Treatment Methods for Lower Back Pain
by M. Gaudry, MD.

Introduction

Pain in the lower back region, is a very common ailment in Australian society, and it has been suggested that at some time in their lives, up to eighty percent of the world’s population will suffer some form of back pain. ^6,9,12,14. The wide-spread incidence of back dysfunction and pain constitutes a major public health crisis - it accounts for half the worker’s compensation payments in the United States and Australia, is the single greatest cause of lost work time in both these countries, and costs $8,000 million annually in the United States. ^4,6,12,13. Besides the economic cost derived from back pain, there also exists personal costs, such as the excruciating pain, anguish and limitations of lifestyle, and also social costs, as back pain represents the most frequent cause of inactivity among people under 45 years of age.^6,12,13

Lower back pain (LBP), in particular, is one of the most common symptoms that results in physician visits. It has been estimated that between one quarter and one half of patients treated by physical therapists in acute care hospital, private office, and outpatient physical therapy clinics suffer from LBP. ^1,8. No one is immune to the risk of LBP, and men and women are equally affected. ¹². The enormity of the problem with LBP is not endured by sufferers alone, however, but also by those people in society who deal with the sufferers, such as doctors, physiotherapists and chiropractors. Despite the high prevalence of LBP, it is often difficult for these people to not only pinpoint the exact cause of the problem, but also to treat it. ^1,5,7,14. Because of the limited knowledge of the specific conditions underlying most back symptoms, there has been a failure to develop a universal specific treatment of LBP. ^1,3,7. Indeed, many methods have been adopted by people in various therapeutic fields to treat back pain, but controversy exists as to which method is the most effective. ^1,7. It is therefore important to understand the difficulty and uncertainty involved in diagnosing and treating LBP.

LBP occurs in the spinal column, which is a complex system of interlocking working pieces. The bones, or vertebrae, that make up the spinal column, are separated by disks and held together by ligaments and supporting muscles. The basic unit of the spine consists of two vertebrae and a disk. The disk acts as a shock absorber and supports and distributes the weight of the body. Two small joints, known as apophyseal joints, guide the movement in your back. Ligaments bind the vertebrae together and give additional strength to the disks and joints of the back. Muscles produce and control movement of the spine, and are an important source of strength and support to the back. ^9,11

Because the spine is such a complex structure, many things can go wrong. Injuries can occur to disks, joints and ligaments due to acute trauma, poor postural habits, and the accumulation of physical stress on the spine. ^9,10,11. It has been suggested that several factors can predispose people to the development of LBP. Smoking is one reason given, due to the fact that smoking can lead to coughing, which increases pressure on the disks, as well as causing a reduction in vertebral body blood flow, which has a negative affect on the nutrition of the disks. ¹². Occupation can also be a risk factor in the development of LBP, especially for those who work in positions that involve excessive vibrating movements (eg, crane workers), or positions that involve very little movement (ie, sedentary occupations). The risk of LBP in the latter of these classifications, may be due to either an increase in intradiscal pressure in the seated position, when compared to the standing position, or to the fact that sedentary occupations are at a greater risk of muscle atrophy, as they lack any form of exercise on the job. Any other occupation that involves lifting, bending and twisting are also subject to LBP ¹². Other risk factors include obesity, drug abuse, aging, and it has even been suggested that genetics may predispose individuals to LBP. Eighty-five percent of whiplash patients also develop LBP within one year of their original injury. ^12,13

Even though the exact causes of back pain are often hard to determine, backache is usually linked to problems arising directly within the spine. These problems can be classified into four main categories:

1. Structural Change - This can be a sudden mechanical problem such as in a prolapsed intervertebral disc (often referred to as a slipped disc) or it can result from general ‘wear and tear’, or postural imbalances within the body. Also, occasionally people are born with mechanical abnormalities of the spine.

2. Inflammatory Disease - Inflammation occurs in the spine and may affect the joints in a way similar to that of rheumatoid arthritis. Inflammation may also be a result of an infection.

