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Chronic Back Pain Physiotherapy

Low back pain (LBP) is the fifth most common reason for physician visits (this means that 20%, or 1 in 5 visits to doctors are because of low back pain). To make matters worse, low back pain affects nearly 60-80% of people throughout their lifetime.

Low back pain that has been present for longer than three months is considered chronic (long term), although there is still no consensus about the definition of chronic low back pain (CLBP).

Right now, specific causes of LBP are uncommon, and in approximately 90% of patients a specific generator cannot be identified with certainty.

Clinically Relevant Anatomy

The lumbar region is situated under the thoracic region of the spine.

The lower back consists of five vertebrae (L1- L5) and has a slight inward curve known as lordosis. The fifth lumbar vertebrae is connected with the top of the sacrum. The vertebrae of the lumbar spine are connected in the back by facet joints, which allow for forward and backward extension, as well as twisting movements.

The two lowest segments in the lumbar spine, L5-S1 and L4-L5, carry the most weight and have the most movement, and this is what that makes the area prone to injury.

In between vertebrae are spinal discs, and they provide shock-absorbing functions to support. Discs in the lumbar region of the spine are most likely to herniate (slipped disc) or degenerate (degenerative disc disease), which can cause pain in the lower back, or radiating pain to the legs and feet.

The spinal cord travels from the base of the skull to the joint at T12-L1, where the thoracic spine meets the lumbar spine. At this segment, nerve roots branch out from the spinal cord, forming the cauda equina.

Some lower back conditions may compress these nerve roots, resulting in pain that radiates to the lower extremities, known as lumbar radiculopathy.

The lower back region also contains large muscles that support the back and allow for movement in the trunk of the body. These muscles can spasm or become strained, which is a common cause of lower back pain.

Epidemiology /Aetiology

5-10% of all low back pain patients will develop into chronic low back pain (ie long term).

From research, CLBP prevalence rates are lower in individuals aged 20-30 years, increasing from the third decade of life, and reaching the highest prevalence between 50-60 years.

That being said, the prevalence rates stabilizes in the seventh decade of life. There’s no difference in CLBP prevalence at different periods of the year or in different places.

There is higher CLBP prevalence in

• females
• people of lower economic status
• people with less schooling
  
• smokers

There’s indication that prevalence has doubled over time too, which may be due to important changes in lifestyle (obesity) and in the work industry.

Factors as a

• family history of disabling back pain
• radiating pain
• advice to rest upon back pain consultation
• occupational LBP or
  
• LBP caused by traffic injury

are all associated with chronic disabling back pain over lifetime. Job satisfaction and psychosocial factors also play a role in the development of CLBP.

In patients with low back pain (LBP), alterations in fiber typing in multifidus muscle and erector spinae are assumed to be possible factors in the etiology and/or recurrence of pain symptoms as it negatively affects muscle strength and endurance.

Characteristics/Clinical Presentation

Most patients who suffer from chronic low back pain experience pain in the lower area of the back (lumbar and sacroiliac regions) and mobility impairment.

Pain can also radiate (travel) in the lower extremities, or generalized pain can be present. Patients with CLBP may also experience movement and coordination impairments. This could affect the control of voluntary movements of the patient.

It can be challenging for the patient to maintain the neutral position, malalignment of the body can occur. It can also be found difficult to maintain a standing, sitting or a lying position, especially in case of radiating pain to the lower extremities.

Carrying things in the arms, or bending can also provoke complaints. Daily activities, such as cleaning, sports and other recreational occupations can become a big task for people with CLBP.

The complaints are recurring and occur longer than three months. It is possible that CLBP passes in episodes. Some episodes are more severe than others, but overall the patient is affected by the impairments. Eventually, social contact and work environment will suffer from this great impact on the patient's health and wellbeing.

Examination

Research has shown that the patient history and biopsychosocial evaluation are crucial to establish chronic LBP. Patient history and self-report forms help rule out serious pathologies such as

• cauda equina
• ankylosing spondylitis
• nerve compromise
  
• cancer
  

There are also clinical tests that could be used to sort patients with a higher risk for CLBP from patients with (sub)acute low back pain. The best predictor is the lumbar spine flexion test.

Other differences might be seen in

• functional tests
• sensation in the feet and
  
• in the different pain provocation tests

what our senior physiotherapists can do for your chronic low back pain

Patients with chronic low back pain generally don't need corrective spinal surgery and tends to respond well to spinal physiotherapy.

Some of the spinal physiotherapy treatments our senior physios may provide includes:

• heat therapy
• cold therapy
• ultrasound therapy
• radio-frequency Indiba physiotherapy
• manual therapy
• deep tissue release therapy
• trigger point release
• computerized spinal decompression traction
• stretching exercises
• strengthening exercises

We may also recommend:

• regular deep tissue release therapy
• regular clinical Pilates