psychological and motivational program, such as cognitive-behavioral therapy.
There are different types of back pain exercises. Stretching exercises work best for reducing pain, while strengthening exercises are best for improving function.
Exercises for back pain include:
Low Impact Aerobic Exercises. Low-impact aerobic exercises, such as swimming, bicycling, and walking can strengthen muscles in the abdomen and back without over-straining the back. Programs that use strengthening exercises while swimming may be a particularly beneficial approach for many patients with back pain. Medical research has shown that pregnant women who engaged in a water gymnastics program have less back pain and are able to continue working longer.
Spine Stabilization and Strength Training. Exercises called lumbar extension strength training are proving to be effective. Generally, these exercises attempt to strengthen the abdomen, improve lower back mobility, strength, and endurance, and enhance flexibility in the hip, the hamstring muscles, and the tendons at the back of the thigh.
Yoga, Tai Chi, Chi Kung. Practices originating in Asia that combine low-impact physical movements and meditation may be very helpful. They are designed to achieve a physical and mental balance and can be very helpful in preventing recurrences of low back pain.
Flexibility Exercises. Flexibility exercises may help reduce pain. A stretching program may work best when combined with strengthening exercises.
Specific Exercises for Low Back Strength
Perform the following exercises at least three times a week:
Partial Sit-ups. Partial sit-ups or crunches strengthen the abdominal muscles.
Keep the knees bent and the lower back flat on the floor while raising the shoulders up 3 – 6 inches.
Exhale on the way up, and inhale on the way down.
Perform this exercise slowly 8 – 10 times with the arms across the chest.
Pelvic Tilt. The pelvic tilt alleviates tight or fatigued lower back muscles.
Lie on the back with the knees bent and feet flat on the floor.
Tighten the buttocks and abdomen so that they tip up slightly.
Press the lower back to the floor, hold for one second, and then relax.
Be sure to breathe evenly.
Over time increase this exercise until it is held for 5 seconds. Then, extend the legs a little more so that the feet are further away from the body and try it again.
Stretching Lower-Back Muscles. The following are three exercises for stretching the lower back:
Lie on the back with knees bent and legs together. Keeping arms at the sides, slowly roll the knees over to one side until totally relaxed. Hold this position for about 20 seconds (while breathing evenly) and then repeat on the other side.
Lying on the back, hold one knee and pull it gently toward the chest. Hold for 20 seconds. Repeat with the other knee.
While supported on hands and knees, lift and straighten right hand and left leg at the same time. Hold for 3 seconds while tightening the abdominal muscles. The back should be straight. Alternate with the other arm and leg and repeat on each side 8 – 20 times.
Note: No one with low back pain should perform exercises that require bending over right after getting up in the morning. At that time, the disks are more fluid-filled and more vulnerable to pressure from this movement.
Some common spinal injuries and conditions we treat:
Acute lower back (lumbar) pain due to spinal disc and/or facet joint injuries
Chronic low back (lumbar) pain
Sciatica – referred pain and symptoms into the lower limb
Pelvic dysfunction syndromes . Often diagnosed in patients who feel ‘out’.
Childbirth related instability and acute pain syndromes of the lower back and pelvis.
Spondylolisthesis (forward slip of one vertebrae on the vertebrae directly below it)
Spondylosis (disc space narrowing combined with degenerative changes in the facet joints common with age)
Acute neck pain due to facet joint and/or spinal disc injury
Chronic neck pain
Brachialgia-referred pain and symptoms into the arm, ‘pinched nerve’ pain and/or pins and needles/numbness (known as paraesthesia)
Mid-back (thoracic) and rib (costovertebral joint) pain (which, in some cases, refer pain around the chest wall)
Acute/chronic (myofascial) trigger point conditions. (These are tender and hypersensitive coin sized zones within the muscle tissue that can cause local pain and tightness and can also refer to distant sites.)
Muscle and joint stiffness
Causes of Spinal Pain
Acute and chronic spinal pain is experienced due to the stimulation, via mechanical or chemical irritation, of small nerve endings, nerve root or spinal cord sheaths, nerve cords, complex pain mechanisms in the central nervous system or a combination of the above.
Acute Spinal Pain
This can involve findings of bulging disc, disc protrusion or disc prolapse/rupture. Disc problems are very common in the lower back (lumbar spine). They are often associated with episodes of bending, bend with twist or prolonged sitting /driving which distorts the rim of the disc causing acute pain. In addition it can produce pressure on the spinal nerves in the lower back which produce symptoms known as sciatica. This is felt as pain, pins and needles sensation, numbness and/or weakness in the leg(s). In the neck (cervical spine), disc injuries can cause debilitating pain into the neck and commonly severe pain into the arm called brachialgia due to compression of the spinal nerves in the neck. This is commonly referred to as ‘pinched nerve’.
These joints are small joints which flank the disc on either side and behind the spinal discs. They are like a finger joint in their structure and when injured swell and inflame and cause acute pain and restriction of movement. They can be sprained in an injury or activities involving twisting, arching and reaching upward movements. In the neck they can become overstrained by an awkward night’s sleep leading to a condition known as ‘Acute Wry Neck’. They can cause local pain and also refer pain to neighbouring and even distant sites.
The joints of the pelvis can suffer acute injuries through high force trauma such as motor vehicle/bicycle accidents, contact sports, slips and falls on to the ground/floor, landing from a height, or when the female pelvis is vulnerable before and after childbirth. Injury and acute instability syndromes can occur which involve the sacroiliac and pubic joints. Lumbo-pelvic dysfunction conditions are common in the sporting population. Muscle imbalance, asymmetrical posture and structural alignment, as well as poor activation and stabilising strength (core control) can create syndromes such as chronic back pain, Osteitis Pubis (OP), recurrent hamstring strains, and contribute to a range of soft tissue injuries/conditions in the lower body.
