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Annals of Physiotherapy and Occupational Therapy Research Article 12 min read

Physiotherapy for Low Back Pain

El Geziry AF*
* Corresponding author
ISSN: 2640-2734  10.23880/aphot-16000170  Received: October 01, 2020  Published: October 14, 2020
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Keywords
Back Pain Exercise Complex Barriers Musculoskeletal Disorder
Abstract

The biopsychosocial model for pain management is widely accepted worldwide. As the mechanisms of pain is multidimensional, management should also be multifaceted, in the core of subacute & chronic pain management, physiotherapy might be considered almost for every & each patient Several mechanisms have been adopted to explain how physical therapy help such wide category of patients. When planned properly, the benefits are many, & side effects are less, patient selection& education plays a crucial role to achieve these goals.

Introduction

Low back pain (LBP) by fare, is the most prevalent musculoskeletal disorder all over the world. Up to 85 % of all population suffering LBP during their lifetimes [1, 2, 3, 4, 5].

Exercise is frequently recommended to patients with LBP, it has proven to reduce pain and maintain or restore strength flexibility, & endurance [6].

Subacute and Chronic Low Back Pain& the Benefit Of Exercise

LBP can be classified according to the duration of symptoms as;

  • Acute; less than 4 weeks
  • Subacute; 4 to 12 weeks
  • Chronic; more than 12 The role of exercise varies according to the duration of back pain symptoms, exercise is advisable for all patients with subacute and chronic LBP when there is decreased strength, muscle atrophy, endurance, and easy fatigability [7, 8, 9, 10, 11].

Several systematic reviews have shown that exercise improved pain and function in patients with subacute and chronic LBP [12], Moreover, patients with chronic LBP who regularly participate regularly in physical activities have less pain and better function compared to those who are less physically active [13, 14, 15, 16, 17, 18, 19].

Mechanisms

The mechanism by which exercise improves symptoms is not clear. Several mechanisms can contribute to the benefit, including neurologic, musculoskeletal, and psychological [20].

Tissue injury leads to complex changes within the peripheral and central nervous system, cell proliferation and neurotrophic factors may amplify the processing of pain from the originally injured tissue and result in the perpetuation of pain symptoms [21].

Several animal studies have shown that exercise can reverse some of these injury-induced neurologic changes in the sensory ganglia, spinal cord, and brain [22]. Exercise also improves behavioral markers of pain. These animal studies suggest that exercise would induce similar changes in the peripheral and central nervous systems that contribute to the production, maintenance, and resolution of pain, including LBP [23]. In addition to animal studies, human studies have found that elevated pro-inflammatory cytokines and oxidative stress accompany LBP, and exercise ameliorate such inflammatory processes [24, 25, 26]. Exercise does have a positive effect on the metabolism of human muscles, joints, and intervertebral discs. These tissues require regular loading so that they can maintain their normal metabolism and be able to repair repetitive micro trauma [27]. It is well known that intervertebral discs do not receive a blood supply and obtains their nutrients and metabolism by imbibition (the direct absorption of fluid by the disc), which can be optimized by continuous motion and impact [28, 29, 30, 31].

Exercise also provides psychological benefits, including significant decrease in stress, anxiety, and depression. It has been proven that here is a strong association between chronic LBP and depression, and exercise can improve the mood of chronic LBP patients which, in turn, can lead to an increase in their level of physical activity [32, 33, 34, 35, 36, 37]. Some patients may be worried about reinjuring their back and exhibit significant fear of movement (kinesophobia); in such patients, exercise can be a means by which they learn to confront and overcome their fear. In addition, physical activity interventions can improve the perception of exercise self-efficacy in activity-restricted individuals [38].

Counseling and Evaluation

Counseling patients regarding their expectations is essential prior to recommending and initiating an exercise. In addition, addressing patient fears and concerns and assessing fitness level, interests, prior participation in exercise, and availability of resources are necessary in formulating an appropriate exercise plan [39].

