Low back pain: A physiotherapist's view

Pain is an unpleasant sensory and emotional experience associated with, or resembling that associated with actual or potential tissue damage. Pain is always a personal experience that is influenced to varying degrees by biological, psychological, and social factors.

Low Back Pain (LBP) is defined as "pain and discomfort, localized below the costal margin and above the inferior gluteal folds, with or without leg pain" LBP is the leading cause of disability globally and inability to work and expected to affect up to 90% of people at some point in their lives.

Causes of LBP

For majority of people with LBP, it is currently not possible to accurately identify the specific nociceptive source. The exact causes of LBP are always hypothetical. Although diagnostic & clinical tests are unable to accurately identify the source of most low back pain, many Imaging findings identified in people with low back pain are also common in people without such pain, and their importance in diagnosis is always a source of much debate. Most episodes of LBP are short-lasting with little or no consequence, but recurrent episodes are common.

Many studies have attempted to identify and evaluate the contribution of different demographic, physical, socioeconomic, psychological, and occupational factors to the development of spinal pain. It is interesting that 37% of LBP worldwide are attributable to occupational risk factors, which represent many potentially preventable sources of pain.

PHYSIOTHERAPY ASSESSMENT

The first aim of the physiotherapy examination for a patient presenting with back pain is to classify the patient according to the diagnostic triage recommended in international back pain guidelines.

Serious (fracture, infection & AS) and specific causes of back pain with neurological deficits (radiculopathy, CES) are rare, but it is of utmost importance to screen for these conditions. When serious and specific causes of low back pain are ruled out, individuals are said to have Non-Specific LBP.

Physiotherapy assessment aims to identify impairments that may have contributed to the onset of the pain or increase the persistent pain. These include.

a) Biological factors (Weakness, Stiffness),

b) Psycho-Sociological factors (Fear of Movement & Pain Catastrophization, Work Environment)

c) Lifestyle factors (Smoking, Obesity, No/low levels of physical activity, Improper Nutrition)

d) Anatomical factors

l Radicular pain occurs when there is nerve-root involvement; commonly termed sciatica. The term sciatica is used inconsistently by clinicians and patients for different types of leg or back pain and should be avoided. Leg pain is a frequent accompaniment to LBP, arising from disorders of neural or musculoskeletal structures of the lumbar spine. Differentiating between different sources of radiating leg pain is important to make an appropriate diagnosis and identify the underlying pathology. The diagnosis of radicular pain relies on clinical findings, including a history of dermatomal leg pain, leg pain worse than back pain, worsening of leg pain during coughing, sneezing or straining, and SLR test.

l Intervertebral Disc Prolapse, Bulge, Extrusion – Name it anyway, proper diagnostic analysis and specific clinical tests can rule out disc injuries. Not every Disc bulge seen in MRI findings is pathological.

e) Pathological factors include Vertebral & Disc Surgeries, Vertebral Fractures, inflammatory disorders, malignancy, infections, and intra-abdominal causes

Physiotherapy Treatment:

l Common Usage of Electrotherapy equipment in relieving pain and radicular symptoms should never be underestimated.

l People often feel strained, irritated, or worthless in regard to Physiotherapy exercises during their treatment sessions. So, Educate, Emphasize & prioritize the exercises. It is not just, the then treatment but also the everlasting. In a clinical trial study conducted, in LBP, diaphragm training has an effect on improving other active stabilizers of the lumbar spine, such as TA, multifidus.

l The exercise comprises a combination of strengthening, stretching, and core-building exercises that aim to:

l Activate and train the muscles surrounding the spine to provide better support and stability to the lower back

l Foster healing in the spinal tissues to reduce pain, improve balance, and restore mobility

l Differential diagnosis plays a key role in treatment decision-making. Ruling out issues with surrounding tissue structures can ease the job.

l Rehab (Therapeutic) Fitness should also be given topmost importance soon after the recovery from the condition to avoid reoccurrences.

l Patient Education is a set of planned activities designed & aimed to facilitate the patient's knowledge base in order to help them make sense of their pain and guide them towards effective, ongoing self-management.

l Sticking to basic treatment approach yields the best results with physiotherapists' knowledge plus patients' trust and composure.

l Enhance Placebo, avoid Nocebo.

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