Lower back pain update post 2013
You may have
previously read my article on lower back pain back in 2013 but like all things ‘Physio’,
the research keeps coming. So I thought that this subject needed an updated article
based on the most recent evidence out there. So what I have done is only looked
at research published from 2013 to now.
Causes: Weight:
How many of you
have been to the G.P. and they said if you lose weight it will help your back
pain? Well the research has found that a relationship between back pain &
weight doesn’t exist (Woolner & Dean 2013).
Muscle imbalance:
Muscle imbalance
relates to muscle that work together being unbalanced meaning some are weak,
some are tight some are long etc. Arbanas et al (2013) found that there is an increased
activity of the Psoas Major muscle (hip flexor) in Lower Back pain patients.
But is this Cause or effect or both?
Bending too much?
How many people
have been told this? I probably have told this to patients in the past but I
would be wrong according to Villumsen et (2014)they actually found that forward
bending may actually lower & not increase pain in low back pain sufferers
(Villumsen et al 2014). That’s me told then!!
Prognosis (how well you are likely to get better):
It was found
that with a Lumbar disc sequestration, which is worse than a prolapsed disc
actually had a significantly higher rate of complete regression compared to a
small disc bulge (Chiu et al 2015). So the worse the disc is “out” the better
you will resolve!
It takes a long time
for back pain to improve. Most primary care patients do not become pain-free
within a year but do improve from how bad they were at the start (Kongsted et
al 2015).
Don’t fear back
pain! It is normal and usually it is nothing major. Research finds that fear
avoidance behaviours (when you stop an activity or movement for fear that it
will make things worse) are associated with poor treatment outcome in patients
with Low Back pain (Wertli et al 2014). So move and do!
Diagnosis:
MRI scans: Disc
bulging was frequently observed in asymptomatic subjects, even including those
in their 20’s (Nakashima et al 2015). Another study found that only 4% of pain
free elite junior tennis players had no abnormalities on MRI scans of the
lumbar spine (Rajeswaran et al 2014). So a scan could be misleading and may
hinder rather than help. It needs to interpreted with other objective and
subjective information.
This was
highlighted by Nakashima et al (2015) who believes that it is dangerous to use
MRI scans alone to diagnose degenerative changes in the spinal cord and discs.
Treatments available:
So there are
many treatment s that are done for lower back pain and the research is no
different. Everyone is different but let’s look at what the research says:
Pilates:
For:
Pilates exercise
helps back pain & functional ability better than usual care & physical
activity in the short term (Wells et al 2014).
Pilates improves
pain, function & aspects related to quality of life in Chronic low back
pain (Natour et al 2014).
Against:
There is
inconclusive evidence that Pilates is effective in reducing pain &
disability in chronic low back pain (Wells et al 2013).
Pilates was not
better than other types of exercise for short-term pain reduction in Chronic
Low Back Pain (Miyamoto et al 2013).
Overall:
It appears to be
effective but maybe no better than any other type of exercise so it is good for
lower back pain.
Acupuncture:
For:
Acupuncture may
be more effective than medication for symptom improvement or pain in acute low
back pain (Lee et al 2013).
Acupuncture
should be considered for short term relief of pain in patients with chronic low
back pain (Colvin et al 2013).
Acupuncture
provides short-term improvements in pain & function for chronic low back
pain (Liu et al 2015).
Against:
Nothing except
the Placebo argument
Overall:
It helps and
whether it is just placebo or not is still up for debate.
Spinal manipulation:
For:
There is short
term benefit over placebo for manipulation in Chronic low back pain (Hidalgo et
al 2014).
There is short
term benefit over placebo for manipulation in acute to sub acute low back pain
(Hidalgo et al 2014).
Manipulation is
effective for reducing pain & improving functional status in patients with
acute & chronic low back pain (Franke et al 2014).
Based on the
findings of this systematic review there is evidence to support the use of
spinal manipulation (Kuczynski et al 2013).
Against:
Spinal
Manipulative Therapy was found to be no better than placebo for Chronic Lower
Back Pain (Dougherty et al 2014).
Chiropractic
treatment consisting of mostly manipulation was superior to sham treatment but
not considered to be a clinically important difference (Walker et al 2013).
Overall:
It works but
there is debate about why.
Mckenzie:
For:
Chronic low back
pain: McKenzie method was slightly more effective than back school for
disability (Garcia et al 2013).
The McKenzie
method seems to have a positive effect on chronic low back pain patients
(Sansonnens et al 2013).
Against:
Nothing.
Overall:
It seems to be
effective but it is not definitive.
Antibiotics:
For:
Disc prolapse:
Antibiotics had significant & lasting improvements in pain, disability
& the condition of the joints on MRI scans (Albert et al 2013).
Against:
Nothing.
Overall:
This is still a
new area and more work needs to be done to understand it better.
Pelvic floor exercises:
For:
Back pain:
Pelvic floor exercise & routine treatment provides improvement in pain
& disability over just routine treatment (Bi et al 2013).
Against:
Nothing.
Overall:
It helps but may
be too limited on its own to achieve a good effect.
Traction:
For:
Nothing.
Against:
Lumbar traction
has little or no impact on pain intensity, functional status, global
improvement & return to work (Wegner et al 2013).
Overall:
Doesn’t work.
Strength/Core stability exercises:
For:
A review of
systematic reviews found benefit of specific stabilisation exercise for non
specific chronic low back pain (Haladay et al 2013).
Core stability
exercises have a place in chronic low back pain due to lumber stability (Khan
et al 2014).
