Low Back Pain

Why do people experience LBP?

Is it genetic, is it acquired through lifestyle exposure? Is it related to our diet, occupation, sport, posture, socioeconomic status and demographics, environmental factors? The answer is probably ‘YES’ to all the above, but rather than there being a single solution or panacea to the problem of society’s LBP, each individual person’s experience of LBP if different. This means each person presenting with LBP must be individually assessed to determine which body, behaviour and environmental factors are relevant to their LBP. Only then can meaningful, specific and functionally directed treatment be employed.

What is the source of LBP?

Any of the structures of the spine and adjacent regions can produce the pain, eg. disc, ligaments, muscles, fascia, nerves, joint etc. The medical profession’s attempt to identify the pain-producing tissue is usually in vain; staggeringly, 85% of LBP is termed “non-specific”. This means that if we are honest, we can’t be precisely sure which body structure is the source of the pain. As disappointing as this appears for the 21st century, it doesn’t really matter in terms of treatment, because treatment is directed at correcting the forces that impose on the pain sensitive tissue, not the pain sensitive tissue itself. That is, more important than the source, is the underlying biomechanical cause of the LBP. Once identified, this gives structure to the physio treatment plan.

How do we diagnose LBP?

Straight Back Physiotherapy has designed a range of comprehensive examination modules that seek to explore and expose the underlying cause of the pain. These examination systems have been developed over years of clinical experience and from exposure up-to-date research and education by world leaders in the field of LBP examination and treatment. We’ll assess your posture, joint alignment, movement patterns, spinal stability, muscle flexibility as well as your work and sport habits, to name just a few elements. We’ll also explore the neighbouring body regions that could impose strain on the pain sensitive region. This enables the physiotherapist to profile your body and lifestyle to determine where and how to direct treatment.

Here’s an example of the biomechanical approach to diagnosis:

A person may report LBP when they bend to pick something up off the floor. When we simulate this action in the clinic for examination purposes, we see that as your thighs come close to your tummy, your hips run out of movement range and so your spine flexes excessively to achieve more lowering range to get to the floor. Doing this once may not hurt, but this action repeated many times over during the day and accumulatively over the years will impose a bending force to the spine, which will eventually fatigue structures such as ligaments, discs and muscles at the rear of the spine. This will cause strain and perhaps damage producing symptoms, which may occur 2 decades after the movement problem commenced. The approach here is to firstly recognise this movement problem, which requires due diligence and clinical skill to detect subtleties of human movement. Then secondly to determine why the lumbar spine preferentially flexes instead of the hip joints, eg. tight buttock muscles or hamstrings, hip joint arthritis, restricted sciatic nerve gliding, hyper-flexible spine, poor function in the spine stabilising muscles, bad habits etc etc. Once the biomechanical cause is discovered, meaningful treatment can begin to address the cause not the symptoms and education and advice can be given to help the patient understand the specifics of their LBP and help themselves. The human body is a wondrous machine and (generally speaking) will heal itself if we can provide a healthy environment for it to live in.

Do x-ray, CT scan and MRI help diagnose the LBP problem?

Sometimes a radiological investigation assists the diagnostic and treatment process. In particular, where there is a strong clinical suspicion that a particular structure is damaged, the appropriate investigation can be used to confirm your hunch, eg. a patient presenting with a severe, burning sciatic pain in their leg and loss of feeling in the little toe. We’d suspect a disc prolapse with S1 nerve root compression, for which MRI is a useful (and essential) investigation. MRI is useful for soft tissue and fluid filled structures such as muscle, ligaments, tendons, disc and cartilage. CT scanning is useful for bone-related problems. X-rays show bone and bony alignment. Diagnostic ultrasound is a new science to physiotherapy, and used extensively by Straight Back Physiotherapy for the management of LBP. It is different in that it gives real-time images of the function of deep muscles of the spine, pelvis and hips, rather than a static image of form. However, what is very important to understand, is that not all x-ray findings correlate with pain. That is, just because you see something on x-rays, doesn’t mean that it is the source of the pain. Unfortunately there is over-reliance on x-rays in medical practice as a substitute for poor clinical examination skills, which can provide compliant and respectful patients with incorrect and misleading information, eg. degenerative changes (arthritis) on x-rays are a normal finding in the over 40 years-of-age population and not necessarily the cause of your pain. Disc bulge on CT scan is a normal finding and not necessarily the cause of pain. In fact, 10% of the population have disc prolapse on CT scan but no pain! MRI, often considered the gold standard in examination, is fraught with its problems. The bottom line is skilled clinical examination can be supported and strengthened by judicious selection of the appropriate radiological test and careful interpretation of the x-ray report, it is not a replacement for it!

How do we manage LBP?

Once the biomechanical cause(s) are determined, the physiotherapist will employ a range of hands-on techniques to re-align joints and correct muscle imbalance in and around the hips, pelvis and spine to improve spinal and pelvic alignment and stability. Diagnostic ultrasound is used extensively to restore function in the “core” or deep stabilising muscles. Exploration of the individual’s work and sport environment is needed to determine if posture, exercise, sport or occupational habits are perpetuating the problem. Education is an essential ingredient to equip the individual to understand the complexities and idiosyncrasies of their LBP and how their body-type interacts with their environment and lifestyle, in order to empower the individual to self-help.