The back is composed of 24 vertebrae plus the sacrum and coccyx. It is a complex system
with an interrelationship between the vertebrae, discs, muscles and nerves. The bones,
separated by intervertebral discs, have the basic function of providing a supporting
structure, protecting the spinal cord, and providing attachment points for muscles. Its
design makes movement possible in many directions. Thirty- one pairs of nerves exit
from the spine.
The multiplicity of potential sources makes the etiology of low back pain difficult to
determine; for most patients with low back pain, no specific cause is ever found.
Establishing a diagnosis can be a frustrating experience and it may have little impact on
care. It is estimated that a clear explanation can be identified in only about 10 percent to
15 percent of cases. (20) Physicians need to rethink the types of tests ordered and to put
them in the context of how they will improve care. A primary goal of assessment must be
to confirm that no serious or life threatening disease is present.
There are many potential sources of pain. Bone itself is devoid of pain receptors, but
periosteal tissues can be a source of pain. The degenerating disc is known to have
neurovascular elements in the annular tissue, including pain fibres. The nucleous pulposis
can be an inflammatory agent. Internal organs can also be a source of pain. (22)
Furthermore, the presence of abnormalities in the low back does not necessarily lead to
low back pain. Thirty percent of people have significant abnormalities on MRI and CT
scans of the lumbar spine and are without low back symptoms (10) Physical measures
such as stiffness and poor mobility poorly correlate with back pain. (2)
Muscle Strain
Muscles are one of the most common sources of low back pain. (23) Muscle strain occurs
when a muscle is over stretched or overexerted. Work and recreation activities can over
stress spinal muscles which may in turn create pain and spasm. Poor muscle conditioning
increases the incidence of strains. (24) The onset may be sudden, but the pain can also be
a delayed response to a previous activity. It can affect any age, but it is especially
common in young or middle-aged people.
Joint Sprain
When the adjacent bones are subjected to more physical force than they can withstand a
sprain or injury to the surrounding ligaments may occur. Stress on the facet joint capsule
and ligaments can occur as the disc degenerates and subsequently alters joint mechanics.
(24) The ligaments can tear or stretch which in turn causes swelling, pain and loss of
function. Muscle spasm often accompanies a ligament sprain as the body reacts to
immobilize the affected joint. Previous sprains may weaken the ligaments and can
predispose the joint for a recurrence. (24)
Osteoarthritis, Degenerative Joint Disease or Lumbar Spondylosis
Osteoarthritis erodes vertebral joint cartilage and becomes more common in patients over
50 years of age. It may occur after injury. This process results in dull pain that generally
worsens slowly over time. Another common symptom is joint stiffness. The pain can be
affected by the patient’s posture. The erosion of the joint cartilage may trigger the
formation of osteophytes.
Spinal Stenosis
Spinal stenosis can be caused by osteophyte formation and it is most common among
people in their 50s and 60s. The symptoms can include pain, numbness, and weakness;
the onset is usually gradual. The symptoms can be located in the lower back and one or
both legs. Aching in the buttocks, thighs, or calves during activity is a common feature of
low back spinal stenosis. (24) The leg pain may be worse than the back pain. (See sciatica
below). It may be relieved by sitting or leaning forward. Lying down may increase the
pain. (20) People with spinal stenosis often have episodes of back pain followed by
periods of relative comfort. (25) http://www.aafp.org/afp/980415ap/alvarez.html
Disc Disease
Disc disease is also a degenerative condition and is common among the elderly. Some
scientists believe that this process may begin in adolescence. (26) The discs act as shock
absorbers cushioning the spinal column from the everyday stresses and strains put on the
back. The intervertebral disc is the largest avascular structure in the body (although there
are some vessels in the outer area of the annulus fibrosis). As the disc degenerates, some
blood vessel invasion occurs. (22;27) A bulging disc is often seen on magnetic resonance
imaging (MRI) but usually does not cause symptoms. (20)
A pathologic weakness of the annular tissues may result in a herniated disc which is also
described as a bulge, rupture, herniated nucleous pulposis or a slipped disc. Repetitive
normal stress from usual activities or from physically stressful activities has not been
shown to cause an annular tear or weak spot. (22) Herniated discs are common among
people aged 35 to 55 and are rare in young people. (23) A deteriorated disc exhibits
higher peak stress levels within it than a normal disc and this could be a mechanism for
pain. (22) This may explain why many people with herniated discs suffer from years of
recurrent mild lower back pain before a single triggering event such as abrupt twisting,
heavy lifting, or sudden bending. (23)
In disc herniation, the onset of symptoms is usually sudden and the pain sharp; the pain
may worsen with bending, coughing and sneezing. The displaced disc’s nuclear material
can cause a significant inflammatory response; this inflammation of the nerve can result
in radiating pain. Over 90% of symptoms radiating to the leg due to disc herniation
involve the L5 or S1 nerve root at the L4/5 or L5/S1 disc level. (10)
Sciatica
Material from a herniated disc can press on the spinal nerves or spinal cord.
