By Rob D. Dickerman, DO, Phd
Patients suffering from most types of low back pain are often referred for physical therapy for four weeks as an initial conservative (nonsurgical) treatment option before considering other more aggressive treatments, including back surgery. The goals of physical therapy are to decrease back pain, increase function, and teach the patient a maintenance program to prevent future back problems.
Common forms of physical therapy include:
- Passive physical therapy (modalities), which includes things done to the patient, such as heat application, ice packs and electrical stimulation. For example, a heating pad may be applied to warm up the muscles prior to doing exercising and stretching, and an ice pack may be used afterward to sooth the muscles and soft tissues.
- See Physical Therapy: Passive PT (Modalities) for Back Pain
- Active physical therapy, which focuses on specific exercises and stretching. For most low back pain treatments, active exercise is the focus of the physical therapy program.
This article focuses on active physical therapy and exercise as a means to help recover from back problems and prevent or minimize future flare-ups of low back pain.
Exercise Benefits for Low Back Pain
Lumbar spine (low back) stability is largely dependent on the supporting abdominal (stomach) and low back musculature. The abdominal muscles provide the initial stabilizing support through their ability to generate pressure within the abdomen which is exerted posteriorly on the spine, thus providing an anterior support column (from the front of the spine). The low back muscles stabilize the spine from the back and lead to posterior support. Simply stated, the bony spine and discs are surrounded by muscles, and the stronger these specific muscles are, the less stress is placed on the discs and joints of the spine. The patients should develop a 'belt' of muscle around their spine.
There is a substantial amount of medical literature supporting specific physical therapy exercises for the treatment of low back pain. While most episodes of low back pain are self limiting and will get better on their own, active exercise plays an important role in helping reduce the patient's pain and improving subsequent function in patients with low back pain. An ongoing exercise program also reduces the likelihood and severity of future occurrences of low back pain.
Physical Therapy Before and After Back Surgery
There is substantial evidence supporting the benefits of physical therapy and exercise both before and after back surgery. The strength and stability that physical therapy provides can significantly shorten a patient's recovery time after surgery. Physical therapy and exercise is considered an important part of most back pain patients' treatments, including those undergoing non-surgical and surgical care. This is because patients with low back pain are most likely to recover when the patient is in optimum physical condition. Unless there is a contraindication for physical therapy or a patient requires emergency surgery, most patients are advised to undergo a trial of physical therapy prior to considering back surgery.
For many patients with low back pain, it is usually advisable to first consult a physician who can diagnose the patient's condition and rule out any serious contraindications for physical therapy, such as a fracture or tumor. Many patients find it most helpful to be monitored by a physical therapist to ensure follow through and avoid problems. Once the initial phase of therapy is complete, those patients who continue to follow an exercise program are often the most successful in managing their low back pain.
Most physical therapy programs that are designed to treat low back pain and some radicular pain (pain radiating down the leg) will include a combination of the following types of exercise:
Stretching. Proper stretching of the muscles along with active exercise will help maintain normal range of motion and provide relief for muscles that are often suffering disuse atrophy (shrinking muscles from lack of use) or in spasm from inappropriate posture or nerve irritation. For many patients it is best to follow a stretching routine that has been individually designed for them by a physical therapist or a spine physician. As a general rule, low back pain patients should focus on stretching the lower back muscles, abdominal muscles, hips, and legs. The patient should never bounce during stretching, and all stretches should be slow and gradual.
Dynamic stabilization exercises. These exercises involve the use of a variety of exercises and may include use of exercise balls, balancing machines or specific stabilizing exercises. The point of dynamic stabilization exercise is to strengthen the secondary muscles of the spine and help support the spine through various ranges of motion.
Core strengthening exercises. These are specific exercises to strengthen the abdominal muscles and low back muscles (erector spinae) to provide the aforementioned 'belt of muscle' around the spine. These exercises typically include:
- Specific abdominal strengthening, such as sit-ups, crunches, abdominal machines, and leg raises.
- Low back exercises (hyperextensions), which can be performed on machines or by simply lying on the stomach and slowly raising the chest off the ground. This exercise utilizes the lower back muscles to 'hyperextend' the spine.
- 'Good-mornings' are also an exercise to strengthen the lower back muscles. This exercise requires the patient to stand with legs straight and shoulder width apart, with a broom-stick or weighted bar across the shoulders. The patient then slowly bends forward until the face is parallel to the floor and then raises back up. Very similar to just bending to touch the toes except there is weight across the shoulders.
Some physical therapy centers may also provide aquatic (water) physical therapy. Water supports the body and minimizes the effect of gravity, making it easier for patients to start an exercise program. Aquatic therapy can be very helpful for elderly patients and disabled patients who may not have the strength to do some of the exercises outside the aquatic pool.
Another aspect of physical therapy program may include lumbar traction. With lumbar traction, the patient lies on his back and is secured on a special table with a cable coming from the foot-end of the table that attaches to a strap that has been placed around the patient's hips. The cable is attached to weights at the foot-end of the table that provide a continuous and gentle pulling force on the hips toward the foot-end of the table. The goal of traction is to unload the disc space and muscles in the lumbar spine. This unloading is thought to provide a recuperative period which allows the muscles to rest and takes pressure off the disc space. Research about the effectiveness of traction is controversial, with some studies showing that it adds value and other studies showing that it is of little or no value for patients with low back pain.
When Exercise Doesn't Work
All too often, spine practitioners refer patients for physical therapy and the patients return to the doctor stating they stopped the therapy because it hurt their backs or they just weren't getting adequate low back pain relief for their efforts. While this is by no means an exhaustive list, here are a few reasons physical therapy rehabilitation may not alleviate back pain:
- The program prescribed does not include active exercise. This occurs when a patient's physical therapy program includes very little muscle training and focuses more on the use of hot packs, cold packs, and stimulation therapy. While hot/cold packs and deep tissue massage can often provide immediate pain relief, they are best used in conjunction with active exercise as opposed to replacing it.
- Patients do the exercises incorrectly. Patients may not have a thorough understanding of how their exercises should be performed to bring about desired benefits. If this is the case, then the patient may benefit from a more thorough explanation of the exercise by a spine specialist and/or supervision and guidance by a qualified physical therapist who could correct possible errors in exercise performance.
- Patients don't stick to the prescribed exercise program. Physical therapy is not likely to alleviate pain if patients do not perform all recommended exercises or do not devote enough time to their program. Continued exercise beyond the assigned therapy time may further strengthen the back and help maintain better posture and prevent recurring pain.
- Patients don't keep up with exercise long term. It is best for patients to continue with the prescribed physical therapy exercises and/or a self directed exercise program following the initial course of physical therapy. Typically, it is recommended that the patient maintain the basic core and dynamic stabilization exercises and may slowly transition into a more extensive exercise program including low impact aerobic exercise and specific weight-lifting exercises that will not load the spine.
Some patients with low back pain are successfully treated with physical therapy but then return a year or two later with the exact low back problem. Most often the patient strengthens the abdominal muscles and low back muscles during physical therapy and subsequently takes the stress off the low back. After physical therapy, the patient does not maintain the abdominal and low back exercise program at home, leading to a slow loss of fitness in the trained muscles and possibly eventual low back problems. Thus, it is highly recommended that once a patient is treated successfully with physical therapy, he/she develops an exercise maintenance program at home to help sustain the strength and muscle mass that was developed in physical therapy.
Originally from: https://www.spine-health.com/treatment/physical-therapy/physical-therapy-low-back-pain-relief