An Interdisciplinary Approach to Reducing the Prevalence of Low Back Pain

Low back pain (LBP) is among the leading causes of disability worldwide (Hartvigsen et al., 2018). The greatest increases in disability from LBP have come from low- and middle-income countries which emphasizes the importance of preventing LBP and educating safe at-home therapies (Hartvigsen et al., 2018). It’s been noted that up to 80% of Americans will experience back pain at least once in their life (Marras, 2008). It can be painful, debilitating, and severely limit a person’s ability to carry out daily tasks. Pain can stem from a variety of reasons. Some cases of LBP can be relieved with the correct treatment or even prevented with preventative exercises. Unfortunately, many people either don’t have access to the proper treatment, can’t afford it, don’t have the time, or are unaware of safe preventative and rehabilitative exercises. What appears true is that reducing the presence of LBP can be achieved through an interdisciplinary approach combining education on preventative techniques, proper medical care and correct rehabilitative treatments.

There are different ideas as to how to go about treating LBP and the best plan of action for physicians and therapists (Hasenbring, Rusu, & Turk, 2012). Nearly 85% of patients with LBP are not able to be given a specific diagnosis (Deyo & Weinstein, 2011). Deyo and Weinstein (2011) note that when seen within three days of the arrival of LBP, up to 90% of patients can feel relief within two weeks based off a study conducted. However, they also report that about 40% of patients have the pain come back again. This is a problem that can turn an acute episode of back pain into chronic LBP. Pain that stems from a traumatic injury likely requires far different treatments then pain coming from a postural deviation. Some sources of LBP can only be relieved through surgery while other sources can be relieved through manual therapy or corrective exercise. Many patients are prescribed opioids to help relieve their pain which can lead to another problem in society. Discrepancies in treatment plans make LBP difficult to treat and therefore, resolving it becomes an issue of time and money for the patient.  

The Treatment-Based Classification System (TBC) was designed in 1995 and has been one of the most widely used references for the treatment of LBP by healthcare providers (Alrwaily et al., 2016). Since 1995, many revisions have been made due to the advances in medical care, and Alrwaily et al. (2016) have completed some of the most recent updates. This system attempts to guide professionals to determine which subgroup a patient falls into when classifying their LBP in order to assign the most appropriate treatment plan (Alrwaily et al., 2016). This can be seen if Figure 1.

Figure 1. Updated TBC with the recommended primary care physician process for LBP. Retrieved from here

This system has classifications for both physicians and rehabilitative providers (Alrwaily et al., 2016). Typically, the primary care physician will have the initial interaction with a patient who is concerned with LBP. It’s recommended that the primary care physician concludes if the patient is high, moderate, or low risk, and determines if they need medical treatment, rehabilitative treatment, or self-care management, respectively (Alrwaily et al., 2016). The physician must first rule out severe pathologies, which are rare, but include things like cancer and fractures (Alrwaily et al., 2016). Severe pathologies are often recognized by certain red flags. Examples of red flags could be unexpected loss of weight, intense pain at night, neurological deficits such as a foot drop, or lack of bladder control (McCarberg, Stanos & D’Arcy, 2012). Severe pathologies would call for a specialist in the intended area to do further evaluations. For non-severe cases of LBP, it should be determined if the patient is in need of rehabilitative treatment or self-care, such as rest or stretching (Alrwaily et al., 2016).

If the rehabilitative provider is the first to see the patient, they should follow the same approach to determining which classification the patient falls into (Alrwaily et al., 2016). In the event the patient is sent to them by referral, their job is to monitor for anything serious that could have been missed and carry out their plan of action, including determining if therapy is necessary (Alrwaily et al., 2016). Good communication among the patient, primary-care physician, specialist, and rehabilitative provider can help increase the fluidity of LBP episodes.