Pressure on the nerve tissues that lead to the sciatic nerve can cause low back
pain, leg weakness, numbness, tingling and diminished reflexes. Only one leg is
typically affected. (23) Nuclear material that is herniated may shrink over time as
the proteoglycan (a water absorbing substance) deteriorates and loses its water
retaining ability. This shrinkage in turn may spontaneously reduce the radiating
symptoms. 50% of patients recover from an acute attack of sciatica within six
weeks. (28)
Cauda Equina Syndrome
In this syndrome, the bundle of nerve roots which begin near the L1 vertebrae are
compressed extensively by disc herniation or other pathologies such as a tumour.
The resulting symptoms can include loss of bowel and bladder control, numbness
around the genital area, buttocks or backs of the thighs or rectal pain. (20) This
severe form of lumbar disc herniation requires immediate emergency medical
attention. Saddle anaesthesia, which is landmark symptom of cauda equina
syndrome, is caused by compression of the S3-5 nerve roots. Most cases of cauda
equina syndrome caused by disc herniation involve large particles of extruded
disc material, compromising at least one third of the spinal canal diameter. (22)
Recurrent Low Back Pain Management
The treatment recommendations for recurrent low back pain are the same as for acute low
back pain. A generalized moderate exercise program to increase fitness is recommended.
Recurrent low back pain is defined as episodes of acute low back problems that last less
than 3 months, but which recur after an interval free of low back symptoms. Recurrences
of low back pain are frequent, ranging from 20-44% within 1 year in occupational
populations to lifetime recurrences of up to 85%. (2) Quick improvement from each
episode can be expected unless the back symptoms are very different from the first
episode or the patient has a new medical condition. (31) Recurrent low back pain is
probably best treated initially in a similar way to acute low back pain episodes.
There is potential to reduce the rate of recurrence by being proactive and making exercise
and lifestyle changes. Active exercise programs are recommended for patients who have
intermittent or recurrent sub acute low back pain without radiation to the leg. (41;59). It
is recommended that patients follow a program of moderate, regular exercise to
strengthen back and abdominal muscles. (60)
There is an opportunity for massage therapists to undertake research to investigate the
efficacy of techniques that could reduce the recurrence of low back pain.
Categories of Low Back Pain****
Most of the medical literature divides back pain into categories determined by the
duration of the symptoms. The category of low back pain will influence the
choice of treatment.
1. Acute low back pain is low back or back and leg pain from its onset
through to 4-6 weeks of symptoms. Some authors consider acute low back
pain to be 7 days.
2. Sub acute low back pain is low back or back and leg symptoms that last
from 4- 6 weeks up to 3 months.
3. Recurrent low back pain are episodes of acute low back problems lasting
less than 3 months, but which recur after an interval free of low back
symptoms.
4. Chronic low back pain is low back or back and leg symptoms lasting
more than three months. (10)
Management of Low Back Pain
The management goals in low back pain include functional improvement, pain control
and disability prevention. Evidence based medicine is informing treatment providers and
funders to select interventions for which there is good evidence for improved clinical
outcomes and to avoid treatments for which there is little or no clinical evidence of
efficacy. The evidence provides a guideline for care, and clinicians must make their own
judgements based on the multitude of factors that each patient presents.
Patients with uncomplicated low back pain should be:
• Reassured
• Treated symptomatically
• Encouraged to remain active
• Patients with red or yellow flags need to be referred to appropriate specialists
The attitudes of treatment providers and the public about low back pain need to
be changed. The medical model of pain- or “Broken Part Hypothesis” leading to
over investigation can lead the patient to chronicity. The amount of chronicity can
be reduced by increased patient self care and a focus on function. (10)
The management of low back pain is divided into three sections:
• Acute and sub acute low back pain (less than six weeks duration for acute and six
weeks to three months for sub acute)
• Recurrent low back pain (intermittent episodes with complete relief between
occurrences)
• Chronic low back pain (more than three months duration)
Acute and Sub Acute Low Back Pain Management
Evidence-based treatments for acute and sub acute low back pain are listed below:
• Advise to remain active and to return to work as soon as possible.
• Reassure that 90% of low back pain cases improve within a few weeks- including
those with symptoms radiating to the leg.
• Bed rest will not improve their outcome, although limited bed rest in severe cases
may be needed for the first two or three days.
• NSAIDS and muscle relaxants are useful.
