A PHYSIO'S Approach to Treating Low Back Pain – What the Research Says.



When writing blog posts, we would usually aim for the target audience to be the general population. Giving out advice on all things health, fitness and rehabilitation. However, with clinicians being so busy and perhaps not having as much time to dive into research – I thought it would be a good idea to do a blog/literature review on all things back pain. One of the most widespread and difficult things to treat – low back pain divides opinion around the world on how it should be treated. I took a look at the recent literature to show you how I approach things, and what the literature says works, and what doesn’t.


To start with, we must give a definition. Low back pain can be defined as pain or discomfort located between the costal margin (ribs) and gluteal fold, which may or may not have referred pain into the legs.(1) Now that we all know where our low back is, let’s move on.

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When we treat back pain, there are many things that we need to consider from a clinicians perspective. Starting with the age, activity levels, how the injury occurred, previous medical history, particular patterns to the pain, biopsychosocial factors (more on this later). We are taught to go through a thorough subjective/verbal history to get a clear understanding of the person sitting before you, rule out any serious causes (cancer, infection), how their injury came about and how it’s been behaving since that point. We then go through a battery of tests, some things are uniform – like range of motion and strength, and others are more ‘special’. However from this point onwards, it depends who you trained with (university, mentors) and the self-learning you’ve done in order to ascertain what is causing the persons pain and what will work to fix them. So what does the research say on this?


Low back pain (LBP) is known to be the leading cause of disability & most common non communicable disease worldwide.(2) It can be divided into 3 different sub categories, acute (less than 6 weeks), sub-acute (6-12 weeks) and chronic (>12 weeks). On top of the serious causes listed above which make up approximately 1-2% of cases, 5-10% of cases will consist of neurological deficits (radiculopathy, cauda equina syndrome). This leaves a significant chunk of cases in the ‘non-specific’ range. We know that 39-76% of patients fully recover after an acute pain episode, which also suggests that a significant portion will go past this 6 week mark and potentially into the ‘chronic’ timeframe. The research backs this up, with the global 1 year prevalence of chronic LBP in older adults is 13-50%.(3) International guidelines and research suggest that in this ‘non-specific range’, it is neither possible nor necessary to identify a root cause or source of the pain to effectively treat LBP.(4) The use of imaging (MRI) is also not recommended, especially within the first 4 weeks. It is only indicated if more serious pathology is suspected, or the client is not responding to treatment.(15)


A framework that is commonly taught in University’s across the world now is the biopsychosocial model. This considers a multifaceted approach to treating injuries, and it is how I will break down the research behind treating such injuries. First you must understand each of the three elements when it comes to physiotherapy.



Bio – genetics, stiffness, mechanism of injury Psycho – fear of movement, catastrophizing, mental state Social – work/home environment, cultural background, relationships



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Biological

The thing that everyone will initially go to and the reason why a lot of you are reading this, will be the biological element. Even if you’re a clinician reading this, I have no doubt that you have heard that your hamstrings are too tight, your glutes don’t fire or your core is too weak. All of these things can have merit and can play a role in LBP, but they are just part of the story.


What does the research say in regards to this? Well, there is evidence that somethings work, however it is unlikely that one kind of exercise training is the single best approach to treating chronic low back pain. Research suggests that ‘active therapies’ such as pilates, resistance training, motor control/stabilization & aerobic exercise training can all impact LBP positively.(3) There is also recent evidence to suggest that diaphragmatic training (breathwork) can have a positive effect on the active stabilisers of the spine, thus improving LBP.(16) The most important element however, is how we guide patients through the process. When the patient is guided and actively encouraged to exercise and move in a forward thinking way, this tends to be the most effective overall. (3)



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A WHO systematic review(8) has shown that NSAID’s (non-steroidal anti-inflammatory drugs) and spinal injections (corticosteroid) have been shown to improve pain in the short term, and acupuncture is supported to work in the subacute phase (6-12 weeks). While potential treatments to avoid include TENS, PENS, Interferential and ultrasound. This is not to say they may not have an placebo effect on the right candidate! The placebo effect is becoming more recognized in the literature for playing a significant role in overall patient outcomes,(9) but its impact on chronic pain is still dubious, due to the complex and individualized elements of pain experiences.(10) Pretty much throughout the literature it rejects the need to offer anyone a belt or corset to manage LBP.