3. Bone Disease - The structure of the bone is weakened, which results in back pain.

4. Tumors - Growths of varying kinds occur in the spine causing spinal damage and pain.¹¹

It has been suggested that less than 3 percent of cases are associated with serious medical diseases (categories 2,3 and 4), and that almost all cases of low back pain are mechanical in origin (category 1).^8,13. In one study, it was found that therapists viewed disk problems as the main underlying cause of LBP, closely followed by muscle strains. ¹. Another study indicated that unexpected loading of the lumbar region of the spine, relative to the posture of the individual at that time probably causes many of the occurrences of back pain. ^10,13. Because of the complexity in assessing mechanical causes of LBP, the Quebec Task Force on Spinal Disorders proposed a classification scheme for low back disorders. This scheme is based on anatomic distribution and duration of pain. The classification system allows therapists involved in the treatment of back pain, to more easily determine the cause of back pain, and to subsequently develop a rational treatment plan. ^7,8

Rather than going into great detail as to the causes of LBP, this review of literature deals primarily with the treatment of LBP resulting from mechanical changes in the spinal column. In this respect, it analyses the treatment methods adopted towards solutions to the problems of mechanical LBP, rather than focusing on the problems of causality.

Treatment methods of LBP

Because of the uncertainty that exists in the diagnosis of LBP, it is difficult to determine the relative efficacy of various treatments. However, each of the treatment methods presented below, outline some independent studies discussed in this review of literature, which may provide more insight relating to this issue

Although education in back care can not be classed as a treatment for LBP per se, it can be seen as a preventative measure to the problem. ¹³ One study indicated that education in relation to proper body mechanics for activities of daily living, was actually one of the most common treatment preferences among therapists.¹. Another study suggested that an educational and practical system for low back health be developed, based entirely on biomechanic, anatomic and kinesiologic principles. The purpose of such a system would be geared towards prevention of back pain and also the understanding of the mechanics and anatomy of the spine would assist in recovery. ¹³

Bed Rest
Bed rest was, for many years, the mainstay of treatment in patients suffering from acute back pain, but it has clearly decreased in popularity, and early activity and exercise are now being promoted. ^{1, 3,12,14} It is a well known fact among back pain therapists that lying flat will decrease intradiskal pressure, however, it is perhaps not quite so well known that lying on one side increases intradiskal pressure, almost to the level occurring in a standing position. Thus, if bed rest is to be effective in the treatment of LBP, the sufferer should lie flat in a supine position.⁸

The optimal duration of bed rest also remains unclear. One study showed that patients with acute LBP who were given bed rest for only two days, returned to work 45 percent faster than patients who were on bed rest for longer periods. In addition to this revelation, other disadvantages attributed to prolonged bed rest include rapid muscle atrophy, reconditioning and an increased risk of thrombophlepitis.⁸ Furthermore, people who suffer musculoskeletal difficulties, may benefit from motion and early mobilisation, which again supports the concept of limited bed rest, and the need for a more dynamic approach in the treatment of LBP. ^3,8,12

Medication
Because most LBP is due to mechanical inefficiencies, drugs are effective in pain reduction, but seldom do they improve the underlying problem.^8,12 The main drugs used for treatment of back pain problems - nonsteroidal anti-inflammatory drugs, muscle relaxants and antidepressants - also have their other drawbacks Nonsteroidal anti-inflammatory drugs relieve back pain quite effectively, but their long-term use may lead to gastrointestinal and other problems. Muscle relaxants generally provide a sedative effect, rather than relaxing the muscles in the problem area, and are a only a short-term cure as they can only be prescribed for about a week. Antidepressants may provide some pain relief, particularly for chronic LBP, but again, the solution is only short-term, as these drugs should only be used for a maximum of one week to avoid patients developing a dependency.^8,14

Physical Therapy
Although physical therapy has been used for many years as treatment for LBP, research has not supported many of the methods used. ¹². There is no evidence that supports the theory that relaxation techniques such as ultrasound and deep heat provide any long-lasting benefits, although they may give brief relief of pain. There is also little evidence to show that traction has any benefit. Traction involves creating negative pressure in the disk, and requires the application of heavy weights, which may not be well received by a back pain sufferer. Back braces are also used for the treatment of LBP, but there is no support to their efficacy.^8,14

There was little evidence to support the use of ice as modality of physical therapy in the treatment of LBP. One study, however, stated that ice was the treatment recommended most often for acute LBP associated with sciatica. ¹ Other studies stated that hot/cold pack therapy did not produce a significant effect on LBP level.^5,14

