Low Back Pain: Physiotherapy Exercises

Low back pain is one of the most prevalent musculoskeletal conditions that affect quality of life of an individual. Pain occurs at the lower back area which can cause great discomfort hindering activity of daily living.

Causes of Low Back Pain

• muscle strain
• poor posture
• herniated disc
• obesity
• lack of exercise
• increased stress
• occupation ergonomics

Typical Symptoms of Low Back Pain

• limited range of motion
• muscle spasm i.e. stiffness around lower back region
• difficulty standing upright
• use of some support when standing from sitting position
• radiating pain mainly to gluteal region and down the leg

Diagnosing Low Back Pain

Differentiating the cause for low back pain can be difficult as there are several factors contributing to it. Therapist can ask following listed questions in order to make a specific and valid diagnosis and suggesting an effective treatment plan.

Duration of onset

Low back pain can be acute or chronic in nature. Patient’s history is important factor in ruling out the duration of onset of pain. Acute pain has a sudden onset while the chronic pain occurs over a period of six months or more.

Mechanical Vs Non mechanical

Mechanical low back pain is often movement and posture related and improves with rest while non mechanical pain is due to some related medical condition  like Herniated disk, Compression fracture, Spinal stenosis etc.

Location

The location of pain in case of low back pain can provide valuable information about the potential underlying causes as following:

• Central Low Back Pain - related to muscle strain, overuse, poor posture and muscle imbalances
• Lumbar Facet Joint Pain- localized to one side of the lower back and may radiate into the buttocks or thighs.
• Sciatica - This pain can be sharp and shooting, affects one side of the body, extend into the buttocks, thigh, and even down to the foot.
• Muscle Spasms - feel like a sudden and intense tightening of the muscles, triggered by sudden movements,
• Spinal Stenosis - pain in the lower back, buttocks, and legs, relieved by sitting or leaning forward.
• Sacroiliac Joint Dysfunction - pain that is usually felt in the buttocks or lower back, might also radiate into the groin or thigh.
• Kidney Issues - pain is often more internal and might be accompanied by other symptoms like urinary changes or fever.

 

Pain Quality

Pain quality helps us narrow down to potential diagnoses. Different types of pain can be indicative of different conditions as listed below:

• Dull and Aching Pain - associated with muscle strain, overuse, or tension in the muscles and ligaments of the lower back. It can also be linked to degenerative conditions like osteoarthritis.
• Sharp and Shooting Pain - sciatica, herniated disc or spinal stenosis.
• Burning Sensation - indicate nerve irritation or compression like herniated discs, spinal stenosis, or nerve impingement.
• Throbbing Pain: associated with inflammation in the lower back  like ankylosing spondylitis
• Stabbing Pain - caused by muscle spasms or sudden movements that strain the muscles and ligaments, facet joint dysfunction.
• Achy and Deep Pain - related to problems with the sacroiliac (SI) joints.
• Tingling or Numbness - indicate nerve involvement like a herniated disc, spinal stenosis, or nerve impingement.

Neurological Symptoms

• Radiating Pain
• Tingling and Numbness
• Muscle Weakness
• Loss of Reflexes
• Difficulty with Balance and Coordination
• Bowel or Bladder Dysfunction

Pain at rest may indicate following reasons

• Inflammation: Pain that is present even when you're at rest could be a sign of inflammation in the affected area. Inflammatory conditions such as ankylosing spondylitis, arthritis, or other autoimmune disorders can cause it.
• Chronic Conditions: chronic conditions like degenerative disc disease or osteoarthritis. These conditions can cause ongoing pain due to wear and tear on the spine's structures.
• Nerve Compression Conditions like herniated discs or spinal stenosis could be contributing to this type of pain.
• Poor Posture: Poor posture, even when you're resting, can strain the muscles and ligaments of the lower back, causing pain even without active movement.
• Nighttime Pain - spinal alignment issues or changes in pressure on the discs. This might be particularly noticeable if you have a herniated disc or degenerative disc disease.
• Underlying Medical Conditions - certain kidney problems or infections can cause lower back pain that persists even when you're not moving.

 

Importance of physiotherapy in maintaining a healthy spine

Physiotherapy can be of great benefit in treating low back pain.

• pain relief
• improve mobility
• strengthening  of muscles
• posture correction
• core strengthening

 

Pain Management

Various methods are available for pain management which include:

• TENS
• Therapeutic Ultrasound
• Interferential Therapy
• Physio Ball Exercises
• Dry Needling

Exercises to alleviate Low Back Pain

Pelvic Tilt

Pelvic tilting exercises are performed in sagittal plane and are generally used to correct the alignment of the lumbar spine of patients with lower back pain (LBP). Alteration in pelvic tilt can cause hyperlordosis and sway back posture.

Anterior pelvic tilting strengthens lumbar lordosis whereas posterior pelvic tilting gives appearance of a flat back. Lumbar lordosis decrease compressive forces in the spine and allow for proper shock absorption. Therefore, when the lumbar lordosis is lost, there is a decreased degree of shock absorption in the spine. Pelvic Tilt exercises activate the intrinsic core stabilizers of back.