There are different opinions on combining therapies, and they are the most used clinically.(6) But despite being the most common route taken by therapists, there are some studies that suggest the evidence is poor. Studies that look at the spine and chronic pain as a whole state that combined therapies work well in the early and mid-phases of treatment. Overall what seems to work best, is when the patient has a part to play in guiding treatment routes.(7)



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Psychological

Having completed a Level 6 degree in Mental Health and completed my Masters dissertation on the impact that mental health disorders can have on people with chronic pain, it is something that I definitely look into when working with someone over a number of sessions. I am by no means an expert in this field, but I do not think you need to be to have an understanding and ability to refer someone on for better guidance when required.


Everyone understands that there is an increase in LBP as we get older, but perhaps less understand the psychological link. In a study of 190,000 (+) people throughout 43 countries, it was found that those with chronic LBP were twice as likely to suffer from anxiety, depression, sleep deprivation or psychosis.(5) The link with mental health has long been researched, and there are positive signs across the healthcare industry that this sub section of LBP is starting to be treated as a symptom.


Having experienced low back pain myself, I understand the burden it can play on your mental health. There are a number of aspects to life that pain can effect, such as playing your favourite sport, playing with your child, grandchild, niece or nephew. It has an overall effect on the social aspect of your life, and as I have referenced earlier; there is a very strong link with mental health disorders.



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Social

The effect of an individual’s background on their pain is very significant. As clinicians, we must take into consideration the impact that social status, work/life balance, relationships and cultural background all have on a person’s perception of pain and how you can guide them best to recovery. Taking the time to understand and get to know someone while treating them is undervalued, and may just unlock the door to the next step of progression on their path to full recovery.


Prevention of Low Back Pain – Can we?

There has been a lot of recent research looking into prevention of LBP. The overall economic effect is pretty substantial with days missed from work and impact on national health resources, so it is in everyone’s best interests to try and be proactive rather than reactive on the subject of LBP.


There is little to no evidence for things like shoe insoles, back belts or lumbar supports for prevention of LBP.(11,12) While the same could be said for specific mattresses or desk chairs preventing any low back pain, there may be some improvement in existing back pain with a medium support mattress.(12) The usual culprits of weight management, smoking and sleep quality are the ones we should be focusing on (outside of general strengthening, it must be said). Obesity can place an increased load upon the spine and surrounding structures, while smoking effects spinal discs by decreasing blood flow, thus reducing overall disc height.(13) Overall sleep quality and significant rest have been shown to be related to developing LBP.(14)


Understanding and accepting the psychological component of LBP, means we must accept the role that psychological factors such as stress, work dissatisfaction and depression have in LBP. Addressing these issues seem to not only positively impact mental health, but could benefit overall physical health too.



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Conclusion

As I’ve said at the beginning, we are all taught a little bit differently through our career, but it’s very important for us to keep up to date on what the research says works, and what doesn’t with LBP. I know for sure it is not a ‘one size fits all’ approach. We need to treat people individually, gain their trust and build on that relationship with treatment approaches that are proven to work time and time again. The real winner here is exercise in general, and should be a staple throughout any rehabilitation process. There are many studies to back this up, and there are many studies demonstrating the importance of having someone guide you through that process. I will finish with the very infamous ‘more research is needed’, which is true, but we are slowly starting to make progress here.



Bibliography

1. Airaksinen, O. et al. (2006) ‘Chapter 4 European Guidelines for the management of chronic nonspecific low back pain’, European Spine Journal, 15(S2). doi:10.1007/s00586-006-1072-1.

