Low back pain is the 2nd most common reason for visits to primary care physicians and the most common reason for visits to orthopedic surgeons and neurosurgeons.  It is estimated that 80% of the population will suffer from an episode of disabling acute low back pain at some point during their lifetime.  Although there are many different treatment options for those who suffer from low back pain, self care is the most important action that a person can take to maintain a healthy back, to prevent low back pain and to facilitate the healing process if low back pain occurs.

Bad habits such as the way you stand (posture) or the way you position yourself (body mechanics) can contribute to the onset of low back pain.  Poor posture and body mechanics change the optimal alignment of the spine over time leading to a process of degeneration.  Often, the process can and will result in weakened discs, inflamed joints, irritated nerves, and painfully tight overworked muscles.  Maintaining proper posture during lying, sitting and standing positions has a significant affect on reducing the stress and strain on the spine which are associated with pain and injury.  Learning how to move properly during common daily activities such as bending, lifting, turning, and reaching is also critical in preventing low back pain.  Many of you may have experienced the ill effects of poor body mechanics during activities such as moving furniture, lifting children, or snow shoveling.

A healthy back needs to be strong and flexible.  Daily exercises aimed at stretching and strengthening muscles and maintaining the flexibility of your spine will help to accomplish this.  One highly recommended exercise for your back is regular walking.

There are many other useful self care tips and techniques that can be learned to keep your back healthy.  Here are a few: maintain an optimal body weight, wear the right shoes, shift positions often at home and work, choose the right bed, use lumbar support for sitting, self-massage, or better yet get someone else to give you a massage.

A physical therapist can help develop an exercise program that is right for you while teaching you the skills you need to move safely and keep your back healthy.  If you are interested in taking care of your back to prevent the onset of low back pain or to address a current back pain problem you should consider seeing a trained physical therapist.

ALEXANDRIA, VA — A new review article published in the Journal of the American Academy of Orthopaedic Surgeons should help convince many patients with low back pain to consider physical therapy as a first line of treatment for their condition, according to the American Physical Therapy Association (APTA). The review, published in February 2009, recommends that in most cases of symptomatic lumbar degenerative disc disease, a common cause of low back pain (LBP), the most effective treatment is physical therapy combined with anti-inflammatory medications. Approximately 75 to 85 percent of adults will be affected by low back pain during their lifetimes.1

Symptomatic lumbar degenerative disc disease develops when a disc weakens (often due to repetitive strain), is injured, or deteriorates from aging. As a result, the disc is unable to hold the vertebrae as it should and the lack of stability can cause back pain.

The review details the different treatment methods for symptomatic lumbar degenerative disc disease, including physical therapy with the use of nonsteroidal anti-inflammatory drugs (NSAIDs), and concludes that, in most patients with low back pain, symptoms resolve without surgical intervention. The review also concludes that physical therapy and nonsteroidal anti-inflammatory drugs are the “cornerstones” of non-surgical treatment.

Physical therapist intervention includes strengthening of core muscle groups, including the abdominal wall and lumbar musculature, which can have positive effects in patients with this condition. According to APTA spokesperson Julie Fritz, PT, PhD, ATC, clinical outcomes research scientist at Salt Lake City’s Intermountain Healthcare and associate professor at the University of Utah, physical therapists have several treatment options that can help patients with LBP whether due to degenerative disc disease or a variety of other causes.

Exercise and manual therapy including spinal manipulation, have been shown to benefit many patients.2, 3. In addition, patient education to remain active and use appropriate body mechanics is beneficial. Physical therapists are trained to identify which of these treatment strategies will be most effective for an individual patient, which further improves the effectiveness of care.

In previous systematic reviews of the literature, it was found that exercise has been shown to improve function and decrease pain in adult patients with chronic LBP and that physical therapy was beneficial for the treatment of acute LBP.2, 3 In another systematic review, NSAIDs were found to provide LBP patients with short-term symptomatic relief.4

“Receiving care from a licensed physical therapist can further improve the odds that a patient can maintain their quality of life and avoid surgery,” said Fritz. In addition to building the core muscle groups, hands-on therapy to mobilize the spine has been shown to be particularly effective. 5, 6  “Spinal manipulation can be an important component of physical therapist treatment for low back pain. Supplementing exercise with spinal manipulation is also beneficial for many patients.”

