By Michael Hall
Of all musculoskeletal injuries, low back pain invokes the greatest images of pain and incapacity. And rightly so, the incidence of low back pain is alarming. 80% of people will suffer a major bout of low back pain at some time in their lives. It is second only to the common cold as the cause of absenteeism in the Western world and increasing at a rate 14 times more than the population growth. And yet prescreening testing, back strengthening and teaching people to lift with bent knees and straight back appear to have had little effect in arresting its growth. Why? Even diagnosing the source of low back pain is difficult with at least 40% of CT scans and MRI scans, showing false positives. How can our best diagnostic equipment and treatment be so inaccurate and so ineffective? Perhaps, if we are to be more effective, we need to change the way that we think about low back pain and develop a new model for its diagnosis and treatment.
Of all the incidences of low back pain that present, the great majority are said to have come on for no apparent reason. Stories such as I bent over to pick up a pen or I reached forward to get something are not uncommon, and yet it is often assumed that such easy tasks are the causes of the injury and that through back strengthening further recurrences will be prevented. It is clear however, that in many cases lack of strength and/or lack of flexibility have little to do with the onset of these injuries as they represent such low levels of our overall physical capacity. Consequently, there must be other factors at work and there are! The fact that low back pain often comes on for no apparent reason suggests that lifestyle or the way that we live might have something to do with its onset. And because life involves postures, movements and activities, then it is reasonable that these will have an effect on both our physical and psychological health.
The Problem of Diagnosis
As up to 40% of MRIs and CT Scans can reveal false positives, the question is where is the pain coming from? In the case of the lumbar spine, it may come from the discs, facet joints, bones, ligaments, muscles and nerves- all structures which are intimately involved and in close proximity. Complicating this further, is the fact that many structures produce similar signs and symptoms making differential diagnosis difficult. Our psyche can then influence the amount of pain that we perceive. We like precise diagnosis, because it gives us certainty, however in the case of the body we may simplify things too much. As the body is made up of systems, it makes sense that if one structure is damaged that this will influence the functioning of other structures which in turn will influence the functioning of the whole body. For example, a facet joint strain, may in turn cause muscle spasm, which will then stress other structures and eventually lead to further pain. If just the original damaged structure is treated in isolation without taking into account the change that has taken place in other structures and the body as a whole, then not only will it take longer for healing to take place, but complete resolution may never be achieved.
Predisposition to Low Back Pain
Poor movement patterns
Poor core muscle tone and control
Regimented, sedentary, stressful lifestyle
Lack of aerobic fitness, flexibility and strength
Classifying back pain can be confusing!
Various researchers and clinicians including Robin McKenzie, Peter OSullivan and Shirley Sahrmann have developed classification systems based upon what movements cause the pain. These movement systems can then easily be related to lower back pathology and specific programs can be developed to best treat these conditions.
As with any treatment plan, the most effective and beneficial treatment must coincide with the assessment findings and also each persons goals. It is essential that treatment take into account the stage of healing and be guided by the injurys irritability. In the acute stage (48-72 hours) this means reducing inflammation by avoiding aggravating movements and applying cold packs for 20 minutes at least 6 times each day. Electrotherapy and hands on techniques may also be used to reduce pain and taping or bracing may be applied to give increased support and awareness.
As pain decreases, healing is then promoted through the use of heat and massage. Various manual techniques may then be combined synergistically with exercises to begin restoring optimal joint mobility, soft tissue length and neuromuscular control. These exercises often begin with isolating particular joints, muscles etc. but then must be integrated into function if people are to achieve, sustained long-term relief. This last point is especially important. It is the authors experience that people often leave treatment before they are ready. Yet research has shown that there is an 80% recurrence rate within one year for people who have suffered an incident of low back pain. Recent research has indicated that the reason for this may lie in the loss of feed-forward muscular bracing that occurs around the spine within 24 hours of an episode of low back pain. It has been found that this bracing does not return even if a persons pain completely resolves. This means that if the spine is again to receive the protection of automatic muscular bracing and the possibility of further episodes of back pain be minimised, the spinal muscles must be specifically trained and integrated back into everyday functional activities. Once this bracing has been established, it then forms a base on which further back and abdominal strengthening can take place.
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