2. Hoy, D. et al. (2014) ‘The global burden of low back pain: Estimates from the global burden of disease 2010 study’, Annals of the Rheumatic Diseases, 73(6), pp. 968–974. doi:10.1136/annrheumdis-2013-204428.

3. Owen, P.J. et al. (2019) ‘Which specific modes of exercise training are most effective for treating low back pain? network meta-analysis’, British Journal of Sports Medicine, 54(21), pp. 1279–1287. doi:10.1136/bjsports-2019-100886.

4. Koes, B.W. et al. (2010) ‘An updated overview of clinical guidelines for the management of non-specific low back pain in primary care’, European Spine Journal, 19(12), pp. 2075–2094. doi:10.1007/s00586-010-1502-y.

5. Stubbs, B., Koyanagi, A., Thompson, T., Veronese, N., Carvalho, A.F., Solomi, M., Mugisha, J., Schofield, P., Cosco, T., Wilson, N. and Vancampfort, D., 2016. The epidemiology of back pain and its relationship with depression, psychosis, anxiety, sleep disturbances, and stress sensitivity: Data from 43 low-and middle-income countries. General hospital psychiatry, 43, pp.63-70.

6. Blanco-Giménez, P. et al. (2024) ‘Effect of exercise and manual therapy or kinesiotaping on SEMG and pain perception in chronic low back pain: A randomized trial’, BMC Musculoskeletal Disorders, 25(1). doi:10.1186/s12891-024-07667-9.

7. de Campos, T.F. (2017) ‘Low back pain and sciatica in over 16s: Assessment and management nice guideline [NG59]’, Journal of Physiotherapy, 63(2), p. 120. doi:10.1016/j.jphys.2017.02.012.

8. Zaina, F. et al. (2023) ‘A systematic review of Clinical Practice Guidelines for persons with non-specific low back pain with and without radiculopathy: Identification of best evidence for rehabilitation to develop the who’s package of interventions for rehabilitation’, Archives of Physical Medicine and Rehabilitation, 104(11), pp. 1913–1927. doi:10.1016/j.apmr.2023.02.022.

9. Hohenschurz-Schmidt, D. et al. (2022) ‘Avoiding nocebo and other undesirable effects in chiropractic, osteopathy and physiotherapy: An invitation to reflect’, Musculoskeletal Science and Practice, 62, p. 102677. doi:10.1016/j.msksp.2022.102677.

10. Rossettini, G. et al. (2023) ‘The biology of Placebo and nocebo effects on experimental and chronic pain: State of the art’, Journal of Clinical Medicine, 12(12), p. 4113. doi:10.3390/jcm12124113.

11. Burton, A.K. et al. (2006) ‘Chapter 2 european guidelines for prevention in low back pain’, European Spine Journal, 15(S2). doi:10.1007/s00586-006-1070-3.

12. Low back pain - physiopedia. Available at: https://www.physio-pedia.com/Low_Back_Pain

13. Guan, J. et al. (2024) ‘Associations between lifestyle-related risk factors and back pain: A systematic review and meta-analysis of Mendelian Randomization Studies’, BMC Musculoskeletal Disorders, 25(1). doi:10.1186/s12891-024-07727-0. 14. Silva, S. et al. (2024) ‘Sleep as a prognostic factor in low back pain: A systematic review of prospective cohort studies and secondary analyses of randomized controlledtrials’, SLEEP, 47(5). doi:10.1093/sleep/zsae023.

15. Hoffmann, T.C. et al. (2013a) ‘Patients’ expectations of acute low back pain management: Implications for evidence uptake’, BMC Family Practice, 14(1). doi:10.1186/1471-2296-14-7.

16. Finta, R., Nagy, E. and Bender, T. (2018a) ‘The effect of diaphragm training on lumbar stabilizer muscles: A new concept for improving segmental stability in the case of low back pain’, Journal of Pain Research, Volume 11, pp. 3031–3045. doi:10.2147/jpr.s181610.


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