Physical therapists can help patients develop a safe and effective exercise program that is tailored to an individual’s specific needs and goals. “Surgery should be the last option, but too often patients think of surgery as a cure all and are eager to embark on it,” said Luke Madigan, MD, an attending physician at Knoxville Orthopaedic Clinic, Knoxville, TN, and the lead author of the literature review.

Physical therapists are highly-educated, licensed health care professionals who can help patients reduce pain and improve or restore mobility – in many cases without expensive surgery or the side effects of prescription medications. APTA represents more than 70,000 physical therapists, physical therapist assistants, and students of physical therapy nationwide. Its purpose is to improve the health and quality of life of individuals through the advancement of physical therapist practice. In most states, patients can make an appointment directly with a physical therapist, without a physician referral. Learn more about conditions physical therapists can treat and find a physical therapist in your area at www.moveforwardpt.com.

1Andersson GB: Epidemiological features of chronic low back pain. Lancet 1999; 354:581-585.

2Hayden JA, van Tulder MW, Malmivaara A, Koes BW: Exercise therapy for the treatment of non-specific low back pain. Cochrane Database Syst Rev. 2005;(3):CD000335.

3Assendelft WJ, Morton SC, Yu EI, Suttorp MJ, Shekelle PG: Spinal manipulative therapy for low back pain. Cochrane Database Syst Rev. 2004;(1):CD000447.

4vanTulder MW, Scholten RJ, Koes BW, Deyo RA: Nonsteroidal anti-inflammatory drugs for low back pain: a systematic review within the framework of the Cochrane collaboration back review group Cochrane review. Spine 2000:25:2501-2513.

5Childs JD, Fritz JM, Flynn TW, Irrgang JJ, Johnson KK, Maikowski GR, Delitto A: A clinical prediction rule to identify patients with low back pain most likely to benefit from spinal manipulation: a validation study. Ann Intern Med. 2004; 141(12):920-928.

6Chou R, Huffman LH: Nonpharmacologic therapies for acute and chronic low back pain: a review of the evidence for an American Pain Society/American College of Physicians clinical practice guideline.; American Pain Society; American College of Physicians; Ann Intern Med. 2007; 147(7):492-504.

[Last updated: 02/23/09 | Contact: public-relations@apta.org]

Reston, VA, January 26, 2009– Richard Deyo MD, the keynote speaker at the American Academy of Orthopaedic Manual Physical Therapists (AAOMPT) National Conference in October 2008, has again published data indicting the US approach to chronic back pain dramatically increases costs without improved outcomes. Deyo and colleagues reported in the January 2009 issue of the Journal of American Board of Family Practice the following staggering statistics:
·    A 629% increase in Medicare expenditures for epidural steroid injections;
·    A 423% increase in expenditures for opioids for back pain;
·    A 307% increase in the number of lumbar magnetic resonance images among Medicare beneficiaries;
·    A 220% increase in spinal fusion surgery rates.
The incidence of chronic and acute Low Back Pain, as documented by office visits, has not changed during the last 12 years. The application of these technologies is not without consequences Deyo et al noted, ‘Innovation has often outpaced clinical science, leaving uncertainty about the efficacy and safety of many common treatments. Complications and even deaths related to pain management are increasing.’ Indeed, the reoperation rates for low back pain have increased, not improved. The authors conclude that the ‘Prescribing yet more imaging, opioids, injections, and operations is not likely to improve outcomes for patients with chronic back pain.’  They note that these approaches often are applying an acute care model to chronic pain and not acknowledging the current evidence that chronic pain requires a different approach and that there are ‘no magic bullets.’  In a “chronic care model” chronic back pain, like diabetes or asthma, ‘is a condition we can treat but rarely cure.’ Deyo et al suggest the solution that  ‘chronic back pain may benefit from sustained commitment from health care providers; involvement of patients as partners in their care; education in self-care strategies; coordination of care; and involvement of community resources to promote exercise, provide social support, and facilitate a return to work.’
Tim Flynn, PT, PhD, president of the AAOMPT states, ‘The manual physical therapist is the health care provider uniquely trained to manage individuals with chronic low back pain.  We utilize low risk, state-of-the-art care incorporating exercise, manual physical therapy, patient education and the application of the biopsychosocial model in managing this chronic condition. The Academy is dedicated to the application of current models for chronic pain management.’ The recent AAOMPT conference in Seattle focused on current theories and practice of chronic pain management with international experts on pain management.