There’s a variety of exercises that can be beneficial to preventing low back pain in the first place. These are called preventative exercises and usually carry the common goal of strengthening the core or stretching tight muscles that can facilitate bad posture. Muscles surrounding the spine need adequate strength in order to help stabilize the low back during daily tasks. Increasing the ability of our muscles to support and stabilize the spine helps in the event of an injury. The exercises should also help reduce the strain placed on our spine by improving our posture. Increasing the stability of the spine should therefore help reduce the risk of injury from many sources. Swezey and Calin (2006), propose a 5-Minute Back Saver program in the book Low Back Pain, that aims to help people prevent the onset of LBP. It’s also recommended that people participate in regular exercise like strength training to help prevent LBP (Deyo & Weinstein, 2001).

When talking about LBP, it’s important to realize why the low back is so susceptible to injury. Risk factors play a large role in the number of LBP cases. For people between 35-55 years old, their age is considered a risk factor as this range tends to present with the highest amount of cases (Marras, 2008). While males and females both present with many cases of LBP, it has been documented that females report more cases when occupation is not reflected in the statistics (Marras, 2008). Males and females taller than 180cm and 170cm respectively have been noted with increased risk of LBP (Marras, 2008). Other notable risks factors include people who are not physically strong, are obese, consume alcohol, or smoke cigarettes (Marras, 2008).

It’s difficult to talk about the treatment and prevention of LBP without having a basic understanding of the anatomy of the back and structures that contribute to stabilizing the spine. The back is composed of vertebrae that are essentially stacked and continue from our pelvis to the base of our skull (Marras, 2008). They help form cervical, thoracic, lumbar, sacral and coccygeal regions of our spine. Conditions relating the lumbar spine and the lower part of the thoracic spine are what commonly constitutes as LBP. Between each vertebra are what’s called intervertebral disks and they can be seen in Figure 2. These disks function in three main ways. They help absorb shock in the spine, they help distribute weight throughout the spine, and they allow movement between the vertebrae (Marras, 2008).

Figure 2. Lateral view of lumbar spine. Retrieved from here

The spinal cord follows a canal that is located between the vertebral body and spinous processes (Marras, 2008). As you can see in Figure 2, nerve roots branch out from each section of vertebrae and their purpose is to send and receive signals to and from the brain to carry out bodily functions (Marras, 2008). These nerves are sensitive are can often be a source of pain if compressed.

Many muscles surround the spine but only a few are thought to have a large enough impact to contribute to supporting the spine in a way that could affect LBP (Marras, 2008). At the ends of each muscle, a tendon is present, and this is how the muscle is attached to the bone. Some of the most notable muscles involved in LBP are the erector spinae, multifidus, internal and external obliques, rectus abdominus and quadratus lumborum which can be seen in Figure 3 (Marras, 2008; Swezey & Calin, 2006). While these muscles directly impact the spine, many other muscle groups like the glutes, hamstrings, and hip flexors can affect the spine indirectly. These muscles can contribute to placing unwanted tension on structures or create imbalances that can affect the spine or muscles stabilizing the spine.

Figure 3. Anatomy of the low back. Retrieved from here

There are numerous causes of LBP. Traumatic injuries like falling on the back can cause damage in the form of a fractured vertebra, in which case has a much different plan of treatment than a musculoskeletal injury. This type of injury is also not necessarily preventable with preventative exercises; however, many causes of LBP are either preventable or the damage to structures could be lessened with prior exercise.

Among the most common lower back injuries are ligament sprains and muscular/tendon strains. Spraining a ligament, which attaches bone to bone, can be a result of over stretching a ligament beyond its normal range. Similarly, a strain can be achieved through stretching a muscle or tendon beyond its capable range. Rest is often advised for these patients in order to let the ligament, muscle, or tendon heal.

Disc herniations or a “slipped disk” are very common sources of back pain. In this case, the intervertebral disk can end up protruding from the spine and place pressure on the nerves causing pain as seen in Figure 4 (Disc Herniation, 2018). The disk can also rupture and begin placing pressure of the nerve. Pain can be around the low back and also radiate down the leg (Disc Herniation, 2018). These injuries are often a result of twisting or picking up heavy objects with improper form. Both of these injuries are very common and often trigger high amounts of pain. Increasing core strength can help guard your lower back and help prevent disc herniations. These types of injuries are often be treated through rehabilitative techniques.