Exercise
A higher incidence of back injuries occur in people who are less physically fit, and it has therefore been suggested that increasing strength and flexibility in the region of the back helps to protect against low back injury.^8,14 According to one study, stretching and strengthening exercises, along with aerobic exercises are among the most common treatment preferences used by therapists. ¹. Initially, trunk flexion exercises were used to reduce pain, but later studies showed that focused exercises which included both trunk extension and trunk flexion movements, provided greater improvement than the flexion exercises alone.⁸

In contrast, some studies ^4,9 have compared the effectiveness of various trunk flexion exercises, and have come to the conclusion that they are beneficial, mainly as a preventative measure to LBP. One study, in particular ⁴, looked at myoelectric activity in the low back muscles, as well as in selected abdominal and hip flexor muscles across different variations of the sit-up. This study supported the view that such exercises may be beneficial in reducing the likelihood of an individual acquiring back pain, but if performed incorrectly, may actually contribute to LBP. Thus, when performing variations of the sit-up, it is important that caution and correct technique are exhibited. ⁴

Another study looked at the effectiveness of using a systematically applied, aggressive stretching manoeuvre as an add-on treatment to a physical conditioning program, in the treatment of chronic LBP patients. Based on the results from this study, it was found that muscle stretching provided immediate gains, as well as cumulative gains in myoelectric activity, muscle force produced, and ranges of motion, and contributes to reduction in pain level. These gains also contributed to the patients physical abilities, as indicated by a significant increase in strength to the region of the lower back. Thus, it was concluded that the particular stretching exercises used for this study was a good form of treatment for the rehabilitation of LBP sufferers. ⁵

A particular type of exercise procedure, known as Mckenzie exercises, are thought to be relatively effective in the treatment of LBP. This method of treatment is said to be the most popular approach used by therapists for managing patients with back pain. ¹ These exercises consist of three stages, and use repetitive directional tests of range of motion of the back, to determine the location of a presumed disk protrusion, by the effect of these movements on leg and back pain.⁸

The beneficial effects of exercise treatment for LBP in one study, showed that a supervised fitness programme helped to reduce pain and disability, as well as improve patients’ confidence in carrying out their normal day-to-day activities (which are often a painful burden to the LBP sufferer). The same study also pointed out that such treatment is relatively cost-effective, compared to other forms of treatment. However, one pitfall of this type of treatment that was highlighted in this study was the motivation and compliance of patients to perform the various exercises when unsupervised. ³

Manipulation
Manipulative therapy, performed primarily by chiropractors, is used to help "restore maximal pain-free movement of the musculoskeletal system in postural balance."⁸ In other words, the goal of manipulative therapy is to correct the joint dysfunction, in the problem areas axes of rotation. ¹² The use of manipulation has been criticised because it involves passive intervention, but at least one study has shown that patient management can be expediated if manipulative treatment is used in the initial phases of treatment. ² Despite a course of chiropractic treatment taking longer than traditional medical treatment, it has also been shown that the benefits of chiropractic treatment for patients with chronic LBP are better and longer lasting than those derived from traditional treatments.⁸ One particular study, which looked at the relative effectiveness of an extension program and a manipulation program with flexion and extension exercises in patients with LBP, suggested that the use of manipulation as an adjunct to an ongoing exercise program was warranted. Rapid improvement was found only when treatment included the manipulative procedure (used in the study), and not with the extension program alone. ²

Besides the apparent pain-reducing benefits of manipulative therapy, another study has pointed out that this form of treatment is relatively low cost compared to other forms of treatment. ¹². This is undoubtedly a major benefit to the LBP sufferer who depends on some form of treatment, especially when other forms of LBP treatment are usually accompanied by ever-increasing costs.

