lower back pain

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Following approach should be followed while managing the patient with low back pain. First try to rule out all the possible serious causes of low back pain like Benign and malignant primary and neural osseous tumors, Infection (e.g., epidural, subdural, intradural abscesses, discitis, peritonitis, and osteomyelitis), metastatic neoplasms, myeloma, trauma like lumbar fractures, metabolic disorders like osteomalacia, parathyroid disease, vitamin B-12 or folic acid deficiency, developmental and congenital disorders like scoliosis, psychogenic like conversion disorder, malingering, extra spinal causes like renal infection and stones, ovarian cyst, pancreatitis, ulcer, aortic aneurysm, etc. Having assumed serious causes have been ruled out, the treatment should be followed as under:

1-Control of pain and inflammatory process

Treatment for the control of pain can be started early and efficiently. Ice, Superficial and deep heating methods like Infrared rays, electrical heating pads, hot packs, moist heat packs, ultrasound therapy, Shortwave Diathermy, microwave diathermy, LASER, transcutaneous electrical nerve stimulation (TENS), Interferential current, Iontophoresis and relative rest may help with controlling the pain and the inflammatory process. Relative rest, which restricts all occupational and avocational activities, for up to the first 2 days following an acute episode, may be indicated to help calm initial pain symptoms. Rest for longer periods of time has not been shown to be beneficial and can cause deconditioning, loss of bone density, decreased intradiscal nutrition, loss of muscle strength and flexibility, and increased segmental stiffness. Passive modalities are valuable during the initial 48 hours of relative rest to aid in pain relief

2-Restoration of joint range of motion and soft tissue extensibility

Extension exercises may reduce the neural tension. An extension bias commonly is employed to help reduce intradiscal pressure. Flexion exercises reduce articular weight-bearing stress to the facet joints and stretch the dorsolumbar fascia.

If sponylolisthesis and/or spondylolysis are present, then improving abdominal strength and flexibility, stretching of tightened hamstring to reduce lumbar lordosis and pelvic tilt exercises are of value. Exercise for improving the strength and endurance of pelvic floor muscle are valuable if there is there is reported weakness of these muscles.

In case of spinal stenosis flexion exercises for the lumbar spine should be emphasized, as they reduce lumbar lordosis and decrease stress on the spine. Spinal flexion exercises increase the spinal canal dimension, thus reducing neural canal. Williams' flexion-biased exercises target increased lumbar lordosis, paraspinal and hamstring inflexibility, and abdominal muscle weakness. These exercises incorporate knee-to-chest maneuvers, pelvic tilts, wall-standing lumbar flexion, and avoidance of lumbar extension. Furthermore, strengthening exercises for abdominal, weak glutei, Quadriceps femoris are helpful. In addition stretching exercise for tightened hip flexors and hamstrings should not be ignored. Longer walking times on an inclined treadmill, stationery cycling, promotes spinal flexion.

3-Improvement of Muscle strength and endurance

Once the adequate control of pain has been achieved the emphasis should be towards gaining the adequate control of musculoligamentous lumbar spine forces to minimize the risk of repetitive injury to intervertebral discs, facet joints, and surrounding structures. Start with the isometrics, then progress to isotonics with effort directed at concentric strengthening.

The spine should be stabilized using strengthening of segmental muscles followed by the prime movers of the spine (latissimus dorsi, abdominals, and erector spinae). Muscle groups should be strengthened in a neutral position to decrease tension on ligaments and joints; this position allows balanced segmental forces between the discs and the zygapophyseal joints and maximizes functional stability with axial loading. The main goal of physical therapy in acute back pain is not to increase strength, but to achieve adequate pain control. No benefit has been demonstrated for strengthening exercises in acute back pain. Exercise should begin with extension exercises in prone position. Flexion exercises can be performed only if no acute dural tension exists.

4- Coordination training
Assess the gait of the patient and try to improve the coordination of the patient. Dynamic exercise in a structured training program maximizes coordinated muscle group activities that lead to postural control and the fusion of muscle control with spine stability.

5-Improvement of general cardiovascular conditioning
Try to improve the conditioning of the cardiovascular system. Aerobic exercises serve best in this regard. Activities like bicycling, stair stepping, brisk walking, aquatics, rowing should be encouraged. These activities raise the endorphin level, create a sense of well being and attain high level function of the patient, thereby maintaining the fitness of the patient.

6-Maintain the exercise programme
Maintenance of the exercise programme is very important for the patient to do at home. This is developed according to patient own tolerance and ability.

7-Correction of the perpetuating factors
An analysis should be made to find all the possible predisposing factors and a resolution plan should be made to correct these discrepancies. Abnormal posture, bad lifting habits, abnormal working position should be analyzed and corrected.