Abstract
Lumbar pain ranks second among the causes of chronic illness, is the fifth cause of hospitalisation and the third most common reason for surgery, its socio-economic impact being quite major. Lower back pain is a complex symptom, involving muscular, articular, vertebral and/or spinal structure and peripheral nerves. Despite the minimal number of studies aiming to prove the change in radiculopathy evolution, we believe that physiotherapy holds a major part. Some authors reported notable results from aggressive conservative (non-surgical) treatments (a strict exercise program associated with epidural steroid injections) applied to lumbar disc herniation with radiculopathy. The protocol of these studies is the foundation of many exercise programs currently used in treating lumbar disc herniation with radiculopathy.Regarding the efficiency of surgical treatment compared to conservative treatment, studies show that improvements have consistently been in favour of surgical interventions, but have been statistically insignificant. Due to the large number of patients combining the two treatments, the conclusions regarding the superiority or equivalence of the treatments are not justified on the basis of the analysis between the two treatments. The aim of this paper is to perform a study of specific literature and to present a series of physiotherapeutic elements with beneficial effects on the treatment of lumbar pain.
Keywords: Low back painphysiotherapyactive mobilisation
Introduction
Lumbar pain (LP), the classic clinical manifestation of lumbar discogenic radiculopathy, is the most costly benign condition in developed countries. Experts have assessed that 80% of US population has or will suffer from spinal pathology caused by LP at one point in their life. The annual prevalence of lumbar pain is 15-45%. About 33.2% of patients with lower back pain show symptoms for less than a month, 33% report pain for 1-5 months, and 32.7% patients – more than 6 months. Chronic symptomatology is observed in about 2-7% of patients.
The lumbar spine has dichotomous roles and functions, namely its strength is coupled with flexibility. The spine holds is vital in supporting and protecting the contents of the spinal canal, at the same time offering flexibility for the movement needed in day-to-day activities.
The strength of the spine is a result of the size and position of bones, as well as of the arrangement of ligaments and muscles. Flexibility results from the large number of joints placed in series, close to one another. Each vertebral segment acts as a complex of three joints – an intervertebral disc with two vertebral terminals and two facet joints. These are coupled with the lobular appearance typical of the lumbar spine, offering flexibility and increasing the power to absorb mechanical shocks. (Braddom, 2015) In time, the spine undergoes changes impacting its function and gives way to common issues, such as the alteration of the intervertebral disc by protrusion/prolapse.
Problem Statement
Although we have not identified studies proving a change in the evolution of acute radiculopathy, we believe that physiotherapy has a firm role in this theory. Some studies put forward very good results from an aggressive conservative (non-surgical) treatment of the lower back pain (a strict exercise program associated with epidural steroid injections) applied to lumbar disc herniation with radiculopathy. The protocol of these studies is the foundation of many exercise programs currently used in treating lumbar disc herniation with radiculopathy. Lumbar epidural steroid injections are now a frequent aid in treating lumbosacral radiculopathy. These injections aid in active therapies reducing pain and inflammation and are best used when combined with an active rehabilitation program. Physiotherapists are well educated and trained to administer interventions through the qualified use of physiotherapy techniques and methods in order to make changes according to the diagnosis, prognosis and set goals.
Research Questions
Numerous research papers on the efficiency of various treatment options for lumbosacral pain showed limited improvement, especially in terms of acute lumbosacral pain.
The most commonly used therapies in large-scale clinical studies, such as medicine and physiotherapy, showed only a 10- or 20-point improvement out of the 100 points of the Visual Analogue Scale for Pain (Braddom, 2015).
Considering the above, we believe that therapeutic solutions are welcome in the complex treatment of lumbar pain, associating several therapeutic means for the set goals and pain relief.
Purpose of the Study
Several authors offer the most accepted theory on the spinal degenerative cascade process, describing the sum of stages in the degenerative lumbar spine pathology, ultimately leading to spondylosis, herniated disc and vertebral canal stenosis. From a biomechanical point of view, many aspects have been observed that may lead to the appearance of various lumbar problems. In general, flexion exerts pressure on the anterior portion of the disc, pushing the nucleus to migrate backwards. When the forces are strong enough, the nucleus can get herniated between the fibres of the fibrous ring. Since lateral longitudinal ligament fibres are the thinnest, they make posterolateral disc extrusions the most frequent type of herniation.
The posterolateral portion of the disc is at the highest risk when spine flexion is associated with spine rotation. Interaphic joints cannot resist rotation when the column is flexed, thus increasing lumbar torsion and shear forces, making the flexion-rotation movements likely to be the most risky for intervertebral discs (Braddom, 2015). Lumbar muscle activity correlates well with intradiscal pressure (when the back muscles contract, it is associated with an increase in intradiscal pressure). These pressures change according to the posture of the spine and the undertaken activities. The vertical orthostatic posture is considered to be 100%, while other postures and activities are calculated relative to it. Combining rotation with a posture in flexion substantially increases pressure on the disc. To reduce the forces acting on the lumbar spine, the load should be raised as close as possible to the body, because the farther away from the body, the higher the pressure on the lumbar spine.
Knowing these mechanisms, the physiotherapist can select the appropriate means and methods for the medical recovery protocol. The program will also be designed based on the patient’s general condition and current symptoms. A program that is not adapted to the patient’s problems might worsen the symptoms.