This refers to the soft tissue layer involving the muscles, tendons and fascial tissues. This can be injured acutely and cause local pain at the site of injury but can also be responsible for ache and pain at distant sites. Myofascial pain is often associated with damage to deeper joint structures, namely disc and facet joints as either a primary (injured tissue) and/or secondary (protective spasm) component of the acute injury.
Millions of people take opioids for chronic back pain, but many of them get limited relief while experiencing side effects and worrying about the stigma associated with taking them.
More than 100 million people in the United States suffer from chronic pain, and those with chronic low back pain are more likely than patients with other types of pain to be prescribed opioids. Unfortunately, these medications are addictive and can cause side effects, ranging from drowsiness to breathing problems.
“Patients are increasingly aware that opioids are problematic, but don’t know there are alternative treatment options,” said Asokumar Buvanendran, M.D., lead author of the study, director of orthopedic anesthesia and vice chair for research at Rush University, Chicago, and vice chair of the American Society of Anesthesiologists (ASA) Committee on Pain Medicine. “While some patients may benefit from opioids for severe pain for a few days after an injury, physicians need to wean their patients off them and use multi-modal therapies instead.”
In the study, 2,030 people with low back pain completed a survey about treatment. Nearly half (941) were currently taking opioids. When asked how successful the opioids were at relieving their pain, only 13 percent said “very successful.” The most common answer — given by 44 percent — was “somewhat successful” and 31 percent said “moderately successful.” Twelve percent said “not successful.”
Seventy-five percent said they experienced side effects including constipation (65 percent), sleepiness (37 percent), cognitive issues (32 percent) and dependence (29 percent).
Respondents also had concerns about the stigma associated with taking opioids. Forty-one percent said they felt judged by using opioids. While 68 percent of the patients had also been treated with antidepressants, only 19 percent felt a stigma from using those.
A major pharmaceutical company recently agreed to disclose in its promotional material that narcotic painkillers carry serious risk of addiction and not to promote opioids for unapproved, “off-label” uses such as long-term back pain. Researchers also note a lack of solid studies on the effectiveness of opioids in treating back pain beyond 12 weeks.
Patients with chronic low back pain, persistent pain lasting more than three months, should see a pain medicine specialist who uses an approach that combines a variety of treatments that may be more beneficial, said Dr. Buvanendran. These treatments include physical therapy, bracing, interventional procedures such as nerve blocks, nerve ablation techniques or implantable devices, other medications such as anti-inflammatories and alternative therapies such as biofeedback and massage, he said.
American Society of Anesthesiologists (ASA). “Many back pain patients get limited relief from opioids and worry about taking them, survey shows.” ScienceDaily. ScienceDaily, 23 October 2016.
Figures suggest that around 80% of people experience back pain at some time in their lives. Back and neck pain can be very debilitating so how a physiotherapist manages back pain treatment is essential to secure a positive result. Back pain can be localised in and around the spine, but can also be experienced as sciatic pain. Headaches and migraines are also commonly caused by neck issues.
Exercise is important
Exercise is gaining recognition as playing a vital role in the long term recovery and in preventing many musculoskeletal injuries, including back and neck pain. Exercise compliments physiotherapy treatment management and achieve long term results when trying to prevent and rehabilitate pain and injury by correcting the underlying causes, not just seeking to stop the pain.
The underlying biomechanics that cause back and neck pain
Most back pain is caused by excessive loading placed on muscles, joints, ligaments, spinal discs, etc. due to poor core stability. Core stability is traditionally defined as; an individual’s strength and control of their lower back, pelvic and abdominal muscles in order to maintain optimal postural alignment of the lower back and pelvis.
However it is important to also include the shoulder girdle and rib cage, as the lower back and pelvis do not operate in isolation, and muscles throughout the torso must act in a coordinated manner in order to maintain optimal postural alignment and also to initiate biomechanically efficient upper and lower limb movements.
A good analogy to help understand core stability is to consider how a tent is supported. A tent is held upright by a rigid tent pole. The bones of your spine act like a tent pole, however your spine is not rigid, so it relies on the support of ligaments and deep stabilising muscles to hold adjacent vertebrae and to help maintain optimal postural alignment i.e. stabilise the spine. If the muscles that stabilise the spine, pelvis, rib cage and shoulder are weak or are poorly controlled then your spine will tend to collapse, just like a tent pole made from a piece of spaghetti. There are many muscles that attach directly onto the spine, pelvis, rib cage and shoulders. These muscles move our torso and limbs and also assist with stabilising the core, acting in a similar way that guide ropes help to keep the tent pole upright. If a tent had guide ropes that pulled more on one side than on the opposite side then the tent would lean, so too, if the muscles on one side pulled more than the other due to imbalances in strength and/ or flexibility, or these muscles compensate for weak stabiliser muscles then they will pull your body into a poor postural alignment. One very important difference to note is that a tent only requires “static stability” i.e. support to maintain a single stationary position, whereas, the human body must have “dynamic stability” to provide support and maintain optimal alignment of their core and limbs whilst moving in many different ways to participate in sport, work and daily living activities.
How a physiotherapist corrects biomechanical faults
Physiotherapists conduct a comprehensive physical assessment and then use this information to design a personalised exercise program to improve posture/ biomechanics, core stability, flexibility, functional strength, cardiovascular fitness, balance and coordination. Programs focus on achieving long term results by correcting the underlying biomechanics causes of your pain, improving the strength of muscles that support your back and neck and teaching efficient movement for your specific sport, work or daily living activities. Expert supervision by an Physiotherapist ensures that each client completes the exercises with good technique to prevent further injury, to ensure that the exercises are effective, and also to ensure that progressions are made at safe and appropriate times.