Sling exercises,
with individually designed segmental stabilizing exercises are more effective
for low back pain (Lee et al 2014).
Strength &
coordination/stabilisation exercises are more beneficial than other
interventions for chronic low back pain (Searl et al 2015).
Against:
The quantity
& quality of literature on the use of core stability exercises for low back
pain in athletes is low (Stuber et al 2014).
There's strong
evidence that stabilisation exercise is not more effective than any other
active exercise in the long term (Smith et al 2014).
Overall:
This is one that
has been used in a major way over recent years. There is no doubt it works but
is it better than other exercise? My opinion is that all exercise works your
‘core’ and so you might as well be more functional.
Mobilisations:
For:
Multiple studies
provided evidence that a single session of spinal joint mobilisation reduced
pain at rest & movement (Slaven et al 2013).
Manual therapy
should be considered for short term relief of pain for patients with chronic
low back pain (Colvin et al 2013).
Manual therapy,
in combination with exercise, should be considered for the treatment of
patients with chronic neck pain (Colvin et al 2013).
Against:
Nothing.
Overall:
Works well short
term but needs a long term solution to back it up.
Epidural injection:
For:
Transforaminal
epidural steroid injection is recommended for 2-4 weeks pain relief in some
lumbar disc prolapses (Jevsevar et al 2013).
Against:
Nothing
Overall:
Works well short
term but needs a long term solution to back it up and it is more invasive with
more potential complications.
Surgery:
For:
Endoscopic
percutaneous discectomy may be considered for the treatment of lumbar disc
herniation with radiculopathy (Jevsevar et al 2013).
Against:
“Failed back
surgery syndrome” occurs in 10 – 40% of back surgery (Shapiro (2014).
Surgical
decompression has similar effects to Physiotherapy in Lumbar Spinal Stenosis
surgical candidates (Delitto et al
2015).
Overall:
It depends. For the
right reasons it can be effective but not always and you should always try
conservative measures first.
Yoga:
For:
12 weeks of
once-weekly or twice-weekly yoga classes were effective for moderate to severe
chronic low back pain (Saper et al 2013).
Early results of
systematic reviews appear promising for the effectiveness of yoga for chronic
low back pain (Hill 2013).
Yoga may be an
efficacious adjunctive treatment for Chronic Low Back Pain (Holtzman &
Beggs 2013).
Against:
Nothing.
Overall:
Very good for
chronic low back pain but not for acute back pain.
Massage:
For:
There is an
emerging body of evidence supporting massage therapy for non-specific low back
pain in the short term (Kumar et al 2013).
Against:
Nothing.
Overall:
A great adjunct for
short term relief but needs to be together with some long term modality for
long term success.
General exercise:
For:
Advice to stay
active in addition to exercise therapy helps long term for patients with
chronic low back pain (Colvin et al 2013).
Moderate regular
physical activity helps to improve fitness & doesn't increase the risk of
pain in chronic low back pain (Ribaud et al 2013).
Against:
Nothing.
Overall:
Great! Works! A
definite one!
Ultrasound:
For:
Nothing
Against:
No quality
evidence was found supporting ultrasound for pain or quality of life in
non-specific chronic Low Back Pain (Ebadi et al 2014).
Ultrasound
therapy had no effect in chronic lower back pain (Licciardone et al 2013).
Overall:
Doesn’t work.
Transcutaneous electrical nerve stimulation (TENS):
For:
TENS works well clinically & is cost effective for chronic low back pain sufferers (Pevic et al 2013).
Against:
Nothing.
Overall:
Can be effective and reduce the need for medication.
Psychological approaches:
For:
Multidisciplinary
Biopsychosocial Rehabilitation: Less
pain & disability than usual care in chronic low back pain (Kamper et al
2014).
Against:
Nothing.
Overall:
Very useful in
Chronic cases due to fear avoidance and catastrophizing.
Proprioceptive exercise:
For:
Improved
proprioceptive control with single leg balance exercises reduced low back pain
by 78% (Riva et al 2015).
Against:
Evidence
suggests there is no consistent benefit in adding proprioceptive training for low
back pain (McCaskey et al 2014).
Overall:
Jury is out for
this specifically. May just be a general exercise effect if effective.
Medications:
For:
Opioids may
offer a favorable treatment option for severe low back pain with a neuropathic
component (Baron et al 2014).
Against:
Paracetamol is
ineffective in the treatment of low back pain (Machado et al 2015).
Overall:
Depends on the
type of medication for the type of pain but effective to manage short term
symptoms but no long term benefit.
Aerobic exercises:
For:
Chronic Low back
pain: Aerobic exercise effectively diminishes pain intensity & improves
physical & psychological function (Meng & Yue 2015).
Against:
Nothing.
Overall:
Effective, but
again mostly due to being a general rather than a specific effect.
Just advice:
For:
Nothing.
Against:
Specific
treatment is better than just advice for low back pain (Chan et al 2015).
Overall:
Not good enough
on its own.
Taping:
For:
Nothing.
Against:
The results of
this systematic review did not show any firm support for the effectiveness of
taping in spinal pain (Vanti et al 2015).
Overall:
No effective,
may be just a placebo effect?
Walking:
For:
A 6 week walk
training programme was as effective as 6 weeks of specific strengthening
exercises for the low back (Shnayderman et al 2013).
Against:
Nothing.
Overall:
Again a good
general exercise effect. As previous all exercise modalities work well to
lesser or greater degrees.
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