What is acute and chronic middle and lower back pain?

Back pain is one of the most common reasons people go to the physiotherapy and miss work. Most people in the North America will experience low back pain at least once during their lives. The following conditions may result in lower back pain and your physiotherapist is trained to be able to perform a clinical assessment and physiotherapy diagnosis.  

What are the common causes of back pain?

There are structural problems that can cause back pain and there are functional imbalances that cause painful repetitive strains often due to poor fitness, core strength, and hip mobility, and there are disease processes such as osteoporosis and arthritis that may be the cause of back pain. The most investigated problems are the structural conditions, those that can be picked up on radiographic imaging. These include:  
  • Facet joint sprain
  • Lumbar disc herniation
  • Spinal Degeneration and spinal canal stenosis
  • Scoliosis and other structural curve deviation
  • Spondylolisthesis
  • Postural dysfunction and imbalances
  On the bright side, you can take measures to prevent or lessen most back pain episodes. Often simple self-care, postural hygiene and maintaining proper body mechanics will improve your back within a few days. If it doesn’t, book an appointment with your physiotherapist.   Your back is an intricate structure composed of bones, muscles, ligaments, tendons and discs. Discs are the cartilage-like pads that act as cushions between the bones called the vertebra of your spine. Back pain can arise from problems with any of these component parts. In many, no specific structural cause for their back pain is found and when that is the case, your physiotherapist will look at the biomechanics and function of movement to determine the imbalances and dysfunctional patterns that lead to back pain.    

Muscle Strains

Overuse is something that occurs by repeating a movement over and over or by sustaining a poor posture or position such as spending too many hours sitting, driving, bending or lifting. Often overuse triggers muscle strains that result in pain and spasm. Back muscles, particularly those that surround your abdomen like a corset (core muscles) and the pelvic floor muscles, become fatigued and eventually strained. Often this is associated with joint and disc injury as well. When you overuse or misuse your back, repeatedly, chronic pain can develop. Once strained, you make not even be able to tolerate even small deviations from optimal posture and over time, other structures may be involved and you may not be able to tolerate sitting at all.   Occasionally with repetitive back strains, and a misunderstood etiology, patients will sit more thinking that this will be a way to rest the back when in fact it may do more harm than good.    

Worn-out joints

Just like all the other joints in your body, the joints in your back tend to experience wear and tear with age, with overuse and with misuse. Osteoarthritis is a disease of the spinal joints may cause pain and stiffness. The most common symptom of osteoarthritis is loss of joint mobility and this is why physiotherapists and massage therapists work to prevent and improve and maintain joint mobility.    

Nerve Compression

A variety of problems in the bones of your back called the vertebrae can reduce the amount of space and compress nerves often referred to as pinched nerves. Examples include:  
  • Aging and damaged discs. As you age, the discs between your vertebrae become dry and stiff, narrowing the spaces in your spinal column where the nerves exit.
  • Herniated discs. Discs can become herniated when the inner gel-like material called the annulus of a disc protrudes through the disc's tougher outer covering. The protrusion can press on nerves exiting the spinal column, causing leg pain known as sciatic (see below) and or weakness, or on the spinal cord itself.
  • Bone spurs. Arthritic joints in your back can develop bony growths that may press on nerves and cause painful conditions.
   

Injuries

Bending, twisting, lifting injuries can cause injury to the structures of the back, car accidents and sports injuries can also result in injuries, which occur when the trunk is forced forward or twisted, stretching the soft tissues and joints of the spine beyond their limits. Facet joints may be sprained, muscles and ligaments may be strained and discs may become herniated in the event of these excessive traumatic forces.    

Bulging or Ruptured Disks

Discs act as cushions between the vertebrae in your spine. Sometimes, the soft material inside a disc may bulge out of place or rupture and press on a nerve. But even so, many people who have bulging or herniated discs experience no back pain from the condition. Over time, however, a degenerative process occurs until the disc as well as the joints become affected.  
  • Sciatica. If a bulging or herniated disc presses on the main nerve that travels down your leg, it can cause sciatica — sharp, shooting pain through the buttock and back of the leg.
  • Arthritis. The joints most commonly affected by osteoarthritis are the hips, hands, knees and lower back. In some cases arthritis in the spine can lead to a narrowing of the space around the spinal cord, a condition called spinal stenosis.
  • Skeletal irregularities. Back pain can occur if your spine curves in an abnormal way. If the natural curves in your spine become exaggerated, your upper back may look abnormally rounded or your lower back may arch excessively.
  • Scoliosis, a condition in which your spine curves to the side, also may lead to back pain.
  • Osteoporosis. Compression fractures of your spine's vertebrae can occur if your bones become porous and brittle.
   

