Mechanical Low Back Pain Treatment & Management

Physical Therapy

The treatment program for mechanical low back pain (LBP) must have specific functional goals and can be outlined in the following 6 steps:

• Control of pain and the inflammatory process - Pain treatment should be initiated early and efficiently to gain control. Ice, transcutaneous electrical nerve stimulation (TENS), and relative rest may help with controlling the pain and the inflammatory process. Excessive bedrest, however, may be detrimental by leading to lumbar segment motion, loss of muscle strength, and general deconditioning with blunting of motivation.
• Restoration of joint ROM and soft tissue extensibility - Extension exercises may reduce neural tension. Flexion exercises reduce articular weight-bearing stress to the facet joints and stretch the dorsolumbar fascia. The use of ultrasound therapy may improve collagen extensibility.
• Improvement of muscular strength and endurance - Exercise training can begin after the patient has passed successfully through the pain control phase. The key is to attain adequate musculoligamentous control of lumbar spine forces to minimize the risk of repetitive injury to the intervertebral disks, facet joints, and surrounding structures. Start with isometrics, then progress to isotonic exercises with effort directed at concentric strengthening.
• Coordination retraining - Dynamic exercise in a structured training program maximizes coordinated muscle group activities that lead to postural control and the fusion of muscle control with spine stability.
• Improvement of general cardiovascular condition - Patients are encouraged to remain active and to initiate brisk walking programs, aquatic activities, or use of stationary bicycles/stair steppers. These activities can increase endorphin levels, promoting a sense of well-being, and allow the patient to perform at a higher level of function before perceiving pain.
• Maintenance exercise programs - A home program is developed within the tolerance and ability of the patient in order to encourage continued exercise after discharge from physical therapy.

Sertpoyraz et al compared isokinetic and standard exercise programs for chronic low back pain.^[13] Pain, mobility, disability, psychological status, and muscle strength were measured. Forty patients were randomly assigned to a program that took place in an outpatient rehabilitation clinic. No statistically significant difference was found between the 2 programs with regard to their effect in the treatment of low back pain.

The main goal of physical therapy in persons with acute back pain is not to increase strength but to achieve adequate pain control. No benefit has been demonstrated for strengthening exercises in persons with acute back pain. Exercise should begin with extension exercises in the prone position after lateral trunk shifts and then progress, as tolerated, to prone lying with support. Flexion exercises can be performed only if the patient has no acute dural tension.^{[14, 15]}

The spine should be stabilized using strengthening of segmental muscles followed by the prime movers of the spine (ie, latissimus dorsi, abdominals, erector spinae). Muscle groups should be strengthened in a neutral position to decrease tension on ligaments and joints; this position allows balanced segmental forces between the disks and the zygapophyseal joints and maximizes functional stability with axial loading.

Physical therapy programs should also include positioning the patient to maximize comfort. Loosening of the hamstrings, glutei, gastrocnemius/soleus group, tensor fascia latae, quadriceps group, and hip flexors also contributes to reduction of LBP and effective conditioning.

In a 2004 multicenter randomized trial, patients who were trained in exercises that matched their directional preference (DP) were more likely to achieve immediate, lasting improvement in pain compared with patients who received nondirectional treatment or opposite directional treatment.^[16] Patients using DP exercises were found to have a 3-fold decrease in medication usage. The idea of patient-specific exercises in managing LBP is recognized as controversial by the authors. Using DP to guide patients may improve outcomes in pain, function, and treatment satisfaction.

Jüni et al found that the addition of spinal manipulative therapy to standard care is unlikely to result in relevant early pain reduction in patients with acute LBP.^[17] In a randomized trial involving 104 patients with acute LBP, pain reduction during days 1-14 and at 6 months were similar (P = .13) in patients who received spinal manipulative therapy plus standard care—consisting of general advice and acetaminophen, diclofenac, or dihydrocodeine as needed—and those who received only standard care. Small initial differences in analgesic use diminished over time.

Hill et al in a study from 2011 tested stratified primary care with nonstratified current best practice to determine which was clinically more effective and cost-effective for back pain. Patients with back pain (N=851) were placed in the intervention (n=568) and control groups (n=283). The results indicate that after 12 months, the patients who received stratified care showed an overall increase in their health, as well as healthcare cost savings compared with the control group.^[18]

Yoga can also be an effective treatment for low back pain, a study by Tilbrook et al has determined. In a randomized, controlled study, 313 patients for a 12-week period either attended yoga classes (n=156) or were given the usual care for chronic low back pain (n=157). After 3, 6, and 12 months, the yoga group demonstrated better back function compared with the usual care group.^[19]

A randomized trial of 228 patients compared yoga (n=92), stretching (n=91), and a self-care book (n=45) for alleviation of chronic LBP. The results indicated that stretching classes were the best treatment option in improving function and reducing chronic LBP for at least several months, followed by yoga classes, and then the self-care book. Outcomes were assessed at baseline, 6, 12, and 26 weeks.^[20]

Mechanical low back pain (LBP) is not a life-threatening illness. Unfortunately, it does have a far-reaching impact on medical care expenditures for injured workers. An in-depth examination of the impact of mechanical LBP on the US workers' compensation system, which varies from state to state, is beyond the subject of this article. Many interesting perceptions about mechanical LBP have been noted.

