// Common injuries - Low back pain
by Paul Wright
Low back pain is one of the most common reasons for attending a
physiotherapy clinic or doctors’ surgery, with some reports indicating
that over 70 per cent of people will, at some stage, suffer from pain
in this area of the body.
Low back pain is also a recurrent problem in the health and fitness industry; many exercising patients report suffering from low back pain following a heavy weight training session or group exercise class, and some even feel a sudden pain when returning weights to the rack.
CAUSES OF LOW BACK PAIN
As a clinical physiotherapist it is often difficult to determine the exact physical cause of a patient’s pain, which is why the issue of low back pain is often shrouded in controversy and open to many different interpretations and solutions.
In their excellent text Clinical Sports Medicine (a must for every health professional’s library) Brukner and Khan note that there are only a small number of low back pain conditions that can be definitively diagnosed, and these include:
a) Fractures – especially following some sort of trauma or accident where the fracture can be clearly seen using imaging methods such as
X-ray, MRI and CT.
b) Nerve Root Compressions – in these cases the patient complains of sharp pain radiating down the leg in a specific distribution that reflects the actual nerve root that is being compressed or damaged. The patient may also have sensory changes such as numbness and/or muscle weakness and reflex reductions.
However, these two conditions are relatively rare and account for less than ten per cent of the overall number of patients that present with significant low back pain. Many experts now group the remaining 90 per cent or more of low back pain sufferers using the diagnosis of ‘non-specific low back pain’ or ‘somatic low back pain’.
WHERE DOES THE PAIN COME FROM?
If we can assume that for more than 90 per cent of patients the medical profession is not able to come up with an accurate or reliable diagnosis, then the question arises ‘where does the pain actually come from?’ Here are a few possible pain sources in the low back:
• the apophyseal (facet) joint at the rear of each spinal segment
• the capsule that surrounds each facet joint
• the ligaments that secure each vertebral body to the one above and below
• any of the small muscles linked to each spinal level
• bone bruising and damage
• the nerve endings and blood vessels in the low back
• the intervertebral disc between each spinal segment (it was originally thought that the intervertebral disc itself had no pain-sensitive nerve endings, however, nerve endings are now thought to be in the outer one third to one half of the disc).
With such a large number of possible structures that can cause pain – and the difficulty in accessing these specific structures during physical examination – it is easy to see why exact diagnosis is often not possible.
Even though it is often difficult to determine an exact clinical diagnosis in many cases of back pain, the therapist must complete a comprehensive physical examination and subjective history to allow for the instigation of a successful treatment program. Many successful treatments are based on identifying and correcting functional limitations such as range of motion, strength and correction of pre-disposing factors that led to the injury initially.
Successful management and treatment of low back pain is totally dependent on the quality of the initial examination and assessment, to allow for the correct factors to be addressed in each individual case.
A typical treatment program, as for any injury, will involve the following stages:
1. Initial examination and referral to a qualified medical professional – particularly if the problem involves symptoms such as nerve signs, pins and needles, weakness, reflex changes, bladder and bowel involvement, muscle wasting and referred pain to the legs.
2. Eliminate possible causative factors – these may include posture issues, prolonged sitting with poor ergonomic setup and poor lifting techniques in the gym.
3. Reduce pain and inflammation – this is best achieved with relative rest, finding positions of comfort, taping, bracing, anti-inflammatory medication, heat and gentle manual therapy.
4. Improve and restore full range of spinal motion – this may involve gentle mobility exercises for the back, manual therapy, massage, swimming, walking, cycling and other gentle exercise methods.
5. Restore and improve overall flexibility and strength – this stage involves the correction of specific flexibility issues and improvements in areas such as core control and general strength.
6. Return to full sport and improve overall fitness – this final stage ensures that the patient returns to their chosen sport and fitness activities with reduced chance of re-injury and correction of the initial causative factors.
AN IMPORTANT NOTE FOR FITNESS PROFESSIONALS
The fitness industry has a huge role to play in the rehabilitation and prevention of low back pain. Many experts believe that the increase in incidence of low back pain in the past 100 years has been a direct result of our gradually reducing levels of activity and reduced strength.
The role of the fitness professional is to refer injured clients to qualified health professionals for injury assessment, implement movement programs that improve functional range, address limitations in flexibility and strength, and encourage increased activity levels for all.
Paul Wright, BAppSc (Physio), DipEd (PE)
Paul is the owner of Get Active Physiotherapy with clinics in St Leonards (Sydney) and Kotara (Newcastle). He has
recently released ‘Core Stability and The Better Back Program’ DVD. Network members who order this DVD will receive
the ‘Lumbar Spine Injury Prevention’ DVD for FREE. To preview and order, visit www.getactivephysio.com.au where you
can also download Paul’s Injury Prediction for Health Professionals e-book, or call Get Active on 02 9966 9464 for more
NETWORK MAGAZINE • WINTER 2009 • PP57-58