ScienceDaily (Jan. 7, 2009) — The novel design of a deep muscle along the spinal column called the multifidus muscle may in fact be key to spinal support and a healthy back, according to researchers at the University of California, San Diego School of Medicine.

Their findings about the potentially important “scaffolding” role of this poorly understood muscle has been published on line in advance of the January issue of the Journal of Bone and Joint Surgery.
“The multifidus muscle was formerly thought to be relatively unimportant based on its fairly small size,” said Richard L. Lieber, Ph.D., Professor and Vice Chair of UC San Diego’s Department of Orthopedic Surgery and Director of the National Center for Skeletal Muscle Rehabilitation Research, based at UC San Diego. Lieber is also Senior Research Career Scientist at the Veterans Affairs San Diego Health System. “Our research shows that it’s actually the strongest muscle in the back because of its unique design. It’s like a long, skinny pencil packed with millions of tiny fibers.”

The researchers discovered that the multifidus has a unique packing design consisting of short fibers arranged within rods, and that these fibers are stiffer than any other in the body. Using laser diffraction methods that they developed to measure muscle internal properties during back surgery, they demonstrated that the multifidus’ unique design serves a critical function as a stabilizer of the lumbar spine. These findings could have implications for surgery, according to Steven R. Garfin, M.D., Professor and Chair of UCSD’s Department of Orthopaedic Surgery.

“It is important to identify what each individual muscle does, and this is just a start, showing that the multifidus contributes significantly to spinal stabilization,” said Garfin. “The more we know about what muscles do, the better we can devise therapeutic interventions such as physical therapy to target specific muscles.”

Garfin explained that currently surgery to treat spinal disorders could actually disrupt the multifidus muscle, which could lead to decreased stabilization and lower back pain. Minimally invasive spine surgery techniques strive to minimize surgical trauma to these muscles in order to best preserve their function.

The lower back, or lumbar spine, can be vulnerable to many pain-causing injuries or disorders because the lumbar vertebrae carry the most body weight and are subject to the most force and stress along the spine. Muscular instability is a risk factor in many injuries and consequent chronic lower back pain, according to Lieber. “The multifidus back muscle keeps us vertical and takes pressure off the discs,” said Lieber. “When muscle function is poor due to back problems, support is lost.”

He explained that many muscles get weaker as they are extended. But the researchers discovered that, unlike all other muscles, the multifidus actually becomes stronger as it lengthens, when the spine flexes.
“The length of the sarcomere—the structure within the muscle cell where filaments overlap to produce the movements required for muscle contraction—is shorter in the multifidus than in any other muscle cell,” explained study’s first author Samuel R. Ward, P.T., Ph.D., Assistant Professor of Radiology at UC San Diego School of Medicine. “But as it gets longer, for instance as a person leans forward, the multifidus actually strengthens.”

Contributing authors to the study include UCSD researchers Choll W. Kim, M.D., Ph.D., Carolyn M. Eng, B.S., Lionel J. Gottschalk, B.S.; and Akhito Tomiya, M.D., Ph.D. Tohoku University School of Medicine, Sendai, Japan. Research was supported by the Department of Veterans Affairs Rehabilitation, Research and Development; the National Institutes of Health and DePuy Spine of Raynham, MA.
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Adapted from materials provided by University of California – San Diego, via EurekAlert!, a service of AAAS.

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A Physical Therapist’s Perspective:

This report should be of interest to any physcial therapist that treats low back conditions because it provides evidence of the role that the multifidus muscle plays in stabilization of the spine. Although, I have issue with the statement that “the multifidus muscle was formerly thought to be realtively unimportant based on it’s fairly small size”. Physical therapy researchers discovered over a decade ago the importance of the multifidus muscle in spine stability and its relation to low back pain. For this reason many physical therapists have advocated the importance of proper rehabilitation following any lumbar spine surgery that disrupts the multifidus muscle.  In addition, much of recurrent and chronic low back pain can be attributed to spinal instability. Thus, there has been much focus in the clinical field of physical therapy to perform exercises that retrain the multifidus in conjuciton with the transverse abdominus and pelvic floor muscles. To read more about the role of motor control exercises for spine related problems read this news release- Report Shows Motor Control Exercises Reduce Persistent Low Back Pain

