Low back pain: an evidence-based approach

Low back pain is an exceedingly common ailment that has been a cash cow for the medical device industry, the pharmacological industry, and individuals who tout scientifically unsubstantiated claims as facts. While we have become much more effective at treating, diagnosing, classifying and preventing causes of low back pain, there is a lack of research-based evidence regarding conservative therapies. My goals in writing this piece are to highlight the current best practice for physical therapists and bring to light a number of therapies that are commonly used but not supported. Please note, I am not a physician and I do not make any recommendations outside my scope of practice as a physical therapist. This article is also applicable only to simple cases of low back pain; there are many serious issues that can present as lower back pain, and they must be ruled out by a licensed professional before you start a therapy program. Any medical or surgical interventions should be recommended by a qualified healthcare provider. Always talk with your primary care provider before starting any medication and/or pursuing a novel treatment.

Low back pain is one of the most common musculoskeletal disorders for which people seek medical intervention. Some studies estimate nearly 36 percent of Americans will seek treatment each year. It is also one of the most common reasons individuals are referred to physical therapy. We have an understanding of the pathophysiology behind most episodic low back pain, as well as evidenced-based medical/surgical interventions for individuals with severe and emergent conditions. Unfortunately, consistently effective conservative management remains only moderately backed by hard science. In this article we will discuss the current clinical practice guidelines (a document that provides the most up-to-date and evidence-based treatment models) and what interventions are supported by scientific literature.

Let’s get things started by discussing the risk factors for low back pain and their potential implications for diagnosis and treatment. There is moderate evidence to support occupational stressors are correlated with development of low back pain. Additionally, comorbidities such as cardiovascular disease and lifestyle factors (such as smoking, being overweight or being obese) are all correlated with sciatica. That being said, when we look to see if these factors impact the duration of symptoms or return to baseline, there is little support from the current literature. Across the board, expectation of a full recovery and lack of fear avoidance behavior are correlated with return to work and return to prior level of function following an episode of low back pain. Overall, the position of the guidelines is as follows: “Current literature does not support a definitive cause for initial episodes of low back pain. Risk factors are multifactorial, population specific, and only weakly associated with the development of low back pain.” As a takeaway, skepticism of claims that your low back pain is due to a specific behavior or trait is warranted.

Once a patient has undergone a full physical evaluation, the next step is to start treating. The first section of the clinical practice guideline addresses the use of manual (hands on) therapy for the treatment of low back pain. There is strong evidence in support of a thrust technique—think of having someone crack your back—to decrease both acute back pain and associated lower extremity pain. It should be noted this only applies to certain subsets of patients as there are many patients who do not feel improvement from a thrust technique. Also recommended, based on strong evidence, is trunk coordination, strengthening and endurance training (a well-designed core workout). In the case of low back pain with radiating pain into the lower extremities, there is strong evidence to support repeated movements that cause the symptoms in the affected lower extremity to lessen (known as centralization of symptoms). The last recommendation supported by strong evidence is progressive endurance exercises and fitness activities. The key takeaway is this: a program based on strong scientific evidence should include core strengthening, repetitive movements that cause pain in your legs to decrease, and as much physical activity as you can tolerate without exacerbating the symptoms.

There are a few additional techniques in this clinical practice guideline that are supported by weak, moderate or conflicting evidence. The first is flexion-based exercises. According to weak evidence, flexion-based exercises can be used in conjunction with manual therapy, progressive walking programs and strengthening activities in older patients with radiating pain into one limb. Additionally, nerve mobilization techniques may be beneficial for patients with chronic low back pain with radiating pain, provided they are used in conjunction with other supported interventions. The technique supported by conflicting evidence is lumbar traction. According to the most up-to-date research, patients with symptoms that correspond to nerve root compression will benefit from intermittent lumbar traction. On the flip side (and the reason there is conflicting evidence on the subject), patients with chronic low back pain and/or non-radicular symptoms should not be treated with static or intermittent traction. The only intervention included in the guideline supported by moderate evidence is patient education. There is evidence to support patient education that promotes understanding of the underlying pathophysiology, the science behind pain, the favorable outcome of most low back pain cases, and the importance of returning to everyday functional activities in a timely manner.

There you have it, a broken-down and somewhat easier to understand version of the physical therapist clinical practice guideline for low back pain. The biggest goal of this post is that PT rehab protocols for low back pain should focus on function, proper classification, and should utilize the interventions that are supported by high-quality literature. You may notice this guideline did not mention TENS, ultrasound, craniosacral therapy, any “brand name” therapy, topical agents, braces or specific exercise equipment. There are many different approaches to treat low back pain on the market and many professionals who will tell you they have the secret to curing your pain. While there is emerging evidence for some of the more unique treatments out there (see my post on trigger point dry needling), it is not yet substantial enough to make it into the clinical practice guideline. So, if you have low back pain without a formal diagnosis, please talk to your doctor about the next steps to take. If you have any questions about the information in this article, please reach out to me and I would be happy to give what answers I can.

Alex Linde is a physical therapist at Dee PT in Hinesburg and treats patients with a range of injuries and fitness levels he can be reached at [email protected].