Lower Back Pain

Low Back Pain

Low back pain (lumbago) is a prevalent health problem worldwide and considered a major cause of disability. At any given time, approximately 1 of every 4 of people in the United States report having low back pain within the past 3 months, with these symptoms often affecting the ability to work and play and ultimately quality of life. It is estimated that 60% to 70% of individuals living in the industrialized world will experience a significant episode of generalized low back pain in their lifetime, with occurrence peaking between the ages of 35 and 55i. The rate of occurrence of lower back pain for children and adolescence is lower that that of adults, however there has been an alarming upward trend in this population. This change may be linked with decreased activity of today’s youth, with a 2010 study reporting adolescents who were less active had lower self efficacy, lower back muscle endurance and a higher incidence of back pain.ii Chronic back pain is thought to contribute to the epidemic of increasing rates of opioid prescriptions written by primary care providers, with approximately 259 million prescriptions written in 2012 aloneiii.

For all those who suffer from low back pain, several risk factors have been identified (including occupational posture, depressive moods, obesity,
body height and age), however the causes of the onset of low back pain can be complex and challenging to diagnose accurately.

CDC:
Physical Therapy, Other Non-Drug, Non-Opioid Approaches Should be First-Line Treatment for Chronic Pain For more information about the risks of opioids and the safe alternative of physical therapy for long-term pain management visit: https://www.apta.org/PTinMotion/News/2016/3/16/CDCFinalOpioidGuidelines/

Diagnosis / Physical Therapy Assessment

Back pain is not a disease but a constellation of symptoms reported by the patient and what’s more, currently there is no reliable correlation between imaging and the source of back painiv. Not only is imaging not necessary in most cases, it results in higher cost for the same outcome. Patients who first received an MRI in effort to diagnose a low back issue prior to being referred to physical therapy spent an average of $4,793 more for their care despite a similar outcome for those who did not have imagingv. Diagnosis of low back pain requires several components to gather information in order to treat appropriately, with imaging used only in conjunction with a thorough history and physical examination. There are multiple potential causes of low back pain as well as associated symptoms such as buttock or lower extremity radiating symptoms (radiculopathy).

Potentially Serious Symptoms

Some associated symptoms may be an indication of a more serious condition. Please visit your local emergency department if you are experiencing:

• Loss of or change in bowel or bladder function
• Numbness in the groin or inner thigh

Symptoms related to low back pain can vary. Symptoms can differ in quality such as dull, sharp or burning. The area involved can be over a small or broad area, and may extend beyond such as into the buttock or legs. Low back pain is classified by behavior and duration of symptoms as well as by specific diagnoses to indicate the contributing anatomy.

Duration of symptoms can be of three types:

Acute: Symptoms lasting less than three months
Recurrent: Acute symptoms that have occurred in two or more episodes
Chronic: Symptoms lasting greater than three months

A specific diagnosis helps to indicate potential sources of symptoms and start on an optimal course of action for reduction of those symptoms. All clinicians use sets of distinct diagnoses worldwide to improve consistency in definitions, these are known as ICD codes (International Statistical Classification of Diseases and Related Health Problems). These diagnoses have a specific corresponding number in order to cross language barriers among the world’s healthcare professionals. Physical therapy is indicated for most categories and diagnoses of low back pain, with interventions aimed at normalization of the patient’s impairments of function.

International Statistical Classification of Diseases and Related Health Problems (ICD)
categories:

• Low back pain
• Lumbago
• Lumbosacral
• segmental
• dysfunction
• Low back strain
• Spinal instabilities
• Lumbago due to
• displacement of
• intervertebral disc
• Lumbago with
• sciatica
• Pain in body part
• specified as pain in
• buttock, groin and
• thigh

Differential Diagnosis
Not all low back symptoms stem from anatomical structures of the spine or are orthopedic in nature. Serious conditions such as cancer or organ dysfunction can also result in low back pain. Therefore physical therapists consider all diagnostic possibilities including those associated with serious medical conditions or psychosocial factors. Physical therapists are trained to initiate referrals to appropriate medical practitioners when physical therapy is not indicated or a more insidious condition is suspected.

Examination
Your physical therapist will perform a thorough evaluation that includes:
• A review of your health history
• Questions about your specific symptoms
• Questions regarding your view on limitations caused by your symptoms
• Assessment of the quality and quantity of your movements, and any movement
• Tests and measures to identify causative factors or signs or symptoms that could indicate a serious health problem, such as broken bones or cancer
• Outcome measures which may use validated self-reporting questionnaires such as the Oswestry Disability Index and the Pain Disability Index

Once your examination is complete, your physical therapist will assess the results, identify the factors that have contributed to your specific back problem, and design an individualized treatment plan for you.