Tamer S. Issa, PT, DPT, OCS

Physical Therapy an Alternative to the High Risks of Methadone

Tallahassee, Florida, August 18, 2008 – A recent investigative report1 published in the New York Times highlights the alarming increase in methadone prescriptions for the treatment of chronic spinal pain.  The result has been a shocking increase in methadone related deaths.  Physical therapists can play a role in providing patients and physicians with an alternative to dangerous pain medications like oxycodone and methadone.

Methadone was once limited to use in addiction treatment centers to replace heroin, but today it is frequently given out by physicians to manage spine and joint pain.  The Drug Enforcement Administration noted that from 1998 to 2006, the number of methadone prescriptions increased by 700 percent.  “Many legitimate patients, following the direction of their doctor, have run into trouble with methadone, including death,” noted pain specialist Dr. Howard A. Heit from Georgetown University.  Florida alone, which keeps detailed data, listed methadone as a cause in 785 deaths in 2007, up from 367 in 2003.

“These are senseless deaths,” said Dr. Timothy Flynn of Regis University in Denver, CO, and President of the American Academy of Orthopedic Manual Physical Therapists (AAOMPT).  “Patients should be aware that these medications are not the best option to reduce the symptoms of spinal pain. Research has shown that early movement and treatments like exercise and spinal manipulation offer strong benefits to spine pain and disability.”  “The medical management of spinal pain in this country is a failure,” continued Flynn, “we too often initiate prescription drug therapy before choosing safe and effective alternatives.”  Flynn suggests that patients seek out physical therapists as a first-line treatment for these conditions.

A February 2008 report published in the Journal of the American Medical Association reports that from 1997 to 2005, pharmaceutical expenditures for the management of low back pain increased by 171% while the rate of good outcomes fell.  “All the imaging we do, all the drug treatments, all the injections, all the operations have some benefit for some patients,” said Richard A. Deyo, a physician at Oregon Health & Science University in Portland and a coauthor of the report.  “But I think in each of those situations we’ve begun using those tests or treatments more widely than science would really support.”

For more on the benefits physical therapists can provide in the management of spinal pain, contact your nearest physical therapist or visit the American Academy of Orthopaedic Manual Physical Therapists website at www.aaompt.org.  AAOMPT represents physical therapists by promoting excellence in orthopaedic manual physical therapy practice, education and research.

Dr. Richard Deyo, MD, MPH will be the key note speaker at AAOMPT’s Annual Conference in Seattle this November.  The conference theme will focus on pain management and physical therapists’ role in this important area of care.

PHILADELPHIA__The American College of Physicians and the American Pain Society recommend doctors prescribe physical therapy when managing patients with low back pain.

“There are many options for evaluation and treatment of low back pain,” said Amir Qaseem, MD, PhD, MHA, senior medical associate in the American College of Physicians Department of Clinical Programs and Quality of Care, and an author of the guidelines. “We wanted to review all the evidence and develop guidance for clinicians and to give our patients a realistic sense of what they can expect when they visit a clinician for low back pain.  In particular, clinicians should consider the addition of non-pharmacological therapies with proven benefits.”
“This recommendation comes as no surprise to physical therapists,” said Dr. Timothy Flynn from Regis University, Denver, and President of the American Academy of Orthopedic Manual Physical Therapists (AAOMPT). “Research has consistently shown the value of particular physical therapy interventions for patients with low back pain.  Specifically, spinal manipulation and exercise have repeatedly been shown to be effective in managing patients’ current pain and preventing future episodes.  We are glad to see that the American College of Physicians and the American Pain Society recommend physical therapy as a safe and effective alternative to drugs for patients with back pain.”  Physical Therapists can help patients with low back pain by performing thorough examinations and designing an evidence-based treatment program to meet their particular needs.  These treatments can include hands-on therapies to mobilize the spine and exercises designed to alleviate low back pain.
For more on the benefits that physical therapists can provide in the management of low back pain, contact your nearest physical therapist or visit the American Academy of Manual Physical Therapists website at: http://www.aaompt.org.