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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)

 

 

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