Rare but serious conditions

In rare cases, back pain may be related to:  
  • Cauda equina syndrome. This is a serious neurological problem affecting a bundle of nerve roots that serve your lower back and legs. It can cause weakness in the legs, numbness in the "saddle" or groin area, and loss of bowel or bladder control.
  • Cancer in the spine. A tumor on the spine can press on a nerve, causing back pain.
   

What is the prognosis of middle and low back pain?

Most acute episodes of back pain get better with a few weeks of avoiding painful positions and careful attention to the specific mechanics that created the problem.  A regular schedule of over-the-counter pain relievers may be all that you need to improve your pain. A short period of bed rest is fine too, however, without a proper physiotherapy assessment, you may not learn enough about the mechanism and or possible risk factors of your injury. Your physiotherapist will evaluate your back and be able to give you an explanation so that you can put a plan in place for yourself to improve your fitness and or habits etc. Some back injuries require a flexion routine, such as facet joint sprains, degenerative disc problems, and stenosis, but other injuries require an extension routine to treat the clinical problems as is the case with herniated discs.

How can physiotherapy and massage therapy help back pain?

Manual Physiotherapy

Your therapist will begin with an examination of your range of motion and determine if it is your joint mobility and or your strained muscles which are predominant and then determine the best treatment plan to improve mobility. The nerves will be examined to determine if there is a pinched nerve effect and/or if there is neural tension and shortening effect causing nerve like symptoms such as sciatic, tingling, numbness, and “pins and needles”.   A manual physiotherapist uses their palpation skills to determine the inter-segmental movements of the spinal facet joints and in so doing they are able to determine which facet and or rib joints are restricted and in which direction this restriction is present. Joint motion analysis consists of manual tests called PIVOMs and PAVIMs which evaluate the small intervertebral joint movements that produce motion in the spine. With this information, your physiotherapist can work to increase these articular motions and restore neck range of motion. These small movements are slides and rolling micro movements and follow the biomechanical term arthrokinematics of joint mobility. They are essential for normal function and exercises will not necessarily restore these motions. These findings are correlated with range of motion and functional movement assessment data to formulate a physiotherapy diagnosis. A treatment plan can then be determined. Various manual joint and soft tissue techniques may be utilized to release the articular and myofascial restrictions and restore mobility in the spine.    

Key areas requiring manual, hands on treatment for good spinal mobility

Typically in the spine, the junctions between the three curvatures and the junction between the head and the first and second cervical vertebra become restricted and become a treatment focus of attention by the physiotherapist and massage therapist.  
  • Occiput – C1/2. The junction between the head and the upper part of the neck can cause jaw pain, headaches, neck pain and causes difficulty sleeping, reaching, working and almost anything that requires working postures.
  • C7 – T1. The junction between the cervical (neck) and thoracic (upper back) is often found to be restricted, the area just at the bottom of your neck, and these restrictions are often the primary cause of injury and degeneration of C5-6.
  • T12 – L1. The lower ribs and joints of the junction between the mid back and the lower back at the level of your diaphragm is another source of hidden restrictions that can cause lower back pain and pain that is often misdiagnosed as SI joint pain.
  • L5-S1. The he junction between the lumbar spine (lower back) and the sacrum (tail bone) is often a source of degeneration and overuse as is the level above, L4/5. An advance Manual and Manipulative physiotherapist is trained to assess and treat these dysfunctions. Typically, restrictions in one area cause pain in another.
  • Hip Joint. Tight hips, as well as restrictions in the lower thoracic spine put additional stress on the lower levels of the lumbar spine L4/5 and L5-S1. Regular preventative treatment techniques to segmentally mobilize these stiff joints will help prevent joint disease further degeneration and a reoccurrence of pain. Exercises are not specific enough to do the trick and this is why a hands on approach to mobilize these joints thru manual palpation may be more effective and if you have not had success with exercise.
   

