Low back pain ( LBP) effects the majority of the population at some time in their lives. With the exception of vertebral fractures, the exact cause of LBP is often difficult to identify. It could be said, the high water mark of therapist folly is to predict definitive cause of the patients’ central back ache!
The compact anatomy around the spinal cord, makes it difficult to determine which pain producing structure is the culprit. These may include, ligaments, joints and invertervertebral discs .
Another area of LBP, although not strictly the lumbar spine, is the Sacroiliac joint (SIJ). This structure involves the pelvic/hip area. Pain radiating from this may mimic pain from the lumbar spine. The spinal assessment should attempt to differentiate these areas.
MANAGEMENT
The management of LBP, like other musculoskletal injuries is multi modal. Although manual therapy may help to relieve or eliminate the acute onset, statistically 50% of patients have at least one recurrent episode. Exercises, especially for the inner core muscles are important. More general exercises involving large range of movements are important to avoid stiffness. Assessment of muscle lengths(Hamstring, Piriformis, hip flexors ) may necessitate a muscle stretching programme. Sometimes over looked are life style changes. Assessment of work practices, activities of daily living, home and work office ergonomics may identify small but significant risk factors. e.g. Loading a toddler into a centre booster seat may significantlystrain the lower back. A school back pack weight may exceed the recommended maximum of 10% body weight. Small changes can have a significant effect.
Summary:
The diagnosis and management of LBP is complex and sometimes misunderstood. It is not a simple matter of taking an X-Ray or MRI scan to clarify diagnosis. Statistically, 25% of asymptomatic (pain free) under 60 year olds show disc herniations (slipped disc) on MRI scan. After the acute stage and when pain free, self management strategies acquired during the formal treatment sessions assist with long term management and prevention.
References:
Clinical Sports Medicine Brukner and Khan 4th Edition
Hodges PW Richardson CA. Inefficient muscular stabilisation of the lumbar spine
Associated with low back pain. A motor control evaluation of transverse abdominis.
Spine (phila Pa 1976) 1996;21 (22)
Nikolai Bogduk Innervation, Pain Patterns and Mechanisms of Pain Production
Chapter 3 Physical Therapy of the Low Back edited by Lance T. Twomey James R. Taylor