Low back pain program management, long-term care
These fixes can all greatly assist in a low back pain program and the long-term management of painful lumbar spine conditions
Low-back pain is a common health care and social problem associated with disability and absence from work. According to the American Chiropractic Association, at any given time, 31 million Americans suffer from low-back pain and re-occurrence is common.1
The long-term and disabling conditions of chronic and recurrent low-back problems are of major concern, from both costs and morbidity aspects.
Chiropractic care has been shown to compare favorably to medical care with respect to long-term pain and disability outcomes in many cases,2 but the chiropractor should carefully consider the optimum treatment plan for each patient on an individual basis. For most cases of chronic low-back pain, a three-step program of spinal adjustments, postural stabilization, and rehabilitative exercise is recommended. Combining these three elements can make the difference between a successful care program and a lingering, recurring low-back condition.
We’ve known for many, many years the efficacy of chiropractic care as a viable option for treating low-back pain. In 2017 the American College of Physicians published an article that recommends “nonpharmacologic” options for the treatment of LBP.3 Of course, chiropractic doesn’t need the “approval” of the ACP, but papers like this can only help. Patients in a previous study were from a university back-pain clinic for patients who had failed to respond to previous conservative or surgical treatment.
The researchers stated that “in our experience, anything less than two weeks of daily manipulation is inadequate for chronic back-pain patients.” In addition, several chiropractic research studies have described various procedures which assisted patients in regaining lumbopelvic structural function and alignment.
A significant factor in reducing excessive biomechanical forces on the lumbar spine is frequently overlooked by practitioners — the use of external supports to decrease external forces. Positioning aids such as sitting postural supports (examples are postural back rests or ischial lifts for chairs and car seats), standing postural supports (such as foot orthotics and heel lifts), and sleeping postural supports (such as mattresses and pillows) can all greatly assist in the long-term management of painful lumbar spine conditions.
During standing and walking (not to mention running in athletes) the lumbar spine and pelvis balance on the lower extremities. If leg or foot asymmetries or alignment problems are present, abnormal forces are transmitted along the closed kinetic/kinematic chain, interfering with spinal function.4 When excessive pronation and/or arch collapse is present, a torque force produces internal rotation stresses to the leg, hip, and pelvis.5
These forces can be decreased significantly with the use of custom-made orthotics, which help to stabilize the spine and pelvis. In patients with degenerative changes in the lumbar discs and facets, the external force of heel strike may aggravate and perpetuate low-back pain, and is easily reduced with the use of shock absorbing orthotics.6,7
Low back pain program management and rehabilitative exercises
Corrective exercises done at home to strengthen supporting muscles are recommended as an adjunct to chiropractic adjustments and postural stabilization. Active involvement of the chronic low-back patient in an appropriate exercise program has been found to be very beneficial,8 even for patients with herniated discs.9 Flexibility and strength exercises can bring about rapid improvements in lumbar spinal function as well as decreases in pain levels.10 Activity should focus on developing strength in the abdominals and supporting pelvic and low-back muscles. This can also enhance the shock-absorbing properties of the tissues.
Specific exercises must develop “dynamic control of lumbar spine forces in order to eliminate repetitive injury to the intervertebral discs, facet joints, and related structures.”11 Recommending specific exercise(s) is not easy, as some research supports the need for abdominal strengthening,12,13 while others advise pelvic tilts,14 and other reports focus on the importance of strengthening the lumbar extensor muscles.15,16 The bottom line is that patients’ needs vary, and exercises that worked for one will not necessarily work for the next.
The first step toward a solution is to use clinical testing and, in particular, postural evaluation to identify the most appropriate and effective lumbopelvic exercise routine. By evaluating the patient’s three-dimensional posture in a reference frame and noting any specific deviations from the ideal intrinsic equilibrium, the doctor is able to identify the sources of excessive biomechanical stress and give specific corrective exercise recommendations. Of course, a general conditioning and flexibility program will complement the specific corrective postural exercises.
2. Nyiendo J, Haas M, Goldberg B, Sexton G. Pain, disability, and satisfaction outcomes and predictors of outcomes: a practice-based study of chronic low back pain patients attending primary care and chiropractic physicians. J Manip Physiol Ther 2001; 24(7):433-439.
3. Qaseem A1, Wilt TJ1, McLean RM1, Forciea MA1; Clinical Guidelines Committee of the American College of Physicians. Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain: A Clinical Practice Guideline From the American College of Physicians.
4. Keane GP. Back pain complicated by an associated disability. In: White AH, Anderson R. eds. Conservative Care of Low Back Pain. Baltimore: Williams & Wilkins, 1991:307.
5. Hammer WI. Hyperpronation: causes and effects. Chiro Sports Med 1992; 6:97-101.
6. Light LH. Skeletal transients on heel strike in normal walking with different footwear. J Biomechanics 1980; 13:477-480.
7. Faunø P. Soreness in lower extremities and back is reduced by use of shock absorbing heel inserts. Int J Sports Med 1993; 14:288-290.
8. Mayer TG, Gatchell RJ. Objective assessment of spine function following industrial injury: a prospective study with comparison group and one-year follow-up. Spine 1985; 10:482-493.
9. Saal JA, Saal JS. Nonoperative treatment of herniated lumbar intervertebral disc with radiculopathy: an outcome study. Spine 1989; 14:431-437.
10. White AA, Panjabi MM. Clinical Biomechanics of the Spine. 2nd ed. Philadelphia: J.B.Lippincott, 1990:429.
11. Saal JA, Saal JS. Rehabilitation of the patient. In: White AH, Anderson R. eds. Conservative Care of Low Back Pain. Baltimore: Williams & Wilkins, 1991:31.
12. Williams PC. Lesions of the lumbosacral spine: chronic traumatic (postural) destruction of the lumbosacral intervertebral disc. J Bone Joint Surg 1937; 19:690.
13. Schmidt GL, Herring T. Assessment of abdominal and back extensor functions. Spine 1983; 11:19-27.
14. Partridge MJ, Walters CE. Participation of the abdominal muscles in various movements of the trunk in man: an EMG study. Phys Ther Rev 1959; 39:791-800.
15. Mayer TG, Smith SS. Quantification of lumbar function: sagittal plane trunk strength in chronic low-back pain patients. Spine 1985; 10:765-772.
16. Beinborn DS, Morrissey MC. A review of the literature related to trunk muscle performance. Spine 1988; 13:655-660.