BACK PAIN AND ITS ASSOCIATED PROBLEMS

This study in the Lancet journal concludes that up to 70% of people will at some point in their life suffer from common low back pain and figures are potentially set to rise due to an ageing population with deteriorating vertebral discs. The same study also highlights low back pain as the foremost reason for work absenteeism worldwide and that it poses a significant financial burden on the individual, their close relatives and governments.

Let’s focus on the individual that walks into your clinic with low back pain for a moment, and the problem-solving that takes place along the road to recovery. The treating physiotherapist has a lot to consider here:

Triage / are they in the correct place: Best done upon initial contact whether the patient calls or fills out a form. For the purpose of this article, let’s assume the patient has no suspected serious pathology or specific pathoanatomical diagnosis.

Red flags: Pertinent to pick up in triage but these are worth reiterating upon initial consultation. They include but are not limited to cauda equina syndrome, unrelenting atypical pain, history of trauma, and patients below the age of 18 or above the age of 50.

Location: The physio considers if the problematic pain is central, unilateral, bilateral, whether it refers to the peripheries and if the dermatomes, myotomes and entire neurovascular system in good order.

Psychosocial factors: As already alluded to, the pain has its own unique origin story but so too does the patient. They have their own health beliefs, coping mechanisms, stressors and the physiotherapist must also be aware that back pain is directly associated with depression.

The onset and pattern of pain are also considered in addition to aggravating and easing factors. 

Although this only represents the first few minutes of an initial assessment with a patient suffering from low back pain, the physiotherapist is already thinking how they will work towards getting this patient symptom-free and back to enjoying a good quality of life. It’s quite clear that it is in our best interest to treat the patient’s symptoms, but also provide education and tools to help them stay healthy post-discharge.

Let’s now assume this patient is usually active and enjoys daily walking and a little recreational sport. Your physical examination findings may include pain on palpation of the paraspinal muscles, altered biomechanics in addition to some positive special tests. You carry out some evidence-based treatments including manual therapy and any adjuncts you feel are clinically reasoned alongside some focused rehabilitation and after a couple of sessions the patient is better.

Typically, the patient thanks you for your help and goes back to their usual activity. They feel good and move good but report being “a bit unfit” and remain unsure how to increase the level of activity so just get back into things “bit by bit”.

This again, poses another problem as patients are understandably wondering how much is too much as they’ve been told they need to get strong but not overdo things. Where’s the sweet spot? We owe it to our patients to clear this matter up or at least provide them with tools to navigate part of the journey.

This process can be improved by either subjectively or objectively measuring the patient outcomes. One approach is to have patients utilise a diary to measure their sleep, recovery, and soreness etc. on a daily basis to pick up on injury risk factors. This approach certainly works well (see here for an example) in elite sports teams with access to monitoring software and the coaches and medics overseeing compliance.

Another approach is to objectively measure the patient’s rehabilitation performance from start to finish and show them how well they are progressing via numbers. While the evidence regarding changes in morphological factors such as muscular and postural control due to low back pain is limited, this journal review concludes that physical reconditioning should be part of the rehabilitation programme. The “cherry-on-top” ingredient here is monitoring that reconditioning programme and measuring the performance of the muscles. Endurance tests have proved to be the most reliable of all core-stability tests. Our spine rehabilitation device, the SPINEO, may come in handy here.

So back to our patient, if we want to stop the cycle of back pain, followed by treatment, followed by “see how it goes” return to activity, followed by recurring back pain and so on, it’s worth educating the patient on the correct course of rehabilitation and actively monitor factors such as their core stability throughout and after treatment. An example might be an agreed upon graded return to their favourite sport alongside monitoring their core stability endurance until they have reached their baseline for four to six weeks, are confident in their movements and symptom-free. Hopefully, this will lead to a healthier, stronger population.