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Lower Back Pain

Causes, Risk Factors, Treatment & Prevention's

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What Is Low Back Pain?

According to European Guidelines for preventing low back pain, it is defined as “pain and discomfort, localized below the costal margin and above the inferior gluteal folds, with or without leg pain. One of the most common type is idiopathic (non-specific) low back pain which accounts for 70% of the cases and is usually is self-limiting. It means it is not associated with any known pathology such as tumor, infection, ankylosing spondylitis, inflammatory process or radicular syndrome.

Symptom by Duration:

  • Acute: <3 months
  • Chronic: >3 months
  • Recurrent: Acute symptoms come back

What Causes Low Back Pain?

While the actual cause of low back isn’t often known, symptoms usually resolve on their own. Although low back pain is rarely life threatening, there are several conditions that may be related to your low back pain such as:

  • Degenerative disk disease
  • Lumbar spinal stenosis
  • Fractures
  • Herniated disk
  • Osteoarthritis
  • Osteoporosis
  • Tumors of the spine

There are 3 categories in low back pain.

Specific Spinal Pathologies (<1%)

These can include spinal infection, cancer/malignancy, spinal arthropathies (e.g. RA or ankylosing spondylitis) cauda equina syndrome or spinal fractures which requires early diagnosis and prompt referral to appropriate medical specialist.

Radicular Syndromes (5-10%)

LBP can result from structural damage that can irritate or pinch a nerve. Some of the conditions that can cause radicular symptoms includes herniated disc, facet joint sprain, spondylolisthesis, spondylolysis, degenerative disc disease, spondylosis and back ligament sprain due to swelling or space occupying material adjacent to the spinal nerve which either irritates, pinch or compress the nerves.

Non-Specific LBP

It is the diagnostic term used to classify sufferers of lower back pain where no specific structure has been injured and specific spinal pathologies and radicular syndromes has been excluded as the cause of your back pain. Approximately 90-95% accounts for this condition and can be successfully managed conservatively and without the need of surgery.

Healing can be accelerated through pain relief and physiotherapy techniques such as manual therapy and back exercises. In many cases, chronic NSLBP is due to physiological and structural fragility in the lumbar region, and it is often caused by improper posture which creates muscle imbalance and weakens the lumbar spine and the structures such as the muscles, fascia, ligaments, tendons, surrounding it.

It is reported that 80 to 90% of acute non-specific low back pain usually heals within six weeks. Because low back pain is self-limited disease, if the symptoms does not improve even after three or four weeks, further tests are needed to check to find out the cause of the pain.

Another contributing factor includes:

  • Obesity
  • Inappropriate posture
  • Poor sleeping position
  • Weight gain during pregnancy
  • Smoking
  • Stress
  • Anxiety and/or depression
  • Build-up of scar tissue from repetitive injuries

What Are The Characteristics Of Low Back Pain?

Every back pain varies. It may be described as dull, burning or sharp and might feel at a single point or over a broad area. The type of pain will depend on the underlying cause of your back and may experience some of the following:

  • Muscle spasms or stiffness
  • Referred pain to the thigh or legs
  • Worse with bending and lifting
  • Worse with sitting or from sitting to standing
  • Often gets flare ups
  • Worse with coughing or sneezing
  • It may extend to the buttocks and outer hip

What To Expect When Physiotherapist Come To Your House?

Before any treatment, the physiotherapist will perform a thorough evaluation that will help identify what the structural source of your pain is most likely to be and enable us to provide a diagnosis and plan an individualized rehabilitation plan accordingly. And this includes:

  • A review of your health history (e.g. past medical/surgical history, social health habits, lifestyle, family medical history)
  • Questions about your specific symptoms (e.g. how and when did it start, what movements make it worse and makes it better).
  • Identifying signs and symptoms that could indicate a serious health problem, such as fracture (broken bone), kidney dysfunction, nerve impingement, cancer.
  • Assessment on how you use your body at home, work, during any sport activity.

If your physical therapist suspects that your lower back pain might be caused by a serious health condition, the therapist will then refer you to other health care professionals for further evaluation.

Red Flags:

  • Major or minor trauma specially with elderly and osteoporotic patients.
  • Age <20 or 50>
  • History of cancer
  • Fever, chills or unexplained weight loss
  • Recent bacterial infection
  • IV drug use
  • Immunosuppression
  • Pain worse at night or when supine
  • Severe or progressive sensory alteration or weakness
  • Bladder or bowel dysfunction
  • On physical examination: evidence of neurological deficit in legs or perineum)

Following the initial assessment, the physiotherapist will then have a provisional diagnosis which will then be confirmed or modified as needed with the following physical assessment that follows.

What Is The Treatment Plan?

Once an individualized plan has been made, the treatment is then aimed at easing pain sensitive tissues, restoring movement and then your physical function as required.