Figure 4. Herniated disk vs. a normal disk. Retrieved from here

Spondylolisthesis is when the actual vertebrae slip out of place over one another (Swezey & Calin, 2006). This can cause the vertebrae to pinch or place pressure on the nerves within the spinal cord Swezey & Calin, 2006). This type of injury can often be treated through self-care and pain management although it can require surgery in some cases. There are many core strengthening exercises can help prevent these types of injuries (Spondylolisthesis, 2019).

These causes of LBP are often seen in both athletes and working people. Sitting is one of the worst positions for our body, which is incredibly common in working people these days. Sitting places extra stress on the spine and enables weakening of many important postural muscles. Often times, the hip flexors become very tight in people who sit for extended periods of time. Tight hip flexors can pull the hips into an anterior pelvic tilt. The tilting causes excessive curving at the lumbar spine and places increased pressure on the vertebrae and discs. This type of posture increases the risk of developing LBP.

LBP is also the leading cause that prevents athletes from playing in games (Lee, 2017). Alternatively, its noted that former athletes tend to have less episodes of LBP than nonathletes, which may be attributed to core strength that athletes acquire over time (Lee, 2017). Contact sports like hockey, football, rugby, wrestling, and basketball see the highest prevalence of LBP (Lee, 2017). Back injuries related to sports are often attributed to bad technique or form, and poor hamstring flexibility (Lee, 2017). The occurrence of LBP can be seen in people of all ages and activity level.

Through an interdisciplinary approach, the prevalence of LBP can be lowered. This involves education, preventative exercises, encouraging people to exercise to become physically strong, and consistent treatment with good communication. Exercises like the ones in the 5-Minute Back saver program by Robert Swezey and Andei Calin, can help in preventing the onset of LBP (2006). An efficient classification system like the TBC can be used by physicians to help identify the needs of their patients and better the outcomes. Lastly, rehabilitative therapists can help people reduce LBP by strengthening core muscles, which will also help prevent further injuries. Education stemming from exercise physiologists, personal trainers, physicians, physician assistants, nurse practitioners, occupational therapists, and physical therapists are the first step in helping prevent LBP. For people who do develop back pain, it’s important that the correct steps are taken in order to quickly reduce the pain and also help prevent it from occurring again. Good communication among physicians and therapists is necessary to ensure patients are receiving the correct plan of action. By educating on preventative techniques, using classification systems like the TBC, and proper rehabilitation, we can help reduce the prevalence of LBP.

References

Alrwaily, M., Timko, M., Schneider, M., Stevans, J., Bise, C., Hariharan, K., Delitto, A. (2016). Treatment-based classification system for low back pain: revision and update. Physical Therapy, 96(7), 1057–1066.

Deyo, R.A., & Weinstein, J.N. (2001). Low back pain. The New England Journal of Medicine, 344(5), 363-70.

Disc Herniation. (2018, May 31). Physiopedia. Retrieved from https://www.physio-pedia.com/index.php?title=Disc_Herniation&oldid=189371.

Hartvigsen, J., Hancock M.J., Kongsted, A., Louw, Q., Ferreira M.L., Genevay, S., … Underwood, M. (2018). What low back pain is and why we need to pay attention. The Lancet, 391, 2356-2367. http://dx.doi.org/10.1016/S0140-6736(18)30480-X

Hasenbring, M., Rusu, A., & Turk, D. (2012). From acute to chronic back pain : Risk factors, mechanisms, and clinical implications. Oxford, UK: Oxford University Press.

Lee, S. W. (2017). Musculoskeletal injuries and conditions : assessment and management. New York, NY: Demos Medical.

Marras, W. (2008). The working back : A systems view. Hoboken, NJ: Wiley-Interscience.

McCarberg, B. H., Stanos, S., & D’Arcy, Y. M. (2012). Back and neck pain. New York, NY: Oxford University Press.

Spondylolisthesis. (2019, April 21). Physiopedia. Retrieved from https://www.physio-pedia.com/index.php?title=Spondylolisthesis&oldid=209332.

Swezey, R., & Calin, A. (2006). Low back pain. Oxford, UK: Health Press Limited.