Low back pain or lumbago is a common disorder involving the muscles and bones of the back. It affects about 40% of people at some point in their lives. Low back pain (often abbreviated as LBP) may be classified by duration as acute (pain lasting less than 6 weeks), sub-chronic (6 to 12 weeks), or chronic (more than 12 weeks).
Low back pain is not a specific disease but rather a complaint that may be caused by a large number of underlying problems of varying levels of seriousness. The majority of LBP cases do not have a clear cause but are believed to be the result of non-serious muscle or skeletal issues such as:
Women may have acute low back pain from medical conditions affecting the female reproductive system, including:
In the common presentation of acute low back pain, pain develops after movements that involve:
The symptoms may start soon after the movements or upon waking up the following morning. The description of the symptoms may range from:
It may or may not worsen with certain movements, such as:
The first experience of acute low back pain is typically between the ages of 20 and 40.
Chronic low back pain is associated with sleep problems, including:
In addition, a majority of those with chronic low back pain show symptoms of depression or anxiety.
The straight leg raise test can detect pain originating from a herniated disc. When warranted, imaging such as MRI can provide clear details about disc related causes of back pain (L4–L5 disc herniation shown).
The initial evaluation for patients with low back pain begins with an accurate history and thorough physical exam with appropriate provocative testing. These first steps are complicated by the subjectivity of patient experiences of chronic spinal pain and the inherent difficulty isolating the anatomic region of interest during provocative testing without the influence of neighboring structures.
may provide useful confirmatory evidence to support an exam finding and localize a degenerative lesion or area of nerve compression.
However, imaging is an imperfect science, identifying the underlying cause of LBP in only 15% of patients in the absence of clear disc herniation or neurological deficit. Furthermore, there remains a frequent disconnection between the symptoms’ severity and the degree of anatomical or radiographic changes. While correlations between the number and severity of osteophytes and back pain exist, the prevalence of degenerative changes among asymptomatic patients underlies the difficulty in assigning clinical relevance to observed radiographic changes in patients with LBP.
Nerve compression symptoms by clinical history may also be confirmed by electromyography studies.
Demonstrating normal distal motor and sensory nerve conduction studies with abnormal needle exam
Exercise therapy (ET) remains one of the conservative mainstays of treatment for chronic lumbar spine pain, and may be tailored to include aerobic exercise, muscle strengthening, and stretching exercises. Significant variation in regimen, intensity and frequency of prescribed programs presents challenges in assessing its efficacy among patients. One meta-analysis of the current literature exploring the role of ET in patients with varying duration of symptoms found a graded exercise program implemented within the occupational setting demonstrated some effectiveness in sub acute LBP. Among those suffering chronic pain symptoms, small, but statistically significant improvements were observed among patients, with regard to pain reduction and functional improvement. The optimal approach to exercise therapy in chronic low back pain sufferers should be a customized program emphasizing stretching and muscle strengthening, administered in a supervised fashion, with high frequency and close adherence. This can be complemented by other conservative approaches, including NSAIDS, manual therapies and daily physical activity.
A “TENS” unit is a therapeutic modality involving skin surface electrodes which deliver electrical stimulation to peripheral nerves in an effort to relieve pain non-invasively. Such devices are available in outpatient exercise therapy settings, with around one-third patients experiencing mild skin irritation following treatment. While one small study identified an immediate reduction in pain symptoms 1 h following TENS application, there remains little evidence of long-term relief. Another larger study did not discover significant improvement with TENS compared with placebo with regard to pain, functional status, or range of motion.
Lumbar back supports may benefit patients suffering from chronic LBP secondary to degenerative processes through several potential, debated mechanisms. Supports are designed to limit spine motion, stabilize, correct deformity and reduce mechanical forces. They may further help by massaging painful areas and applying beneficial heat; however, they may also function as a placebo. There is moderate available evidence evaluating efficacy of lumbar supports within a mixed population of acute, subacute, and chronic LBP sufferers to suggest that However, lumbar supports are not more effective than other treatment forms; data is conflicting with regard to patient improvement and functional ability to return to work.
Lumbar traction applies a longitudinal force to the axial spine through use of a harness attached to the iliac crest and lower rib cage to relieve chronic low back pain. The forces, which open intervertebral space and decrease spine lordosis are adjusted both with regard to level and duration and may closely be measured in motorized and bed rest devices. Temporary spine realignments are shown to improve symptoms related to degenerative spine disease by relieving mechanical stress, nerve compression and adhesions of the facet and annulus, as well as through disruption of nociceptive pain signals. However, patients with chronic symptoms and radicular pain don’t find significant improvement with traction. Little is known with regard to the risks associated with the applied forces. Isolated case reports cite nerve impingement with heavy forces, and the potential for respiratory constraints or blood pressure changes due to the harness placement and positioning.
Spine manipulation is a manual therapy approach involving low-velocity, long lever manipulation of a joint beyond the accustomed, but not anatomical range of motion. The precise mechanism for improvement in low back pain sufferers remains unclear. Manipulative therapy may function through: release for the entrapped synovial folds, relaxation of hypertonic muscle, disruption of articular or periarticular adhesion, unbuckling of motion segments that have undergone disproportionate displacement, reduction of disc bulge, repositioning of miniscule structures within the articular surface, mechanical stimulation of nociceptive joint fibers, change in neuro physiological function and reduction of muscle spasm.
Available research regarding its efficacy in the context of chronic LBP finds spinal manipulation to be “more effective” compared to sham manipulation with regard to both short- and long-term relief of pain, as well as short-term functional improvement. Compared with other conventional, conservative treatment approaches such as exercise therapy, back school and NSAIDs, spinal manipulation appears comparable in effectiveness in short- and long-term benefits. Research exploring the safety of such therapy among trained therapists found a very low risk of complications, with clinically worsened disk Herniation or cauda equina syndrome occurring in fewer than 1/3.7 million.
Treatment should be carried out 3 to 4 times a day depending on the severity of the condition. If an upper respiratory tract infection is contracted again, treatment should be started as soon as possible to prevent it from developing into bronchitis or further severe complications.
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