The length of time and number of visits of your physiotherapist before your condition is healed will depend on several factors such as the severity of your condition and especially for how long your problem has been present. The longer the symptoms have been present, the longer it will take time to settle. So, it is also important and have realistic expectation of the treatment process

Non-surgical Treatment

REST: Continue to do your daily activities but rest from movements that may make your symptoms worse. If severe pain is present, total bed rest for a day or two is advised.  After getting rest, daily activities is encouraged to keep the blood and nutrients to flow in the affected area which will inhibit inflammation and reducing muscular tension.

ICE: Ice applied to the low back for 10-15 mins every 1-2 hours will be very helpful in reducing pain and inflammation. It is inadvisable to use hot packs especially within 48 hours of injury as it increases pain and inflammation.

NSAIDs: Anti-inflammatory medicines such as Voltaren, Clofen or Panadol, Reparil may be prescribed by your doctor.

POSITIONING: Changing your sleeping habits can help ease strain on your low back. If you prefer to sleep on your back, try putting pillow under your knee and a small pillow under your head. If you prefer side lying, put a pillow in between your thigh. And make sure your bed is firm enough to give adequate support.

If your symptoms have not been Your physical therapist will conduct a thorough initial evaluation, identify the factors that have contributed to your specific back problem and design an individualized treatment plan for your specific back pain. Your physical therapist can help you improve or restore mobility and reduce low back pain – in many cases, without expensive surgery or the side effects of medication.

Physiotherapy Treatment Might Include:

  • Transcutaneous Electrical Nerve Stimulator (TENS) which is a method of electrical stimulation that aims to excite your nerves to provide a short-term relief.
  • Therapeutic Ultrasound is the use of sound waves to increase local blood circulation and help to reduce local swelling, chronic inflammation and is often used to breakdown scar tissues. It can also be used as a non-invasive way to administer medications to tissues below the skin which is known as phonophoresis.
  • Infrared radiation which is application of heat to your body via radiation.
  • Ice applied to the overlying skin send impulses to the cord that competes with pain-producing impulses, thus providing momentarily relief of the muscle spasms.
  • Soft tissue mobilization or manual therapy to improve mobility of joints and soft tissues.
  • Exercises for low back pain which aims to improve posture, strengthening of the abdominal muscles and muscles of the back and acquiring flexibility of the soft tissues.
  • Techniques for proper lifting and sitting and proper sleeping position.

Surgical Treatment

Surgery should only be considered once non-surgical treatment for at least 6 months to a year have been tried but have failed.

The following are some of the most common back surgeries:

  • Discectomy is the removal of part of a disc that is herniated and causing pain or other symptoms.
  • Laminectomy is a surgery performed to enlarge the spinal column when narrowing of the spine causes pressure on the nerve roots.
  • Spinal Fusion is the “welding” process by which two or more vertebra are fused together to form a single immobile unit.

Prevention

Due to the normal wear and tear of our spine that goes along with aging, it might not be possible to totally prevent the occurrence of back pain. But there are ways to lessen the impact of the condition such as:

  • Core strengthening exercises that will help to keep your muscles to be strong and flexible and provide your trunk with adequate stability.
  • Proper body mechanics when lifting. Stand in front of the object you want to carry, bend your knees and hold the object with both your hands. Use your thighs and not your back to carry the load such that your push your foot against the floor as you straighten your knee.
  • Maintain a normal body mass index. Being overweight or obese gives additional stress on your back.
  • Proper posture when you are using your computer, watching TV, sitting idly, carrying your bag, lifting heavy weight, etc. Your therapist can teach you these things.

When Should Physiotherapy Be Stopped!

Physiotherapy should be stopped once patient is pain-free; he is able to manage his symptoms and return to normal activity; if patient has done considerable time of consecutive treatment but there were no changes in the condition; and if the treatment causes worsening of the condition.

Reference:

  1. Chapter 2. European Guidelines for Prevention in Low Back Pain: November 2004.
  2. Chronic Low Back Pain: Evaluation and Management by Allen R. Last, MD, MPH and Karen Hulbert, MD, Racine Family Medicine Residency Program, Medical College of Wisconsin, Racine Wisconsin. Am Fam Physician. 2009 Jun 15;79(12): 1067-1074
  3. Moveforwardpt.com. Physical Therapist’s Guide to Low Back Pain
  4. Prescribing Guidelines for Primary Care Clinicians: LOW BACK PAIN: Rational Use Of Opioids In Chronic Or Recurrent Non-Malignant Pain By NSW Therapeutic Assessment Group
  5. Physioworks.com.Au. Low Back Pain.
  6. Low Back Pain in Young and Middle-Aged People by Toshihiko Taguchi: JMAJ, October 2003 – Vol. 46, No. 10
  7. Management of Low Back Pain in Physiotherapy by Max Folkersma: 2010
  8. Arthritis.org. Surgery for Back Pain
  9. Orthoinfo.aaos.org. Low Back Pain: Dec2013
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