Research Methods
Physical therapy can be used in all stages of lumbar disc sciatica, but should be individualised according to its clinical form. A classification allowing the synthesis of the means of treatment is useful to guide the therapist. Clinical examination will specify the current stage of the patient: acute, subacute, chronic, or remission (Kiss, 2007).
Several methods can generally be included in the complex treatment of lumbar radiculopathy.
Extension exercises are still commonly used by therapists for the treatment of lumbosacralgia, especially pain accompanied by lower-limb root pain. Extension-based exercises are often performed using the McKenzie principles of physical therapy. This therapeutic approach divides the diagnosis of lumbar pain into three categories: disorder, dysfunction and postural syndrome. Although initial studies were promising, subsequent studies have shown that this type of exercise is useful, but not more effective than other types of exercise (Braddom, 2015).
Flexion exercises, the Williams three-phase program, were very popular in treating acute lumbar pain, but the use of a series of flexion exercises has not been proven to be more useful in acute lumbar pain compared to other interventions, such as spine manipulations. We have not found any research to highlight the effectiveness of flexion exercises in chronic lower back pain. Since lumbar radiculopathy may be caused by lumbar canal stenosis, flexion exercises are usually recommended to increase the size of the canal and reduce nerve irritation.
Diadynamic currents – rectified and modulated currents deriving from the main one (a sinusoidal alternating current with a frequency of 50 Hz) show analgesic, hyperaemic and dynamic effects.
Trabert currents – rectangular currents, with a visible analgesic and hyperaemic effect, are indicated in painful spondylosis. Transcutaneous electrical nervous stimulation (TENS) is a non-traumatic method of fighting acute and chronic pain.
TENS – the Gate theory of Melzack and Wall underlies the development of TENS. Average frequency currents are sinusoidal alternating currents with a frequency between 3 and 10 KHz.
Interference currents – obtained by the interference of two medium frequency currents. High frequency currents – the types of high frequency therapy used in the treatment of spondylosis are: short waves; high-frequency pulse therapy (Diapulse). The caloric effect is the main effect of this therapy. Electromagnetic currents and magnetodiaflux are two forms of applying magnetic field therapy. The continuous form of application is used for its sedative effect. Low-frequency magnetotherapy can also be applied and interrupted – rhythmically or at no rhythm, resulting in a general stimulation effect.
Ultrasound – this therapeutic method is used in degenerative rheumatic conditions, with important therapeutic success.
Findings
Studies on the effectiveness of various treatments for lumbosacralgia, especially in its chronic period, have shown limited efficacy. The most commonly prescribed treatments, such as drugs, physiotherapy (kinetotherapy, electrotherapy, manual therapy), achieved, during major clinical trials, only 10 or 20 points out of the 100 points in the Visual Analogue Scale for Pain (Braddom, 2015).
Considering the above, we believe that therapeutic solutions are welcome to address the complex issues of lumbar radiculopathy.
Physiotherapists are professionals educated and trained to administer interventions through the qualified use of kinetotherapy methods and techniques according to the diagnosis, prognosis and set goals.
Conclusion
Studies targeting the effectiveness of various treatments for lumbosacralgia, particularly in its chronic period, have shown limited efficacy. The most commonly prescribed treatments are drugs and physiotherapy (electrotherapy, kinesiotherapy, manual therapy), which showed improvement in patients during clinical trials. We believe that therapeutic solutions are welcome to address the complex issues of lumbar radiculopathy.
Many opinions argue that the evolution of acute radiculopathy has not been shown to change with physiotherapy; recent studies have found that physiotherapy has a role in this regard; they have reported very good results using an aggressive non-surgical treatment (an active kinetotherapy program associated with epidural steroid injections) in the treatment of lumbar disc herniation, combined with radiculopathy. The established protocol is the basis of many current exercise programs used to treat lumbar disc herniation associated with radiculopathy.
Cognitive-behavioural therapies, kinetotherapy, spinal handling and interdisciplinary rehabilitation have moderate effectiveness in chronic or subacute pain. For acute low back pain, the only therapy with evidence of efficacy consists in applying superficial heat. (Chou & Huffman, 2007)
References
- Braddom, R. L. (2015). Medicină fizică şi de reabilitare (Ed. a IV-a). Bucureşti: Elsevier.
- Chou, R., & Huffman, L. H. (2007). 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. Annals of Internal Medicine, 147(7), 492-504.
- Cordun, M. (1999). Kinetologie medicală. Bucureşti: AXA.
- Kiss, I. (2007). Fizio-kinetoterapia şi recuperarea medicală. Bucureşti: Editura Medicală.
- Sbenghe, T. (1987). Kinetologie profilactică, terapeutică şi de recuperare. Bucureşti: Editura Medicală.
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About this article
Publication Date
16 February 2019
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eBook ISBN
978-1-80296-054-9
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Future Academy
Volume
55
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1st Edition
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Sports, sport science, physical education
Cite this article as:
Chiriac, O., Cordun, M., & Gherghel, C. L. (2019). Physiotherapy Options For Low Back Pain. In V. Grigore, M. Stănescu, M. Stoicescu, & L. Popescu (Eds.), Education and Sports Science in the 21st Century, vol 55. European Proceedings of Social and Behavioural Sciences (pp. 406-411). Future Academy. https://doi.org/10.15405/epsbs.2019.02.51