• Spinal manipulation may reduce acute low pain, but is no more effective than
other treatments
• The effects of massage for acute low back pain have not been measured in any
high quality trials, but it is likely beneficial in the sub acute phase.
• No indication that specific back exercises are effective for the treatment of acute
low back pain.
• Walking or a generalized low impact community exercise program is
recommended for sub acute patients. (2)
Advise to Stay Active and Avoid Bed Rest
Traditionally the treatment for low back pain has inappropriately focused on pain relief
and analgesics along with advice to rest and ‘let pain be your guide’ when doing
activities. All of these have been shown to delay recovery. (10) Current research shows
that remaining active leads to a more rapid recovery with less chronic disability and
fewer recurrent problems than either bed rest or back mobilizing exercises. (31;39)
The majority of patients with low back pain do not require bed rest and they should be
advised to stay as active as possible. Radiculopathy accounts for a very low percentage
(approximately 5%) of all cases of low back pain. (41) If patients have severe initial
symptoms of primarily leg pain, a short period of bed rest (2 to 4 days) may be an option.
(4;42) Bed rest should be of as short duration as possible and intermittent rather than
continuous. If the patient is still resting in bed after three or four days, they should be
strongly encouraged to progressively resume their activities. (41) Bed rest is
contraindicated for sub acute low back pain.
Patients who have intense pain radiation to an entire defined leg dermatome, with or
without neurologic signs must be referred for a specialized back pain evaluation if they
have not begun to progressively resume their daily activities after 10 days. (41;43)
The best available evidence suggests that advice to stay active alone has small
beneficial effects for patients with acute simple low back pain, and little or no
effect for patients with sciatica. There is no evidence that advice to stay active is
harmful for either acute low back pain or sciatica. If there is no major difference
between advice to stay active and advice to rest in bed, and there is potential
harmful effects of prolonged bed rest, then it is reasonable to advise people with
acute low back pain and sciatica to stay active. (44)
It is recommended that patients increase their physical activity progressively according to
a timetable rather than be guided by the intensity of their pain. The patient may need
short term modification of their activities and postures. (10) If the patient is advised to
return to normal work in a short time frame this may lead to shorter periods of work loss.
Chronic Low Back Pain Management
Evidence-based recommendations for the management of chronic low back pain are
listed below:
• Exercise
• Encouragement to continue working
• Seek massage therapy, especially if combined with exercise and education
• Attend a back school in occupational settings
• No bed rest
• Should be referred for behavioural therapy or to a multidisciplinary treatment
program if they have psychosocial yellow flags and have not returned to work. (2)
Chronic low back pain can leave a person miserable and unemployable and is a major
cause of disability today. It is very difficult to treat and efforts should be focussed on its
prevention. (10) Of the 10% of patients with chronic symptoms, 90% fall into the chronic
low back pain category and only 10% fall into the chronic sciatica category. (31)
Psychological factors are important contributors to the transition from acute to chronic
pain and some researchers feel that psychological factors are more potent than
biomechanical or biomedical factors. (37) There is a consensus that management of the
chronic low back pain patient should be aimed at restoring normal function and
behaviour. (2;51)
Sufficient evidence on the effective management of chronic low back pain is still lacking.
(56) Knowing the normal time frames for recovery from an acute episode of LBP can
help identify those with psychosocial risk factors of chronic pain and this in turn can alert
the therapist to the need for referral. All patients who have not regained usual activity
after four weeks should be receive a full reassessment and this should be done again at
six weeks. The assessment should include retaking the history and examination, looking
for Red or Yellow Flags, neurological deficit and any evidence of systemic disease.
Treatment providers must consider whether continuing treatment will accelerate recovery
or simply prolong the ‘traditional’ medical model. (10) Passive treatments are not to be
continued after 12 weeks in low back pain with no radiating symptoms. (31)
Advice to Stay Active and to Avoid Bed Rest
There was no evidence in the literature about treating chronic back pain with bed rest.
(58) The consensus view is that bed rest is contraindicated in chronic low back pain
without neurological symptoms. The consensus of the Paris Task Force in 2000 was that
bed rest must not be prescribed, and it must be stopped in patients still resting in bed at
this stage. Total inactivity may cause back pain (41), lead to muscle wasting,
deconditioning and impact other health conditions.
The maintenance or progressive resumption of activities of daily living is recommended
in chronic cases.