• In studies in which subjects had to answer self-assessment instruments, patients with insurance referrals had poorer self-assessment scores regardless of functional status.
• Among different health care providers, patients rated care and communication, followed by competence, over efficacy of treatment.
• Chiropractors often have been favored over internists and orthopedic surgeons on the basis of their "high touch" approach to treatment.
• Orthopedic surgeons were found to be less restrictive with activities compared with family practitioners.
• In a Dutch study, factors such as better health, better job satisfaction, status as breadwinner, lower age, and reporting of less pain were favorable prognosticators of return to work in individuals who had not been working for more than 3 months. The authors of the study believed that more focus was necessary on the psychosocial aspects of health behavior and job satisfaction.
• Exercise was found to be more effective than usual primary care management.

Surgical interventions for mechanical low back pain (LBP) are the last choice for treatment. Diskectomies are performed in the United States at a rate proportional to the number of spine surgeons in the community. The US rate of surgeries is twice that of Europe, Canada, and Australia and is 5 times the rate in the United Kingdom. Better results occur with open excisions compared with percutaneous diskectomies. Results are best when no workers' compensation or litigation is involved.^{[21, 22]}

Evidence-based clinical practices on selected rehabilitation interventions for low back pain (LBP) have focused on the timing of interventions.

• Acute LBP is defined as pain that does not radiate below the knees with current symptoms that have been present 4-6 weeks or less.
• Subacute LBP is defined as pain that does not radiate below the knees with current symptoms that have been present 4-12 weeks from onset.
• Chronic LBP is defined as pain that does not radiate below the knees with current symptoms that have been present greater than 12 weeks.
• The Philadelphia Panel evaluated the literature on the treatment of LBP and assigned Grades of Recommendation based on the clinical importance of the studies, statistical significance of the findings, and the study design.^[3] Randomized control trials with statistically significant findings were assigned an A grade. Any study design without clinically significant findings but thought to have been worth performing was assigned a D grade. Grades of Evidence were assigned to the various studies. The highest grades were I for randomized control trials and III for the opinions of respected authorities.

  • For LBP of less than 4 weeks duration, the Philadelphia Panel found poor evidence (grade C) to include or exclude therapeutic exercises, traction, ultrasonography, or TENS. Return to work was strongly encouraged.
  • For LBP of 4-12 weeks duration, the Philadelphia Panel found good evidence for the inclusion of therapeutic exercise and manual traction.
  • For LBP of greater than 12 weeks' duration, the Philadelphia Panel found good evidence for the inclusion of therapeutic exercises, therapeutic ultrasonography, and electromyographic biofeedback. These treatments were positive interventions for achieving adequate pain control, increasing functional activities of daily living, and promoting return to work.
• Evidence-based clinical practice guidelines from the American Pain Society (APS) for patients with chronic low back pain describe the use of interventional diagnostic tests and therapies, surgeries, and interdisciplinary rehabilitation.^[23]

  • Practice guidelines for nonradicular pain
    • Interdisciplinary rehabilitation that emphasizes cognitive-behavioral approaches should be considered for patients who fail to respond to usual interventions.
    • Provocative diskography (in which material is injected into a disk nucleus to reproduce the patient's typical pain) is not recommended.
    • Facet joint corticosteroid injection, prolotherapy (stimulation of an inflammatory response through repeated injections of irritant material), and intradiskal corticosteroid injection are not recommended.
    • Degenerative spinal changes and persistent, disabling symptoms should lead to discussion and shared decision-making regarding surgery or interdisciplinary rehabilitation. (The evidence is insufficient to weigh the risks and benefits of vertebral disk replacement in these patients.)
  • Practice guidelines for persistent radiculopathy
    • For patients with herniated disks, the use of epidural steroid injection should be discussed.^[24]
    • For patients with herniated disks and disabling leg pain from spinal stenosis, surgical options should be discussed.
    • For patients with persistent pain after surgery, the risks and benefits of spinal cord stimulation should be discussed.