Oh, My Aching Back! Contemporary Evidence in the Treatment of Low Back Pain

Oh, My Aching Back! Contemporary Evidence in the Treatment of Low Back Pain

Feature Article:

If you are reading this article, you are likely one of the many persons in the United States who has encountered low back pain. According to the National Institutes of Health, low back pain is second only to the common cold for visits to the doctor, and roughly 80 percent of all persons will encounter low back pain at some point in their lifetime.

Back pain is not only highly prevalent, it is very costly — estimates indicate low back pain costs the U.S. economy $75-80 billion per year. As a common cause of illness and lost economy, much research has been ongoing to effectively diagnose and treat this problem.

The conventional wisdom that the vast majority of low back pain resolves itself spontaneously over a short amount of time isn''t supported well by evidence. A 2003 systematic review of research regarding low back pain found that, on average, 62 percent of sufferers still reported pain 12 months after the initial onset.

The average percentage of sufferers who had relapses of pain was 60 percent, and the percentage of those who experienced relapses of work absence was 33 percent. The review also found that those with prior episodes of low back pain had a much higher recurrence rate over those who never had it. Rather than resolving spontaneously, low back pain is more characterized by periods of onset and remission without true resolution.

Diagnostic studies, clinical examination, and history often lead to a diagnosis; however, for most forms of general low back pain, in the absence of serious pathology such as cancer, infection, or trauma, the identification of a true anatomical cause is often difficult.

A 2004 study of the relationship between the onset of low back pain and changes on diagnostic imaging studies such as X-ray, MRI, and CT scan concluded that there is little to no association between image study findings and the onset of new low back pain; that is, abnormal study findings were not necessarily the cause of low back pain in the majority of cases.

Additionally, the study found that depression was actually a stronger predictor of the occurrence of new low back pain than image study findings. Given that a true anatomic cause of low back pain is often obscure, research in recent years has been directed toward identifying subgroups of low back pain patients where the particular problem is matched to a specific treatment with the intent of improving the chance of a successful outcome.

The development of a low back pain treatment based classification system helps to define which patients will more likely respond favorably to a particular treatment approach. This is accomplished through key history and clinical examination findings known as clinical prediction rules. These rules are useful decision-making tools that use clusters of factors such as symptoms, history, test results, age, gender, etc., to predict the chance of a desired outcome, such as a response to treatment, the diagnosis of a problem, or prognosis of a problem. In the case of low back pain, useful clinical prediction rules have been developed to successfully classify low back pain patients into specific subgroups– Mobilization/Manipulation, Immobilization, Directional Preference, and Traction.

Patients categorized into Mobilization/Manipulation are those that will likely respond favorably to spinal manipulation and mobilization — these are people who have a tendency toward less mobility of the spine and no evidence of frank nerve involvement. Immobilization patients are those who respond better to exercises directed toward improving control over the spine and its regional muscles and joints. These persons characteristically have poor spine control during movement and only respond in a short-term manner to spinal manipulation.

Patients who fall into the Directional Preference category are those whose symptoms typically include leg pain and who tend to favor postures or positions of comfort. These patients respond better to directional exercise that is intended to decrease symptoms in the leg and improve spine position tolerance.

The last category, Traction, is for those who have frank nerve involvement whose symptoms are unresponsive to directional exercise. Traction is utilized in an attempt to decompress spinal segments to relieve nerve root compression causing pain.

The improved success of treating low back pain according to classification, or category, reveals that it is not uniformly the same for all individuals and cannot be treated as such. It is also important to note that patients can fall into different categories at different times depending on the course of the low back pain.

Although low back pain is highly prevalent and costly, it is rarely serious and can be successfully treated conservatively. Early identification, classification, and intervention are often the keys to success. Research will continue to evolve the way this condition is diagnosed and treated, and will likely lead to improved outcomes. But, the first step is one that you alone control – seeking help from your physician or physical therapist.

Troy L. Grubb, PT, OCS, ATC, is the director of KORT - Middletown Physical Therapy and is a physical therapist, board-certified in orthopedics and athletic training. He can be reached at tgrubb@kort.com