Massage Therapy

The goal of the Massage Therapist is to reduce pain and spasm in the affected muscles as well as decreasing the compression and the disc and nerve. By evaluating and determining where the tone and restrictions are, massage therapy can help release and restore soft tissues. Common muscles that are affected with back pain are erector spinae, latisimus dorsi, quadratus lumborum, piriformis, gluteals, hamtrings and quadriceps. Techniques used for back pain is dependent on the stage, if it is acute or chronic. Myofascial and gentle Swedish massage techniques are used during the acute phase and then progressing to deep tissue, Swedish massage and trigger point techniques. During either stage the focus is to release and decrease tone and spasm in the musculature of the back and legs.    

Physiotherapy Exercise Training

As pain improves, the physiotherapist will perform a functional movement screen and evaluate the functional and biomechanical roots to your back pain. This information, along with the orthopedic examination performed on your initial visit will be analyzed, a physiotherapy diagnosis made, and treatment plan of exercises to correct any deficiencies that you may have including flexibility, endurance, posture, alignment, and core and back strengthen.    

How can exercise and physical development help after back pain?

Assessment of Functional Movement

We start with a functional movement screen that looks at some of the essential movement skills for daily living and also for an activity based lifestyle. This information in addition to our previous orthopaedic assessment findings will allow us to develop a personal improvement plan just for you. This plan will have specific goals, be measurable, will call you to action, will be realistic, and will be time sensitive so that you will see progress and we will monitor and support your success from a medically based standpoint and from a sports science stand point.    

Rehabilitative Exercise after Back Pain and Injury

It is important to regain functional back range of motion, as well as to strengthen the muscles which help to support the back and spine. In addition to Manual hands on therapy techniques, exercises to increase range of motion can be performed at home and at physiotherapy. These include flexion (knee to chest), extension (back arching like a cat), side flexion (arm down side of body), and rotation (twisting). Your Physiotherapist will perform manual therapy techniques to release restrictions and follow up with range of motion exercises in order to maintain this new range of motion. Maintaining range of motion exercises can help to decrease pain and improve joint health by aiding blood and nutrients in getting to the joint. The next important goal following a back pain is to regain strength and correct posture. There are a series exercises to progressively develop optimal posture. Patients will start with simple posture correction exercises that both reinforce good posture but also stretch and strengthen this postural pattern. Trunk control, engaging the abdominal and scapular muscles by engaging your core muscles and brining your shoulder blades back and down initially in standing and in supine, later in sitting and while lifting and bending. Abdominal control during different activities and in different positions are essential for the development of safe functional movements such as when, lifting or bending, or working and then during posture control while driving a car or putting dishes away or working at the computer etc. We typically start with active postural correction and then with resistance using elastic bands and cables. Your Physiotherapist will advise which exercises are appropriate at which point of each patient's treatment and will progress the exercises throughout the course of treatment.    

Physical Development after Back Pain

The final step is to establish a personal improvement health plan to continue to develop physically throughout your life. This is especially necessary after injury or an accident when you have become deconditioned. All of our staff have a combination of health sciences and sports sciences training, having dual training in both kinesiology and physiotherapy and allowing us to provide a biomechanical focus. Once you have recovered from your injuries, our therapists will perform a functional movement screen and analysis to identify individual muscle imbalances that are unique to your inherited structure, to your movement patterns, and to your goals and interests in living a healthy physical life. We develop a individualized program that focus on:  
  • Your specific imbalances and movement patterns at work, home, and those evident during the activities that you participate in.
  • You structural and genetic posture and alignment characterizes and how they affect your interests to do activity etc.
  • We look at the ergonomics specific to your workplace and home
   