Individuals who have back pain reduce their activity for periods the duration of which
depends on the intensity of pain, the nature and intensity of their normal activities, and
their psychosocial and occupational environments. The longer this period lasts, the
greater the risk of the condition’s becoming chronic. (41)
Activities of daily living recommendations also apply to occupational activity. Patients
should maintain or resume their work activities as far as the pain allows. The probability
of returning to work is approximately 50% after six months of work absence and is
approximately 30% after an absence of one year. (41) A large majority of persons with
chronic back pain continue working and this information might be a motivator for some
patients. (10)
Promote Exercise
Eight systematic reviews found that exercise therapy improved pain and functional status
more than other treatments. There was no evidence that one type of exercise was more
efficacious than another (flexion, extension, or fitness). (31;51;58) Exercise was not
shown to be helpful for the chronic pain group with pain radiation down to a precise and
entire leg dermatome. (41)
There is strong evidence that exercise therapy is more effective than usual care by
GPs and that exercise therapy and conventional physiotherapy (consisting of hot
pack, massage, traction, mobilization, shortwave diathermy, ultrasound
stretching, flexibility and coordination exercise, electrotherapy) are equally
effective. (51)
In patients with chronic low-back pain, physiotherapy, specific conditioning with training
devices, and aerobics were similarly effective for reducing the pain- intensity score and
pain frequency. The aerobics and devices groups maintained their post-treatment
reductions in disability at 12 months of follow-up, but the physiotherapy group did not.
(61) The physiotherapy group received instruction on ergonomic principles and home
exercises, the aerobics performed low impact aerobics and the machines group used
specific trunk muscle reconditioning machines.
There is scientific evidence indicating that programs should combine strength training,
stretching, and/or fitness. (41) In patients with sub acute or chronic mechanical low-back
pain, a community exercise program improved functional and clinical status at 12
months. The program consisted of stretching, low impact aerobics and strengthening
exercises aimed at all main muscle groups. Cognitive behavioural principles were used to
promote self reliance. (52) Three months of gym workouts were shown to reduce pain
and improve spinal and muscle flexibility significantly more than a home exercise
program. Both aerobic exercise and flexion exercise carried out for three months reduced
the pain score significantly. Three-month trunk muscle function training was effective in
reducing pain and disability and improving lumbar endurance compared to passive
treatment consisting of thermal therapy and massage. (62)
A well-designed randomized controlled trial by Mannion et al (2001) investigating
exercise for low back pain showed that improved muscle fatigability and strength were
not explainable on the basis of structural changes within the muscle. These changes may
appear to be due to changes in neural activation of the lumbar muscles and psychological
changes such as motivation or pain tolerance. (63) Further research is warranted to
investigate the impact of various techniques believed to influence muscle recruitment
patterns, patient motivation and pain tolerance.
Further research is also necessary to clarify if different types of exercises are effective in
managing different types of biomechanical problems.
Massage Therapy for Chronic Low Back Pain
There is moderate evidence indicating that massage is beneficial in reducing pain
intensity and improving function for patients with chronic low back pain; the beneficial
effects are long lasting (at least one year after end of sessions). (45) In patients with
chronic low back pain, the massage was more effective on improving symptoms and
function when it was combined with exercise and education. (13;58)
More studies are needed to assess the impact of massage on return-to-work, and to
measure the longer term effects. Research is also needed to determine the costeffectiveness
of massage as an intervention for low back pain. (45)
In a trail by Cherkin (2001), massage was found to be an effective short term
treatment for chronic low back pain, with benefits that persist for at least one
year. The study used Swedish, deep tissue, neuromuscular and trigger and
pressure point techniques for chronic LBP. After 10 weeks of treatment significant
treatment effects that favoured massage emerged. The massage treatment group
had a lowered use of medications. The study found that deep tissue massage was
the most helpful treatment for back pain. (46)
The effectiveness of massage therapy could be explained by several related factors:
• being touched in a therapeutic context; stimulation of the limbic system and the
production of endorphins
• relaxing for an hour in a quiet environment
• effects of the soft tissue manipulation on the structure and function of the
tissues and on pain sensation
• providing a opportunity for focussed education about exercise or other lifestyle
changes
• receiving ongoing attention and care
The long term effects of a short course of treatment could translate into lower total
medical care consumption for massage therapy patients, making this intervention both
efficient and effective. (46)
Prevention
There is strong evidence that exercises are an effective preventative intervention. There is
strong evidence that back schools and lumbar supports were not effective in the
prevention of low back pain. (2)
More research is needed to assess effective prevention practices and to decide when they
should be begun. There was no good quality evidence on the effectiveness of ergonomic
or modification of risk factors. (78)
In spite of the lack of evidence, some common recommendations include:
• weight reduction of obese patients
• maintaining good posture
• taking breaks
• changing position often
• reducing the demands on the back
• using good lifting techniques (especially avoiding lifting and twisting)
• quitting smoking
• wearing of soft soled shoes with low heels
• having fit and flexible back muscles (20)