Low back pain is very common and most people have some experience of a back pain episode at some time of life. Attendances at physiotherapy clinics for low back pain are very high so physios have a variety of assessment and treatment techniques to manage spinal pain and improve patients' function.



A serious medical condition such as cancer or infection is a very uncommon cause of back pain, but several medical problems can present this way and physiotherapists need to be aware of this so they can refer the patient on to the appropriate doctor. The physio will ask about past medical history (cancer, arthritis, diabetes, epilepsy), any loss of weight or appetite, bladder and bowel control, feeling unwell, sleep disturbance and worse pain when lying down to sleep.

This subjective history tells the physio that the back problem is mechanical, i.e. it is related to the stresses and strains on the spinal joints now and in the past. They can then move on to the objective examination, looking at the patient with their clothes off. Initial examination starts with the patient walking in and with how they sit for the questioning, and posture is noted next. Many postural changes are not of great significance but some fit the overall picture and increase the confidence in the correct therapeutic diagnosis.

Next the physiotherapy examination moves on to active movements. Lumbar flexion is bending over forwards as if the hands are to touch the toes, and the range of movement and any pain is noted. This is repeated for extension and perhaps side flexions and side gliding, all adding to the picture forming in the physio's mind. The physio may test the hip joints, the sacro-iliac joints, the sensibility, the reflexes and muscle power. Palpation of the spinal joints can tell a skilled physiotherapist about the stiffness and reaction of individual spinal segments, thus localising a problem to a specific level.

With all the information from the subjective and objective examinations the physiotherapist will use their diagnosis to form the goals and plan of treatment. A pain problem will need to be approached with respect, using gentle mobilisations, TENS, stabilising exercises and painkillers. A stiff spinal segment can be mobilised more vigorously with direct manipulations and stronger exercises.

One of the most common therapies for athletes, gym attenders and those undergoing rehabilitation after injury or illness is to perform core stability work. Many Pilates classes are available using this approach to holding a mid-range spinal posture while performing activities. Initial technique is taught on a plinth until the patient has good control then progressed to keeping their stability control whilst performing harder and harder activities, finishing off with relevant functional work

Spinal joints do not appreciate being at end of their range for too long such as remaining slumped in sitting for a long period. This stretches the ligaments and can cause and maintain a pain problem. Physios teach patients to understand the new strange posture they are being asked to perform is the norm and that they need to perform it regularly until they do it naturally.

Many back pain physios use the McKenzie technique which uses repetitive movement to change the forces which the disc nucleus exerts on the walls of the disc, the annulus fibrosus. An increase in pressure against the posterior disc wall can worsen symptoms while a decrease can improve pain. Repeated movements in one plane establish a "directional preference", a direction of movement which improves the presenting symptom. McKenzie therapists treat patients depending on whether they have postural syndrome, dysfunction syndrome or derangement syndrome. McKenzie therapy is a popular technique, based on the idea that the disc nucleus exerts a force on the walls of the disc and can cause pain problems.

Apart from treatment the patient needs to consider changing some aspects of their behaviour if the treatment is going to get the best result. Pacing activity to avoid overdoing activities and suffering afterwards is important, allowing the problem to ease. Aerobic and muscle fitness in the gym or pool has good scientific evidence behind it for reducing the number and severity of back pain episodes, while many back pain treatments have little evidence to prove their effectiveness.