How can low intensity laser therapy help acute and chronic low back pain

Low Intensity Laser Therapy (LILT) is the use of monochromatic light. Meditech Bioflex has been producing this technology for 20 years and has an extensive in house clinical lab.   The light source is placed in contact with the skin allowing the photon energy to penetrate tissue, where it interacts with various intracellular biomolecules resulting in the restoration of normal cell morphology and function. This process also enhances the body's natural healing propensities.   Low Intensity Laser Therapy does not heat or cut tissue. Unlike many pharmacological treatments that mask pain or only address the symptoms of the disease, Laser Therapy treats the underlying condition or pathology to promote healing. The technology utilizes superluminous laser diodes to irradiate diseased or traumatized tissue with photons. These particles of energy are selectively absorbed by the cell membrane and intracellular molecules, resulting in the initiation of a cascade of complex physiological reactions, leading to the restoration of normal cell structure and function.   The process is curative and therefore results in the elimination of symptoms including pain. In addition, it enhances the body’s immune system response and facilitates natural healing. The therapy is completely safe and has no adverse side effects. The technology is highly effective in the treatment of musculoskeletal conditions, arthritis, sports injuries, wound healing and a wide range of dermatological conditions. Whiplash injury typically involves injury to muscles, ligaments, and joints and typically involve several levels and a more wide spread area of injury due to the force full nature of the injury. Muscles of the neck, although short, cross over several joints and so the discomfort is generally more global initially. Laser therapy directed by multiple diodes are able to reach these tissues.    

Physiological effects of Low Intensity Laser Therapy

With LILT there is an increased production and release of:  
  • Endorphins which - natural analgesics
  • Cortisol – a precursor of cortisone
  • Growth hormone – instrumental in tissue repair
  • ATP – improves and regulates cellular metabolism
  • An increase in protein synthesis – collagen, DNA, fibroblasts
  • A facilitated venous and lymphatic flow
  • Increased angiogenesis – the elevation of oxygen saturation
  • Enhanced immune response
  These responses are some of the many processes that accelerate cellular regeneration (cartilage, epithelium) and restore normal cell morphology and function. Treatments are typically 25 minutes to over 1 hour depending on the condition and area being treated   The most popular technical / clinical information requested is available on the Meditech website under Laser Reports. You may visit the Meditech website research section directly for detailed abstracts, case profiles and articles on a variety of topics relating to the use of low intensity laser therapy in the treatment of various medical conditions.      

What life style and self-care measures can you do for yourself to relieve acute and chronic back pain?

Back pain is often associated with poor posture during the years where age-related wear and tear occurs. To help prevent neck pain, keep your head centered over your spine, in a neutral position as we call it. Some simple changes in your daily routine may help. Consider the following:  
  • See your physiotherapist or massage therapist and be proactive in your physical development and your personal improvement plan. Learn about proper lifting and working mechanics.
  • Avoid sitting for prolonged periods. Sitting is one of the worst things that you can do to your back and as much as you can avoid sitting in your life you should. The most common injury of overuse sitting is disc herniation. Prevention is the best treatment.
  • Take frequent breaks when you must sit for long periods. if you drive long distances or work long hours at your computer. Keep your back supported into lordosis and your spine in a neutral position such that your chin is tucked into your throat, your ears in line with your spine, and this will reduce back strain.
  • Adjust your desk, chair and computer so the monitor is at eye level. Knees should be slightly lower than hips. Use your chair's armrests, and your shoulders pull back and down in a position of scapular retraction. This keeps the spine in a neutral position.
  • Avoid sitting in lounge positions.  Avoid sitting crossed legged and sitting with legs up at the same time as your trunk is raised as it is stressful on our back. Instead sit with your feet on the floor when reading and watching TV.
  • Stretch frequently if you work at a desk. Every few minutes adjust your position and pull your shoulder blades back and down such that your head comes back into line with your neutral spine. Stand up and arch your back into extension several times. This simply reverses the flexion posture and protects you from prolonged creeping, which occurs with prolonged sustained tissue stretch.
  • Balance your muscles. Stretching the front chest wall muscles and strengthening the muscles around the shoulder blade and back of the shoulder can promote a balanced your muscles.
  • Lift with proper movement skill and to avoid excessive stresses. If you have to lift or bend, use the large muscles called the gluteus Maximus rather than bending and hinging from the waist, sit back into a squat position and keep your spine in a neutral position. This movement skill, the squat, is fundamental to lifting. Also, avoid repetitive lifting and twisting light loads. Bring the weight close to you and learn how to lift with the lifting muscles by training the functional squat movement so that you do not bend and hinge from the waist when you lift.

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