Child Pose

Child pose assist in alleviating low back pain. A mild stretch promotes relaxation and flexibility.

Cat-Cow Stretch

It involves moving between two positions – the "Cat" pose and the "Cow" pose – to create a gentle, rhythmic stretching and movement of the back.

Bridge Exercise

The Bridging Exercise is a simple yet effective exercise that can help alleviate low back pain by strengthening the muscles of the lower back, core, and hips. It also promotes stability and flexibility in the spine.

Knee to Chest Stretch

The Knee-to-Chest Exercise is a gentle stretching exercise that can help relieve lower back tension.

Pelvic Clock Exercise

The Pelvic Clock Exercise is a movement-based exercise. This exercise can help improve the mobility of the pelvis, enhance body awareness, and address any imbalances or stiffness in the pelvic region.

Pelvic Movements are given below.

• 12 o'clock: Tilt your pelvis so that your lower back presses into the floor, Imagine your tailbone reaching towards your navel.
• 6 o'clock: Tilt your pelvis the opposite way, arching your lower back slightly off the floor. Imagine your tailbone reaching down towards the floor.
• 3 o'clock: Gently tilt your pelvis to the right, allowing your right hip to lift slightly while your left hip drops toward the floor.
• 9 o'clock: Tilt your pelvis to the left, lifting your left hip slightly and dropping your right hip.

Manual Therapy

Segmental Mobilization

Back pain is associated with altered functional ability in individual with LBP. Assessment of spinal mobility includes  non-surgical treatment approach for example a patient with restricted spinal motion may receive interventions directed at improving intervertebral mobility whereas an individual with symptoms and an excessively mobile spine may receive active and/or resistive exercises to provide stabilization.

A manual Posterior-Anterior force to a lumbar spinous process sufficient in amount to reach end-range may produce more motion since it's not self-limited by pain. 

Maitland Mobilization

Maitland mobilization technique is done to reduce lumbar mechanical pain through the stimulation of joint mechanoreceptors .They alter the pain gate cycle through the presynaptic inhibition of nociceptive fibers in associated structures and the inhibition of hypertonic muscles which ultimately improve functional abilities.

It is done at spinous level (L4-L5) while therapist stands to side of patient placing their pisiform/ulnar surface of hand over the selected spinous process (SP) with their wrist in full extension.

Movement With Mobilization

Mobilization with movement (MWM) also known as sustained natural apophyseal glide (SNAG) is applied to the peripheral joints at the level  of L4-L5 spinous process. In the following technique accessory passive glide is given to the affected segments while the patient simultaneously performs an active movement. The direction of the passive glide is to be along the plane of the lumbar facet and the technique is performed in either in a sitting or standing position.

McKenzie Extension

It is done as shown below:

Soft Tissue Mobilization

Soft tissue mobilization techniques target areas of tension, adhesions, and restricted movement within these soft tissues.

• Myofascial Release: Targeting the fascia (connective tissue) to release restrictions and improve mobility.
• Trigger Point Therapy: Focused pressure on specific trigger points within muscles to release tightness.
• Stretching: Passive or active stretching of muscles to improve flexibility and range of motion.

Lumbar Traction

Lumbar traction is provided along the spine to reduce compressive forced on the affected vertebra. It can be of great benefit where compression of nerve is involved.

Muscle Energy Technique

This technique improves joint mobility, correct muscle imbalances, and alleviate pain by using the patient's own muscle contractions to achieve therapeutic effects.

It is done in the following order:

1. Assessment: The therapist assesses the patient's range of motion, joint function, and areas of discomfort to determine the appropriate muscles and joints to target.
2.  Positioning: The patient is positioned in a specific way to facilitate the desired muscle contraction against resistance. This position is often carefully chosen to optimize the effects of the technique.
3.  Isometric Contraction: The patient is instructed to contract the target muscle group gently and gradually against the therapist's counterforce, which can be provided manually or through the use of props.
4.  Relaxation Phase: After holding the contraction for a brief period, the patient relaxes the muscle.
5.  Repositioning: The patient's position might be adjusted slightly, and the process of contraction and relaxation is repeated.
6.  Reassessment: The therapist evaluates the patient's range of motion and joint mobility after the MET has been applied to determine any changes and further treatment needs.

Prevention Methods for Low Back Pain

Education of patient by the therapist can reduce the likelihood of low back pain. patient is educated through lifestyle modification and posture ergonomic techniques. It helps maintaining proper body alignment and positioning to reduce stress on the spine and minimize the risk of developing or exacerbating back pain

• Take Breaks: Whether sitting or standing, take breaks to change your position and stretch periodically.
• Stay Active: Regular exercise, including exercises that strengthen your core and back muscles, can help support your spine and prevent back pain.
• Maintain a Healthy Weight: Excess weight can strain your back, so maintaining a healthy weight is important.
• Listen to Your Body: Pay attention to your body's signals. If you start feeling discomfort or fatigue, adjust your posture accordingly.