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One of the most common places physical therapists will find pain is in the lower back. Statistics show that over 80 percent of all adults will suffer from low back pain at some point in their lives and it is one of the most common reasons for missed work.¹

"Many people believe that back pain is just something you have to endure; a fixture of modern society," said Lowen Cattolico, MS, PT, OCS, a physical therapist with San Francisco Sport and Spine Physical Therapy. "As therapists we work with people on a daily basis that are living with pain. These patients may feel isolated, like no one understands exactly how they feel."

Unfortunately, people may unknowingly exacerbate their back pain by having poor posture or exercising improperly. Certain conditions can increase one's potential for back pain as well: strains on the body, such as obesity and pregnancy.

"The postures that emphasize extra weight around the belly are terribly hazardous to the back," said Beth Baudendistel McMahon, PT, MPT, a physical therapist with Physical Therapy with HEART in San Antonio, TX. "A large part of the American population has gotten to be lazy and have disregard for their physique, so we've created our own problem with back pain."

Unfortunately, this problem is especially challenging to solve, since each person experiences pain that is uniquely their own. That makes pain difficult to assess and really understand. For successful treatment, physical therapists must toss aside preconceived notions and tap into the patient's personal experience.

"A professional cannot feel what the patient is going through, so you must accept their subjective statements and try to do the best for them and what is manageable for them. Everyone has a story, and the most important thing is to make sure you listen intently to what the patient is saying when performing an evaluation," explained Amisha Lotwala, PT, DPT, practice manager for Amurvel Physical Therapy Services in Phoenix, AZ. "What is affected in their life and what are their goals? The thing that is difficult sometimes is to make sure you are acknowledging their goals and not what you believe would be best for them. A patient's goal may be to walk to their front door and back to their bedroom-you may think they need to walk around the block, but if they have never done before, they are probably not going to start now."

Listening is not as easy as it seems. People define pain differently and use many different words and analogies. They might use terms like annoying, numb, tingling, sharp, dull, low level and high level, among other descriptors.

"I try to relate it to functions. Maybe a patient can give me an idea of how long they can sit with the problem, how long they can stand, how long they can walk, how much they lift with it," said Tom Papke, PT, a therapist at Capital Metro Physical Therapy, in Washington, D.C., metro area. "Their comparison to certain functions gives me a measurement, even though it's subjective on their part. It's also something for me to come back to as a way to measure progress down the road, because you should be seeing improvements and progress in that function."

Progress, Instead of Pain
Most therapists use the 10 point scale to begin understanding what kind of pain patients are experiencing. After evaluation, however, pain modification begins and a vision of what patients can accomplish takes shape.

"There's a lot of education involved, especially on the movements that exacerbate the problem and the ones that help. Help them understand mechanically what's going on with the back," Papke explained. "For some people, their problem is exacerbating to sitting in the chair, so we might look at their position in the chair and rearrange the height of the chair, allowing more freedom to move through the hip joints."

As patients learn about the adjustments they can make on their own, with different postures and positions, they start to regain a sense of control in a situation they thought was hopeless. Treatments vary depending on a patient's presentation or situation, but often include postural and movement training, joint mobilizations, soft tissue mobilizations, neuromuscular retraining and addressing adverse neurodynamics, hip flexibility and ROM exercises.

As an aquatic specialist, McMahon's treatment of choice is aquatic therapy. This form of treatment takes away the weight-bearing stress on the spine.

"In the water you're weightless, so you don't have the compressive forces on your herniated disk or arthritis. The change in the forces allows you to work on your trunk stabilizing muscles, so you can use the water for support and resistance at the same time," she said.

When concentrating on pain management, McMahon has patients do some Pilates exercises in the pool or put weights on their ankles and a floatation device around the shoulders for traction.

"If they feel better, I'll let them jog with the weights on," she said. "It's very gentle traction compared to what we have on land.

Another simple pain reliever and exercise she directs patients to do at home is a back massage with two tennis balls tied into a sock. With a ball on either side of the spinal column, patients lean against a wall and roll the tennis balls.

"Patients can hold a pelvic tilt while they roll the tennis balls up and down either side of their spine. And you can grade how deep the massage by how far away from the wall you stand," she said. "It is pretty universal and works for almost anybody with back pain."

Other self-care techniques for patients include teaching proper ergonomics and body mechanics through postural exercises, lumbar stability exercises (what you might find in Pilates), sitting with lumbar support to avoid full lumbar flexion, sitting on top of a rolled towel or pillows, using a pillow between the knees to sleep and standing every 30 minutes or so to give postural muscles a chance to rest.

"Lumbar stability exercises, also known as core training, often includes training hip and pelvic muscles as well, and this is often an important component of rehab for lower back pain," Cattolico said. "This involves coordination, and sensory retraining, as well as strengthening and endurance training. These exercises can address movement dysfunction, as well as just reinforce proper posture and adequate stabilization for daily activities."

Cattolico also encourages safe and regular cardiovascular exercise for patients, with education about safe exercise techniques and stretches to maintain normal hip and leg flexibility.

"Cardiovascular exercises have been shown to help back pain, and probably help with healing in general," she said. "I think regular exercise would go a long way to treat a lot of the nagging lower back pain that is not currently addressed."

Prevention
Back pain doesn't typically hit until people are in their mid-20s, however it is often the result of postures and actions done over a long period of time.

"Trying to undo what's been happening for the last 20 years is tough," Papke said. "Preventative education back in adolescence could introduce the concept of back care-correct postures, proper stretching and fitness."

Lotwala believes prevention could start with a few basic rules for movement. One key she educates her patients about is regular stretching of the hamstring, calves, piriformis, quadriceps-all done in a neutral spine position (on the floor or side).

"This can be incorporated into a regular cardiovascular program by adding a stretching and core strengthening component like pilates, yoga or tai chi," she said. "Have a professional evaluate your exercise program once a year, to check form and update it as needed for any injuries or to advance it to another level. Back pain prevention also involves taking breaks from your desk job for a short walk."

Education about activity level and modification of posture along with physical therapy treatment can go a long way in reducing this nagging, common pain in the general population. When Papke saw a client who had four abdominal surgeries, and had back pain and leg pain, he saw she assumed this was how her life was going to be.

"Just with simple education about stretching and modifying how she was sitting, her back pain has dramatically reduced," he said. "People are very surprised, they've been in pain for years and think they just have to live with it, but physical therapy really modifies and eases their pain."

Sarah Lebo is a freelance writer based in Royersford, PA. 

Reference:
1. Vallfors B. Acute, Subacute and Chronic Low Back Pain: Clinical Symptoms, Absenteeism and Working Environment. Scan J Rehab Med Suppl 1985; 11: 1-98.