Low back/lumbar spine

ACUTE NON-SPECIFIC LOW BACK PAIN

Low back pain refers to pain in the area between your lowest ribs (around your waist) and your bottom. Acute refers to pain that started recently. Non-specific means the cause of the pain is not serious or trigged from arthritis, infection or sciatica (an irritated nerve in your back). It also means that it is not possible to find a specific source of the pain (eg, joint, muscle, ligament, disc). Most low back pain is non-specific. Even the best imaging techniques cannot identify what is causing your back pain. The good news is that imaging is not required for you to manage the problem effectively.

What causes acute non-specific low back pain?

Studies have identified some risk factors for acute non-specific low back pain. Lifting heavy loads at work and repeated lifting at work, as well as lifestyle factors such as smoking, obesity and depressive symptoms, can increase your risk of experiencing low back pain. However, these factors only increase your risk of experiencing low back pain by a small amount.

 

How do I know if I have non-specific low back pain?

Your physiotherapist is trained to distinguish between serious and non-serious causes of low back pain. They will do this by asking you a series of questions about your pain and examining your back. Imaging is not needed to diagnose acute non-specific low back pain. It can be tempting for clinicians to make an educated guess about which back structure is responsible for the pain. Many patients and clinicians find ‘non-specific’ hard to accept. However, specific diagnoses, for example, disc injury, joint problem or muscle strain for low back pain are not well supported by scientific evidence and are not needed to manage your pain.

 

How can physiotherapy help with acute non-specific low back pain?

A physiotherapist can help confirm that you have non-specific low back pain and rule out other conditions that require additional testing and treatment. Once a diagnosis of non-specific low back pain is confirmed, they can give you some advice about recovery time, what you can do and how your physiotherapist can offer to help speed up recovery. This will usually involve a combination of physiotherapy treatment and some things that you can do at home. Physiotherapy treatment might include hands-on therapy, education, exercises or a combination of these. Many people with acute non-specific low back pain require minimal physiotherapy treatment. Techniques to help you manage at home might include advice on how to stay active, how to manage the pain at home and at work, and how to return to your normal activity levels.

 

How effective is physiotherapy for acute non-specific low back pain?

Many studies have looked at the effectiveness of physiotherapy treatments for people with acute non-specific low back pain. There is some evidence that hands-on treatment can reduce pain in the short term. The good news is that most people recover quickly from acute non-specific low back pain.  It may be surprising but exercise, whether it is back-specific (muscle stretches, tummy exercises, repeated back movements) or general (walking, cycling, swimming), does not seem to reduce pain in the short term for people with acute non-specific low back pain. While specific exercises are not useful for relieving pain, returning to the normal physical activities you do around the house and at work is very important. Your physiotherapist can give you advice about how best to do this in a sensible way. 

 

What can I do at home?

Resting in bed for long periods is generally discouraged. Staying active, and using heat and simple medications (eg, ibuprofen such as Nurofen or a diclofenac such as Voltaren) for pain relief can be helpful. Most people can safely return to work even if the pain has not yet gone away.

 

How long until I feel better?

Most people recover very quickly from low back pain, with much reduced pain within two weeks. Your physiotherapist might use a short questionnaire to help determine whether you should expect your recovery to be fast or slow. Some tools such as the STarT Back Tool and MyBack are available online for you to fill out yourself. You can use this information to help decide on a management plan that is right for you. The results of these questionnaires are good things to discuss with your physiotherapist.

Source: Choose.physio

PERSISTENT NON-SPECIFIC LOW BACK PAIN

 

Persistent low back pain is low back pain that has lasted for longer than six weeks. Like acute low back pain, most persistent low back pain is non-specific. Non-specific means the cause of the pain is not serious or trigged from arthritis, infection or sciatica (an irritated nerve in your back). It also means that it is not possible to find a specific source of the pain (eg, joint, muscle, ligament, disc). Even the best quality imaging techniques (eg, a CT scan or an MRI) cannot identify what causes most persistent low back pain. 

What causes persistent non-specific low back pain?

Studies have identified some risk factors for developing persistent low back pain after an acute episode. Your risk of getting persistent low back pain is increased if you have high levels of pain or pain that extends into the leg, or if you are feeling down, depressed, or very worried about your recovery. On their own, these factors only increase your risk of persistent low back pain by a small amount. In combination, they can double your risk of developing persistent low back pain.

 

How do I know if I have persistent non-specific low back pain?

Your physiotherapist is trained to distinguish between serious and non-serious causes of low back pain. They will do this by asking you a series of questions about your low back pain and by examining your back. Imaging is not needed to diagnose persistent non-specific low back pain. It can be tempting for clinicians to make an educated guess about which back structure is responsible for the pain. Many patients and clinicians find ‘non-specific’ hard to accept. However, specific diagnoses for example, disc injury and facet joint problem are not well supported by scientific evidence. Most importantly, treatments directed at these specific structures (eg, an injection of steroid-based medications into the ‘problematic’ joint) have not been shown to be effective for persistent low back pain.

 

How can physiotherapy help with persistent non-specific low back pain?

A physiotherapist can help confirm that you have non-specific low back pain and rule out other conditions that require additional testing and treatment. Once a diagnosis of persistent non-specific low back pain is confirmed, they can help you decide how to manage it. This will usually involve a combination of physiotherapy treatment and things that you can do at home. Physiotherapy treatment might include hands-on therapy, education, exercises or a combination of these.

Physiotherapists also work in pain clinics and contribute to the team-based care that may be required for some people with persistent non-specific low back pain. For example, persistent low back pain can be associated with feelings of depression, poor lifestyle habits, and difficulties participating in work and social activities. Different professionals, including physiotherapists, GPs and psychologists, work together to help with these different aspects of low back pain.

