Getting the Low Down on Low Back Pain
By: Richard Gardner, PT, DPT: Board Certified Clinical Specialist in Orthopaedic Physical Therapy
One of the most common conditions we treat in clinic is lower back pain. It is a very common condition that effects up to 36% of the population annually (Hoy, et. al., 2010) In addition, there are several types of lower back pain. The scary thing is there are several different “professionals” that claim to effectively treat lower back pain. People will go from their doctor, chiropractor, massage therapist, orthotic inserts, supplements, back braces, mattresses, infomercial sales, YouTube videos, Instagram, and more seeking a resolution to their pain. Why so many treatments to one condition? We don’t do this for other joints in the body. If we slip on the ice and blow out our ACL in our knee, we don’t ping pong around this much for treatment. This is due to lower back pain having several factors involved. I don’t want to spend this blog going over pain science education and other factors on why that is. My goal of this article is simple. I want to break lower back pain down into 4 treatment categories and present some evidence on treatment. I will also share a few at home treatment techniques that will hopefully out do the last video you saw on Tik Tok for treatment. These treatment recommendations are based on the Journal of Orthopaedic and Sport Physical Therapy guidelines published in 2012 (Delitta, et. al. 2012.)
Lower back pain can fit into four treatment categories. These categories are manipulation, stabilization, specific (or directional) exercise, and traction. Now, let me describe who fits what categories and what you can do about it. Again, this is somewhat oversimplified but this is just a blog and not my research thesis right😊
Manipulation or what we will refer to as a high velocity/low amplitude (HVLA) thrust to the spine is what your chiropractor has been doing for years. They do a good job at this. Here is the problem though. Where your chiropractor describes this as putting your spine “into alignment, or adjustment” we describe it as joint cavitation or simply a stretch with a "pop." I will often tell patients your spine is not “out of alignment.” If our spine came out of alignment, we would get spontaneous spinal cord injuries and find ourselves unable to walk. However, we do not throw the baby out with the bath water here. Physical therapists are also trained to apply safe HVLA thrust manipulation to the lumbar spine. We feel there is a place for spinal manipulation for treatment of lower back pain, but it is not a one size fits all. Again, without getting to heavy into the science of it, think of a manipulation as a great “reset” for your spinal joints/muscles. It can be a very powerful tool for quick reduction of symptoms. According to research people that can benefit most from spinal manipulation are individuals are as follows.
- Onset of low back pain less than 16 days ago.
- Pain does not extend or radiate beyond the knee (no numbness/tingling.)
- Hypomobility (stiffness) of the lumbar spine.
- Good hip mobility present
- No fear of getting a HVLA to the lumbar spine.
So, if you get a recent onset of lower back pain that does not extend below you knee, come see your trained physical therapist quickly. In addition, this is one technique a trained professional needs to perform on you. I am not going to teach home manipulation techniques (even though some of you guys “pop” your back every day.) I will say come see us if you need assistance here and have recent onset of lower back pain.
Stabilization is probably the most common category we treat in physical therapy. This condition applies to several types of lower back pain. However, this is often the treatment category that people with long standing persistent low back pain fall into. People in this category have localized lower back pain that does not radiate or produce numbness/tingling down the leg. People who would benefit from a stabilization treatment approach are individuals who will get pain during activity, pain after activity, are under 40 years of age, have increased flexibility, report feeling a “catch” in their lower back, and are post-partum. Exercises for this condition need to be tailored to each individual case but improvements can be achieved. A general starting point I will start my patients at here are the three exercises listed below. They are adapted from Stuart McGill’s big 3 exercises (Mcgill, 2007.) This is not ALL of what you need to do but a general starting point to become proficient in before doing other progressive loading exercises. If you do this and your pain is resolved with all activities GREAT if not, give us a call.
Specific (Directional) Exercises
Specific (Directional) Exercises are used to treat sciatica that is present in certain positions. Sciatica can be due to a few different causes that this blog will not describe. However, I will describe symptoms and how to address those with specific exercises.
Is your leg and sciatica worse with sitting or bending? Is it relieved in standing and walking? If so, you have what is called an extension bias. This means that when you bend your spine your sciatica symptoms get worse but when you extend it improves. This type of sciatica does well by performing exercises to reenforce this position. I will usually start my patients with the exercises below.
Is your sciatica worse with standing and walking? Do you have to sit to relieve symptoms? If this is the case your sciatica could mean you have a flexion bias. For this type of sciatica I will start my patients with the exercises below.
Keep in mind this is not a one size fits all and symptoms do generally take time to resolve. Generally as symptoms start to improve you will notice less pain in your leg and possibly more pain in your back! Don’t freak out here. That is actually a good sign that we are heading in the right direction. Stay the course and keep consistent.
The last category is traction. This is not a treatment you can do at home and its use is met with mixed research evidence. This does not mean it is not safe, the debate is whether it is effective. No matter if it works or not, you must get help from your physical therapist to perform correctly. Traction involves either a mechanical or manual (applied by the therapist) force to help lengthen the lumbar spine. Patients who fit this category will get pain in sitting, standing, lying, or walking. They have no positions that improve their symptoms. If this is you, then you could benefit from traction. Some of you will be dusting off your inversion tables but I do not recommend doing that until you talk to your health care provider. I recommend professional help for traction needs.
So, in conclusion I want to make a few more points. Number 1 is to always seek the advice of your trusted medical provider before doing any of these home programs. Back pain can be complicated and a screen to ensure you are safe to do home exercises is important. In certain cases, dangerous red flags must be ruled out. These are rare but you never want to be the effect of one of the serious causes of lower back pain. Number 2 don’t wait on back pain. Chronic lower back pain can best be prevented by getting help early on. Don’t wait for months to treat. If you fit the manipulation or traction categories come see us! If you find my exercises helpful for stabilization and directional groups that is great! However, don’t hesitate to call Specialized Physical Therapy if we can help design a program more specific to your needs. In addition, we offer several hands-on manual therapy treatments that can further accelerate your program and recovery. Most people don’t think physical therapy first when it comes to back pain. Not saying other professionals don’t help but we will spend an hour with you on your visits helping you recover. Let us know if we can help.
Have a great September….is it Fall yet?? 😊
Delitto, Anthony & George, Steven & van Dillen, Linda & Whitman, Julie & Sowa, Gwendolyn & Shekelle, Paul & Denninger, Thomas & Godges, Joseph. (2012). Low back pain. The Journal of orthopaedic and sports physical therapy. 42. A1-57. 10.2519/jospt.2012.42.4.A1.
Hoy, P. Brooks, F. Blyth, R. Buchbinder,The Epidemiology of low back pain, Best Practice & Research Clinical Rheumatology,Volume 24, Issue 6,2010,Pages 769-781,
McGill, S. (2007). Low back disorders: Evidence-based prevention and rehabilitation. Champaign, IL: Human Kinetics.