Understanding the Problem

Low back pain is a diverse condition that can range from mildly aggravating to totally debilitating. It is extremely common and often cited as causing more disability around the world than any other condition.  And individuals who develop chronic low back pain (CLBP) are increasing over time. This means that as people age, more and more of them are not getting better from their low back pain, despite treatment efforts from doctors, therapists, chiropractors, and others. Any therapist who has seen a patient for low back pain has likely come away at some point confused and frustrated by a patient that didn’t improve. 

So how do we get better at this extremely diverse and increasingly challenging condition to treat? The first step for any healthcare practitioner is to determine how severe their patient’s pain is so that they can guide them toward the right type of care. Read on to learn the top three recommended lower back pain treatments from an AAOMPT Fellow, and Duke Professor, Chad Cook, PT, PhD, MBA, FAPTA.

The Truth about What’s Contributing to an Increase in Low Back Pain 

Nearly 75-84% of the general population will experience low back pain at some point in their lifetime. The fact that the problem is so common makes identifying causes or contributions challenging. Further complicating the process of identifying causes is the fact that most people will heal on their own without visiting a doctor. 

Dr. Cook shares, “It is important to recognize that there are no definitive “home run” contributors or causes of low back pain. Individuals with various activity levels, occupations, ages, and other factors may influence who experiences disabling low back pain.”  Next, we will explore factors associated with initial, chronic, and recurrent low back pain. 

Biological Factors That Correlate with Higher Risk of Low Back Pain 

Some of the biological factors that can affect a person’s likelihood of developing low back pain include:

• A person’s strength
• Their engagement in certain risk activities (e.g., incorrectly lifting, overuse)
• The physical demands of their job (e.g., lifting, standing, and exertion requirements)
• Genetics 

Psychosocial Factors That Affect a Person’s Risk of Low Back Pain

Likewise, psychosocial factors play a role. “People with negative moods, and lower socioeconomic status and education are more likely to experience short- and long-term low back pain than those with higher socioeconomic status and a positive mood,” explains Chad Cook, PT, PhD, FAAOMPT. 

Factors Contributing to Disabling and Chronic Low Back Pain

Contributors to severe, disabling, recurrent low back pain that leads to high levels of disability are also biologically and psychosocially oriented. 

Biological factors include:

• Higher levels of initial pain intensity
• Higher body weight
• Carrying heavy loads at work (> 25 lbs)
• Difficult (compromised) working positions
• Sitting more than 2 hours
• Standing or walking more than 2 hours

Psychosocial factors include:

• Poor coping and self-management strategies
• Depression
• Perception of carrying heavy loads at work
• Perceived inadequacy of income
• Job dissatisfaction
• General anxiety
• Smoking 
• Catastrophizing (e.g., worrying about all areas associated with their back pain)
• Fear avoidant beliefs
• Fear of movement

Preventative Measures to Reduce the Risk of Future Low Back Pain 

There are no “silver bullets” for preventing future episodes of low back pain, but there are characteristics of those who have a reduced likelihood of experiencing a low back pain episode. Regardless of age, individuals who regularly perform resistance and aerobic exercise are less inclined to have low back pain episodes. Educated individuals who have high levels of self-efficacy (a person’s capacity to use their own behaviors to accomplish what is needed) also are less likely to experience a low back pain episode. 

Some Job Duties Have Higher Than Average Associations with Low Back Pain 

While it is common to associate certain occupations with higher instances of low back pain, the reality is that it’s less about a person’s occupation and more about the demands associated with their specific jobs. It is also about the individuals’ perception of their work and their satisfaction on the job.

Workers who repeatedly are required to lift heavy objects in comparison to their own weight, transfer patients, work in confined areas, perform repetitive tasks, or are exposed to stressful working environments may have higher chances of experiencing low back pain. Those lacking the physical conditioning to meet the demands of jobs are at further risk. 

The Top Three Treatment Options for Lower Back Pain 

For individuals experiencing CLBP, there are three treatment options well supported within the literature:

1. Education. A focus of education is on supporting self-management for the individual with low back pain so that they do not require potentially risky invasive procedures such as surgery, injections, or opioids. Self-management also entails reduction of the development of psychological risk factors for CLBP.
   1. When it comes to acute low back pain. The best education involves encouraging the patient to avoid bed rest. They should be encouraged to remain active and keep moving as the body heals itself. Letting the patient know that a majority of acute low back pain episodes may resolve in six weeks on average with no interventions but that low risk care options such as over the counter NSAIDS (directed by MD), physical therapy, chiropractic care, and massage may be helpful. 
   2. When it comes to chronic low back pain neuroscience education combined with exercise may be useful in addition to advice to remain active. It may also be useful to counsel the patient on ways to modify and priorities daily tasks to reduce pain flare ups.
2. Manual therapies. Manual therapies, such as manipulation, mobilization, and massage, are useful in reducing low back pain intensity and have been shown to increase overall activity levels, which may further mediate symptoms. These interventions are best carried out in the short term and most successful when combined with exercise.
3. Exercise. Exercise may also improve physical activity and has been shown to reduce pain when used over time. There are no superior “one exercise fits all” approaches, in particular with chronic low back pain. But there are certain aspects which may be more useful than others.
   1. Acute pain. Muscle strength and endurance as well as specific trunk activation exercises – these can include yoga, movement control exercise, proprioceptive neuromuscular facilitation. 
   2. Chronic pain. Chronic pain favors a much wider range of exercise and no particular type of exercise really stands out. Yoga, Pilates, strength training, aerobic training, general exercise, specific trunk exercise and activation, and others combined with education seem to be the most effective.