 

How effective is physiotherapy for persistent non-specific low back pain?

Many studies have now looked at the effectiveness of physiotherapy treatments for people with persistent non-specific low back pain. There is high quality evidence that exercise can help reduce pain. Believe it or not, the effects of exercise on pain are similar to those of opioid drugs (eg, codeine, oxycodone, tramadol). There is also some evidence that massage and other hands-on treatments can reduce pain.

There a lots of treatment options for low back pain. Examples of interventions that have been shown to be ineffective for persistent low back pain include: antidepressant medication, paracetamol, ultrasound, electrical stimulation eg, TENS, as well as spinal fusion. Machines that were once popular in physiotherapy (eg, ultrasound, electrotherapy, traction) have been shown to be no more effective than fake machines. On their own these therapies are not useful.

Your physiotherapist will be able to discuss the pros and cons of different treatments. They can help design an effective exercise program for you and this program is likely to reduce your pain in the short term.

 

What can I do at home?

Staying physically active is likely to be helpful. Gradually upgrading your activity levels using the principle of pacing (do a bit more each week but not too much more) is also recommended. Remaining at work is important. If your work provokes your back pain, a physiotherapist might be able to suggest some strategies to modify your work tasks and build your physical capacity.

 

How long until I feel better?

Just because you have persistent low back pain does not mean you cannot recover. Some (nearly one in two) people with persistent low back pain recover in 12 months. Many people with ongoing persistent low back pain have relatively mild pain or mild disability. In cases where pain lasts longer, tackling the problem from different angles can help. For some people, this is where a pain clinic may help.  

Source: Choose.physio

RADICULAR LEG PAIN

Radicular pain is a type of back pain that spreads from the back and travels down the leg below the knee. Sometimes there is no back pain and only leg pain. This sort of leg pain is thought to originate from irritated nerves near the spine. A more general term for this problem is sciatica. However, sciatica is usually used to describe pain down the back of leg—it does not indicate that the sciatic nerve, which is located in the muscles of your buttock and is about as thick as your thumb, is irritated or pinched. Rather, the problem is normally with a nerve branch that can get irritated where it exits the spine. This can lead to different regions of the leg becoming sore, depending on which nerve branch is irritated. 

Tell me more about radicular pain.

The nerve branches that become irritated are called nerve roots and are labelled according to the area of the spinal column that they exit from. For example, you might have been given a diagnosis of ‘L5 nerve root compromise’ or ‘L5 radiculopathy’. While that sounds a little scary, all it means is that there is an irritation of the fifth lumbar (L5) nerve root. If there is compression on the nerve (eg, from swelling), you might experience weakness and numbness in your leg—this is known as radiculopathy. Most people who experience weakness related to this type of nerve compression recover their strength within one year, without any surgical intervention.

 

What causes radicular pain?

Radicular pain is thought to be related to problems with the intervertebral disc. Intervertebral discs are made of strong ligament and cartilage tissue. They function as natural shock absorbers for the spine. Because they are very strongly attached to the vertebrae above and below, the use of the terminology ‘slipped disc’ is not accurate. It is normal for intervertebral discs to bulge and swell. However, changes in the shape of the disc—sometimes referred to as a disc herniation—can irritate nearby nerves and soft tissues. Problems with discs are not necessarily permanent. Even large disc herniations can disappear over time.

 

How do I know if I have radicular pain?

If you have radicular pain, your leg pain might feel worse than your back pain, or you might have no back pain at all. Sometimes the leg pain is accompanied by a numb sensation in your foot or a feeling of weakness in your leg. Your physiotherapist is trained to distinguish between radicular pain and other causes of low back and leg pain. They will do this by asking you a series of questions about your pain and examining your back and legs. They might do some nerve tests, such as checking the reflexes, sensation and strength of your legs.

Imaging is not needed to diagnose radicular pain. Radicular pain is one of the few conditions where physiotherapists can make a fairly good estimate about the source of back and leg pain.

 

How can physiotherapy help with radicular pain?

A physiotherapist can help confirm that you have radicular pain and rule out other conditions that require additional testing and treatment. Once a diagnosis of radicular pain is confirmed, they can help you decide how to manage it. It is widely recommended that people with radicular pain have conservative treatment for six weeks before considering further tests or treatments. Your options might include self-management techniques, education, exercises or a combination of these.

 

How effective is physiotherapy for radicular pain?

There is limited evidence for the effectiveness of physiotherapy treatments for people with radicular pain. However, evidence suggests the long-term outcomes between surgery and conservative care are similar. Supervised exercise might provide some relief in the short term. The safety and efficacy of spinal manipulation (hands on therapy) for radicular pain has not been clearly demonstrated. There is evidence that patients who receive non-surgical management, including physiotherapy, for radicular pain have similar long-term outcomes to those who have surgery.

Some treatments are known to be ineffective for radicular pain. These include bed rest, traction (using a machine to lengthen and stretch the spine), and injections of steroid medications into the space near the nerve. Steroid injections could also have harmful effects.

Like in other types of back pain, it is important to stay active and return to your normal activities as soon as possible. Your physiotherapist can give you some strategies on how to do this.

 

What can I do at home?

Staying physically active is likely to help. Gradually upgrading your activity levels using the principle of pacing (do a bit more each week but not too much more) is also recommended. Remaining at work is important. If your work provokes your pain, your physiotherapist might be able to suggest some strategies to modify your work tasks and build your physical capacity.

 

How long until I feel better?

Radicular pain generally takes longer to recover than common forms of back pain. Some (around one in three) people with radicular pain improve within two weeks and most (nearly 90 per cent) improve within three months. Sometimes radicular pain can become persistent and a team approach to management is needed.

Source: Choose.physio

SPINAL STENOSIS