Injections
Injection therapy has failed to be supported as an effective treatment for LBP, and trigger-point injection therapy has not been studied widely, so remains a matter of controversy. ⁸. Epidural injections, on the other hand, have been used successfully for many years, and although some researchers question the efficacy of epidural injections, others have reported short-term improvement using this treatment method on LBP sufferers.⁸

Surgery
Surgery for sufferers of LBP has been met with some controversy, as it is believed that only a small percentage of sufferers are real candidates for this type of treatment. It is generally considered that surgery should be used as a last resort when dealing with mechanical back pain problems, and that conservative treatment options should be tried even before a surgical consultation is considered.⁸

Therapeutic aquatics
Only one study in this review of literature focused on the use of rehabilitation aquatic exercises in the treatment of LBP. ¹⁴. The results from this study indicated that rehabilitation aquatic exercises and modified swimming strokes can significantly improve the strength and flexibility of the major muscle groups of the trunk and lower extremities, but does not significantly decrease the feeling of pain in LBP sufferers. It was suggested that the physiological benefits of exercise can counter the effects of muscle atrophy. As indicated earlier, this may indirectly be beneficial in preventing the onset of LBP.

Other Forms of Therapy
Other forms of treatment for LBP have been tried, but few studies conducted to test their efficacy, so they remain not very well understood. These treatments include the use of orthotics (to correct a short-leg gait problem), massage therapy, acupuncture and neural therapy.⁸

Summary

This review of literature has looked at some of the methods that have been used in the treatment of LBP. It has highlighted the fact that back pain is a major health problem, which carries an enormous economic, personal and social cost. LBP can affect any person in society, either directly, or indirectly. Despite these pitfalls, no universal treatment has been devised to counter the effects of LBP. Therefore, the treatment of LBP has been a burden and frustration to those who suffer from the problem, as well as to those people involved in LBP treatment.

From the treatment methods that have been reviewed, it appears that stretching, strengthening and aerobic exercises (such as the McKenzies method) appear most useful in the management of individuals suffering from LBP. Some support towards manipulative therapy was also given.

BIBLIOGRAPHY

1. Battie, M.C., Cherkin, D.C., Dunn, R., Ciol, M.A. and Wheeler, K.J. 1994. Managing low back pain: attitudes and treatment preferences of physical therapists. Physical Therapy. 74(3). pp 219-226.
2. Erhard, R.E., Delitto, A. and Cibulka, M.T. 1994. Relative effectiveness of an extension program of manipulation and flexion and extension exercises in patients with acute low back syndrome. Physical Therapy. 74(12). pp 1093-1100.
3. Frost, H., Klaber-Moffett, J.A., Moser, J.S. and Fairbank, J.C. 1995. Randomised controlled trial for evaluation of fitness programme for patients with chronic low back pain. British Medical Journal. 310(6973). pp 151-154.
4. Hall, S.J., Lee, J. and Wood, T.M. 1990. Evaluation of selected sit-up variations for the individual with low back pain. Journal of Applied Sport Science Research. 4(2). pp 42-46.
5. Khalil, T.M., Asfour, S.S., Martinez, L.M., Waly, S.M., Rosomoff, R.S. and Rosomoff, H.L. 1992. Stretching in the rehabilitation of low-back pain patients. Spine. 17(3). pp 311-317.
6. Laughlin, K. 1996. Overcome neck & back pain. p1. Little. P., Smith, L., Cantrell, T., Chapman, J., Langridge, J. and Pickering, R. 1996. General practitioners’ management of acute back pain: a survey of reported practice compared with clinical guidelines. British Medical Journal. 312(7029). pp 485-488.
7. Margo, K. 1994. Diagnosis, treatment and prognosis in patients with low back pain. American Family Physician. 49(1). pp 171-179.
8. Minikin, B. and Crawford, D. 1990. Physical exercises for conditioning the muscles of the trunk with a view to preventing pain in the region of the lower back. Sports Coach. 13(2). pp 12-16.
9. Omino, K. and Hayashi, Y. 1992. Preparation of dynamic posture and occurrence of low back pain. Ergonomics. 35(5-6). pp 693-707.
10. Oppedisano, R. 1994. How to heal a bad back. pp 9-10.
11. Pustaver, M.R. 1994. Mechanical low back pain: etiology and conservative management. Journal of Manipulative Physiological Therapy. 17(6). pp 376-384.
12. Segal, D.D. 1983. An anatomic and biomechanic approach to low back health. A preventive approach. Journal of Sports Medicine and Physical Fitness. 23(4). pp 411-421.
13. Woods, D.A. 1989. Rehabilitation aquatics for low back injury: functional gains or pain reduction? Clinical Kinesiology