Motivational interviewing and motivational enhancement therapy techniques can improve exercise motivation and compliance in patients with chronic LBP [40]. Health coaching for people with LBP with low recovery expectations can result in goal setting and action planning. These individuals report complex barriers, demotivators, and motivators to performing exercise. Demotivators to exercise are so many, including, but not limited to, lack of interest, unavailability, unaffordable coast, self-consciousness, embarrassment, anxiety, frustration, and anger. On the other hand, motivators to exercise may include goal setting and achieving, enjoyment, feeling good and “normal,” optimism, self-redefinition, and “escape from everyday boundaries.” Patients with LBP need to have clear and consistent follow up from their health care providers regarding treatment options including self-management, as well as information on prognosis and impact on their occupation [41].

Patient Education

Educating patients regarding incorrect understanding about the role of structural back “abnormalities” as the cause of their back pain. Patients who have had prior imaging may misunderstand the importance of the anatomic variations that have been identified, such as desiccated, narrow, degenerating, bulging, or herniated discs; facet joint arthritis; ligamentum flavum hypertrophy; Schmorl’s nodes; spinal stenosis; and hemangiomas. We have to educate patients that these anatomic findings are not necessarily associated with their pain, do not necessarily require intervention, and can be found in without any symptoms. Patients need to be educated that although these anatomic variations may persist, however, their, pain can be still well managed and improve over time [42].

Patients may believe or have previously received advice that certain activities (e.g., bending from the waist, twisting, lifting heavy items, exercise, and sports activities that stress the spine) are unsafe, particularly if those activities provoke discomfort. Providing education by offering a neurologic explanation for provoked pain as an abnormally low pain stimulus threshold may be helpful for some patients. It may also be helpful to challenge patient concerns such as having been told that they have an “unstable” spine; “misaligned” vertebrae, hips, and/or sacroiliac joints; or a leg length discrepancy [43]. These “diagnoses” are usually incorrect and are not generally accepted as contributory to symptoms.

Possibility of Exacerbation in Low Back Pain with Exercise

Some patients might experience temporary worsening of pain during or after therapeutic exercise. Counseling& reassuring the patient can reduce kinesiophobia [44]. Increased LBP following exercise is not uncommon, usually benign, and simply indicates that the pain-producing tissues have been stimulated. Overall, when compared with non- exercising control populations, exercise does not appear to increase the risk of LBP exacerbations. Evaluating Exercise Options All patients with subacute and chronic LBP will likely derive benefit from physical activity, but there is significant variability in exercise ability and tolerance among patients, which should be considered when making exercise program recommendations. Some patients may never have been regularly physically active, while others may have stopped or greatly diminished physical activities and exercise because of their pain. Patients who have never been active should be encouraged to begin exercise but may benefit from a supervised graded program with more support. Patients

who are already active and exercising should be encouraged to continue [45].

Exploration of the exercise options available within the patient’s community, while taking into consideration their preferences, circumstances, fitness level, and exercise experiences, will help to determine the most appropriate exercise program [46]. Referral to physical therapy for formal exercise instruction and education may be reasonable for some patients who might benefit from a more structured, guided approach such as those with subacute or chronic LBP and significant functional impairment, deconditioning, and fear-avoidance of movement.

Conclusion

Nowadays, it is widely believed that multimodal approach must the norm for proper pain management Physical therapy is an essential component for managing subacute& chronic LBP, However, patient education& follow up is of paramount importance to correct the myths & misunderstanding that might affect patient compliance.

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@article{el2020,
  title   = {Physiotherapy for Low Back Pain},
  author  = {El Geziry AF},
  journal = {Annals of Physiotherapy and Occupational Therapy},
  year    = {2020},
  volume  = {3},
  number  = {3},
  doi     = {10.23880/aphot-16000170}
}
El Geziry AF (2020). Physiotherapy for Low Back Pain. Annals of Physiotherapy and Occupational Therapy, 3(3). https://doi.org/10.23880/aphot-16000170
TY  - JOUR
TI  - Physiotherapy for Low Back Pain
AU  - El Geziry AF
JO  - Annals of Physiotherapy and Occupational Therapy
PY  - 2020
VL  - 3
IS  - 3
DO  - 10.23880/aphot-16000170
ER  -