There is significant evidence in the literature to support the utilization of physical therapy for the treatment and management of the patient with low back pain, regardless of the duration of the pain. The following summary relies in part on an evidence-based review of the literature by Mark Bishop PT, PhD, CSCS.

The treatment protocols followed by The Jackson Clinics parallel the management guidelines as described in the current medical literature. There is ample evidence that physical therapy can be an effective intervention if the intervention is proactive and delivered by licensed physical therapists and assistants following evidence based treatment guidelines. The management guidelines are as follows:

I. Acute Nonspecific Low Back Pain: Less than 7 Weeks.

1) Education:

Accurate education should be the primary focus of treatment 1,2 including expectations of a favorable prognosis, safe and effective methods of symptom control, safe and reasonable activity modifications, and prevention. 1,3 The physical therapist, after patient examination, is best suited for this form of education.

2) Safe and effective symptom control

For non specific complaints, manipulation should be considered for pain relief. 3

Modalities should not be used as primary interventions.1,4

3) Prevention

Remaining active and continuing a minimum of 30 minutes of aerobic conditioning on 3 to 5 days a week is recommended.1

There is growing evidence that strengthening the trunk muscles, particularly the erector spinae, is important and simple exercises should be advocated5

4) Activation and exercise. Beside educating the patient and managing symptoms, the therapist must ensure that the patient does not begin the physiological cascade known as deconditioning syndrome. 6 The deleterious effects of inactivity on bodily systems have been well documented, and the ameliorative effects of exercise should be equally well known. 7 The AHCPR guidelines 1 recommend the following:

Low stress aerobic exercise can prevent debilitation caused by inactivity during the first month of symptoms, and thereafter may help to return patients to the highest level of functioning appropriate to their circumstances.

Conditioning exercises for the trunk (especially the back extensors) that are gradually increased are helpful for patients with acute low back problems, especially if symptoms persist.

Exercise quotas that are gradually increased result in better outcomes than symptom-limited exercises.

It should be realized that there is a paradigm shift from focusing solely on symptomatic relief to the prevention of activity intolerance.

II. Subacute Low Back Pain: 7 weeks to 3 Months: Due to the decreased likelihood of return to work after six months of back pain it is imperative to treat this group of patients with aggressive intervention8

1) Education

Education continues to be of paramount importance9

The goal of treatment should be to improve activity tolerance, and the patient should be educated that activity or exercise, not rest, leads to comfortable performance.10

2) Activity recommendations

A graded return to sitting and lifting is recommended regardless of symptoms. 1

A proactive disability prevention plan that emphasizes early return to work needs to be followed. 11

3) Activation and exercise

Lindstrom et al 12 used a simple graded activation protocol for nonspecific LBP and reported positive results concerning return to work (5weeks earlier return to work), sick leave (8 weeks fewer sickness absences during first and second follow-up year), back mobility, and fitness during the follow-up period. This rehabilitation program with operant conditioning may decrease the percentage of persons disabled by benign LBP.

The Philadelphia Panel evidence-based guidelines recommend that flexion, extension, and general strengthening exercises are of clinical benefit to the patient after four weeks. 13

1) Education: The education process again is extremely important and should include the following:

Nature of the problem

Natural history of LBP including regression toward a mean

Importance of self-management

Non-addictive, safe and effective methods of symptom control used in a time-contingent manner.

Importance of weight reduction, smoking cessation, and graded exercise.

2) Safe and effective symptom control

At least nine randomized trials have evaluated the efficacy of manipulation in the treatment of chronic LBP. The two studies with the highest methodological quality show benefits.14,15

2) Activation and exercise

There is strong evidence that exercise therapy is effective for chronic LBP.3,4,13

The multifidus has been shown to suffer from reflex inhibition after an episode of LBP.16

Strengthening of multifidus has been shown to reduce recurrence of LBP from 85% to 32% one to three years following injury.17

Strengthening of the erector spinae as demonstrated by Manniche et al 18,19 was extremely effective in rehabilitation of patients with low back pain.

However, telling patients who are in pain to exercise is an ineffective strategy.20 Supervised exercise therapy programs have been shown to be beneficial for LBP and appear to improve compliance.21,22,20

REFERENCES
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