Low back pain is one of the most prevalent musculoskeletal disorders affecting up to 55.2% of the population worldwide. Individuals may either experience a single episode of back pain or suffer a number of recurring episodes throughout their lifetime. According to the European guidelines for chronic low back pain, which is defined as pain that persists for more than 3 months, 44-75% of patients who have suffered a previous episode of back pain will go on to develop recurrent episodes of pain.
Low back pain may be classified into 2 types: specific or non-specific.
· Specific low back pain is caused by a specific pathology that can be diagnosed from medical investigations. This usually includes spinal fractures, disc bulges and degenerative conditions such as osteoarthritis.
· Non-specific low back pain presents in the absence of an identifiable pathology and can present with a variety of accompanying symptoms. This type of back pain is the most prevalent.
Nonspecific low back pain has been acknowledged within the literature as a multidimensional process where the sensation of pain may be prolonged, or intensified, by both physical and psychological factors.
Physical factors that may lead to the onset of pain include prolonged postures, muscle weakness, the use of incorrect muscles during repetitive daily activities or from lack of exercise. On the other hand, some of the psychological factors that have been found in close association with non-specific low back pain include high anxiety levels, fear-avoidance beliefs and maladaptive coping habits.
Manual therapy is one of the most commonly implemented treatment strategies for the management of back pain. It usually consists of a hands-on approach that makes use of joint mobilisations and manipulations to help reduce pain and restore mobility between spinal segments. Research has shown manual therapy to be effective, in the short term, in reducing pain and in improving movement in clients suffering from low back pain.
Psychological factors may be targeted through adequate educational strategies and regular exercise. Education about the origin of the patients’ pain and clarification of the true meaning of pain may help reduce psychological distress and avoid maladaptive behaviours. It is especially important to make patients more aware about the fact that pain does not always implicate harm. Patients that suffer from chronic pain tend to develop a more sensitive nervous system, meaning the brain loses the ability to distinguish between good and harmful movements. Therefore, pain is also produced in the absence of injury.
Education should also stress on the importance of maintaining a level of activity during episodes of pain. There is strong evidence within the literature and within various guidelines around the world that recommend exercise therapy, alongside manual therapy, for the treatment of low back pain. Exercise has been shown to reduce pain, disability levels and target psychological factors, in both the short and long term, in clients suffering from chronic low back pain. In chronic pain, the deep muscles that surround the spine become inhibited or ‘switched-off’ during movement. These deep muscles act in a similar way to a ‘corset’ and are important in increasing the support around the spine.
When inhibited, the bigger and more superficial muscles tend to generate greater forces on the spine and this may start off a vicious cycle of pain and inflammation especially during repetitive movements. Exercise therapy should be commenced within a clinical setting to ensure a better understanding of how to appropriately activate these deep muscles to help reduce the risk of developing poor muscle recruitment strategies by the client. This can then be transferred confidently to a home exercise program that is functional and specific to every client’s needs.