Lower Back Pain

Non-specific Lower Back Pain: Movement is Medicine

Lower back pain (LBP) is the most common physical disability effecting people worldwide and is the second most prevalent complaint received at medical practices, second to only the common cold. The high incidence of LBP creates a problem that has a vast impact not only on the health of the individual but also places strain on healthcare resources, work/business performance and the financial system.  On an individual level, LBP can have a detrimental effect on all aspects of a person’s life including their physical capacity, psychological wellbeing, social connections and quality of life.

Non-specific lower back pain (NSLBP) is a subcategory of lower back pain and makes up the majority of cases that present in GP and allied health clinics.  It is estimated that approximately 8-15% of all clinical presentations of lower back pain can be attributed to a patho-anatomical diagnosis and therefore are deemed “non-specific” in nature.  

So, what does the research say in terms of optimal treatment for NSLBP?

The answer in short, is a holistic, patient centred approach aimed at improving physical and psychological wellbeing through a combination of education, activity and movement modification, exercise and manual therapy that takes into consideration a patient’s goals, lifestyle, occupation and personality type. When you break it down, it really does come down to promoting one thing – movement.

    1. Preventing a decline in movement or the development of poor movement patterns/behaviours.

    2. Finding ways in which we can maintain movement, engagement and participation in the key roles of the patient’s life.  

    3. Improving strength and movement to allow for a return to pre-injury capacity.

Education:

Patient education has become an integral part of rehabilitation of NSLBP with an increased emphasis in the literature on utilising a biopsychosocial model of treating LBP.  Patients with NSLBP often develop negative cognitive behaviours such as fear, avoidance and hypervigilance, which feed into a negative feedback cycle that may cause further exacerbation of the pain and lead to poor movement behaviours. Our job as physiotherapists and allied health professionals is to prevent these behaviours from developing early in the rehab process by clearly informing them about the prognosis of NSLBP, debunking myths and addressing common misconceptions and explaining the importance of exercise and movement in the rehabilitation of LBP.   

Activity and Movement Modification:

NSLBP is a condition that can substantially limit not only the physical capacity but also the social engagement of an individual from significant activities of normal daily living.  This is just as important and even more frustrating to a person than being able to simply touch their toes or not when they walk in the clinic. While an objective measure such as range of motion is significant to us as allied health professionals, the real importance for a patient is whether they can return to their normal work duties or if they can play golf or garden on the weekend.  These types of activities and essential parts of their daily routine play a massive role in not only their physical health but also their psychological wellbeing and overall happiness. There is an opportunity during the early stages of NSLBP to collaborate with patients and modify certain tasks to make them more achievable.  This allows for patients to still be socially engaged and participating in tasks they enjoy which goes a long way in the prognosis of NSLBP.  By developing a clear understanding of what is important in the lives of our patients we can work collectively to develop goals, practice tasks and prescribe exercises that are focused on getting them back to doing what they love in the quickest time possible.

Exercise:

The evidence for exercise and what exercise modality should be performed for the rehabilitation of NSLBP varies within the literature. What is agreed upon universally, is that exercise should be a part of a rehabilitation program for those with NSLBP.  There is evidence to suggest that modalities such as Pilates, core stabilisation/motor control, resistance training and aerobic training can all have positive effects on the management of NSLBP however, the results were highly dependent on the interest of the participant in their chosen method of training allocated within the study.  As allied health professionals, it is crucial that we incorporate exercise as part of the management plan of those with NSLBP but that we also collaborate with our patients and their interests to maximise adherence and the overall outcome.   

Manual therapy:

The use of manual therapy is one that is widely contested and debated within the physiotherapy world with radicalists on either side of the coin.  There is an abundance of literature that basically indicates:

    1. Manual therapy should not be utilised on its own as a treatment modality.

    2. Manual therapy can provide some benefit when used with other methods like education, exercise and activity modification.  

The usefulness of manual therapy practices such as massage and joint mobilisation, lies in their ability to provide therapeutic relief from symptoms which can assist in promoting movement and exercise and also assists in developing a strong therapeutic alliance with the patient.  It’s important we educate and communicate with our patients in regard to the reasoning behind the use of manual therapy in order to avoid an increase in dependent behaviour.  

Key takeaways:

    • LBP is a highly prevalent and can be a highly debilitating injury that effects many aspects of a person’s life.

    • NSLBP is the most common type of LBP that presents to GP and allied health clinics.  

    • Physiotherapy treatment should focus on the combination of treatment modalities such as education, activity and movement modification, exercise and manual therapy.  

    • Treatment should always be patient centred and any treatment plan should be built around the patient’s goals, lifestyle, personality, beliefs/values and behaviours.  

References:

O'Keeffe, M., O'Sullivan, P., & O'Sullivan, K. (2019). Education can ‘change the world’: Can clinical education change the trajectory of individuals with back pain? British Journal of Sports Medicine, 1385-1386.

O'Sullivan, K., O'Sullivan, P., & O'Keeffe, M. (2019). The Lancet series on low back pain: reflections and clinical implications. British Journal of Sports Medicine, 392-393.

O'Sullivan, P. (2012). It's time for change with the management of non-specific chronic low back pain. British Journal of Sports Medicine, 224-227.

O'Sulllivan, K., O'Sullivan, P., & O'Keeffe, M. (2017). NICE low back pain guidelines: opportunities and obstacles to change practice. British Journal of Sports Medicine, 1632-1633.