Intervention
Physical therapy was born of the medical profession more than a century ago and utilizes evidence-based practice to efficiently address issues such as low back pain. Treatments are tailored to your specific issues as assessed in examination and may include manual therapy techniques such as spinal, peripheral joint and soft tissue manipulation. Treatment may also involve modalities such as electrical stimulation, exercise, traction and training/education depending on your situation. Treatments used by physical therapist have undergone strenuous review through research to establish effectiveness.

As research evolves, building on previously understood causes and concepts, new evidence is discovered. Not all research and conclusions are of the same statistical power and impact. The resulting evidence from amassed research is graded in a recognized system of hierarchy. Active Lifestyles Physical Therapy is apprised of the most efficacious treatments available today for low back pain. Interventions are employed depending on the acuity and behavior of symptoms as well as the structures involved as discovered through examination. The treatment modalities chosen are based on evaluation findings, your values and goals as well as current legitimate research and the level of evidence.

Differential Diagnosis
Not all low back symptoms stem from anatomical structures of the spine or are orthopedic in nature. Serious conditions such as cancer or organ dysfunction can also result in low back pain. Therefore physical therapists consider all diagnostic possibilities including those associated with serious medical conditions or psychosocial factors. Physical therapists are trained to initiate referrals to appropriate medical practitioners when physical therapy is not indicated or a more insidious condition is suspected.

Examination
Your physical therapist will perform a thorough evaluation that includes:
• A review of your health history
• Questions about your specific symptoms
• Questions regarding your view on limitations caused by your symptoms
• Assessment of the quality and quantity of your movements, and any movement
• Tests and measures to identify causative factors or signs or symptoms that could indicate a serious health problem, such as broken bones or cancer
• Outcome measures which may use validated self-reporting questionnaires such as the Oswestry Disability Index and the Pain Disability Index

Once your examination is complete, your physical therapist will assess the results, identify the factors that have contributed to your specific back problem, and design an individualized treatment plan for you.

Intervention
Physical therapy was born of the medical profession more than a century ago and utilizes evidence-based practice to efficiently address issues such as low back pain. Treatments are tailored to your specific issues as assessed in examination and may include manual therapy techniques such as spinal, peripheral joint and soft tissue manipulation. Treatment may also involve modalities such as electrical stimulation, exercise, traction and training/education depending on your situation. Treatments used by physical therapist have undergone strenuous review through research to establish effectiveness.

As research evolves, building on previously understood causes and concepts, new evidence is discovered. Not all research and conclusions are of the same statistical power and impact. The resulting evidence from amassed research is graded in a recognized system of hierarchy. Active Lifestyles Physical Therapy is apprised of the most efficacious treatments available today for low back pain. Interventions are employed depending on the acuity and behavior of symptoms as well as the structures involved as discovered through examination. The treatment modalities chosen are based on evaluation findings, your values and goals as well as current legitimate research and the level of evidence.

Get Active Stay Active

Author: Christopher Harper, PT, DPT, OCS
July 2016

References

i Al Mazroa, Mohammad A. Years lived with disability (YLDs) for 1160 sequelae of 289
diseases and injuries 1990-2010: a systematic analysis for the Global Burden of Disease
Study 2010. Lancet, 2012, 380(9859):2163- 96. doi: 10.1016/S0140-6736(12)61729-2.
Erratum in: Lancet, 2013, 381(9867):628.

ii Anne J. Smith, PhD, et al. The Relationship Between Back Muscle Endurance and Physical,
Lifestyle, and Psychological Factors in Adolescents. J Orthop Sports Phys Ther
2010;40(8):517–523. doi:10.2519/jospt.2010.3369

iiiPaulozzi LJ, Mack KA, Hockenberry JM. Vital signs: variation among states in prescribing
of opioid pain relievers and benzodiazepines—United States, 2012. MMWR Morb Mortal
Wkly Rep 2014;63:563–8. PubMed

iv Maus T. Imaging the Back Pain Patient. Phys Med Rehabil Clin N Am. 2010
Nov;21(4):725-66. doi: 10.1016/j.pmr.2010.07.004.

v Fritz JM, Brennan GP, Hunter SJ. Physical Therapy or Advanced Imaging as First
Management Strategy Following a New Consultation for Low Back Pain in Primary Care:
Associations with Future Health Care Utilization and Charges. Health Serv Res. 2015
Dec;50(6):1927-40. doi: 10.1111/1475-6773.12301. Epub 2015 Mar 16.

vi Anthony Delitto, PT, PhD et al. Low Back Pain: Clinical Practice Guidelines Linked to the
International Classification of Functioning, Disability, and Health from the Orthopaedic
Section of the American Physical Therapy Association J Orthop Sports Phys Ther.
2012;42(4):A1-A57. doi:10.2519/jospt.2012.0301