More than 50% of my caseload is low back pain. Recent estimates suggest that upwards of 632 million people suffer from low back pain worldwide. At some point, it is thought that 60-70% of the population will suffer from low back pain. Pain suffers come from all walks of life. The high level endurance athlete, the high school gymnast, the retired weekend warrior, the 9-5 desk job. It seems that, regardless of age, profession, activity, or ability, back pain is waiting for you around the corner. The question becomes, how to decrease the risk of low back pain and how to treat it, should it affect you at some point in your life.
As a physical therapist and a movement expert, I evaluate low back pain on a daily basis. Often, the complaint, the pain location, the description of symptoms, the location of symptoms are the same. So we can treat them all the same way, right? Absolutely not. No one case of low back pain I evaluate is the same. I feel that this contributes to so many failed episodes of low pain pain interventions and so many people simply accepting that some low back pain will plague them for the rest of their life.
When a patient steps into my evaluation room, the first thing I want to do is listen. Because, if you’re attentive, they will (directly, or indirectly) clue me into causes, postures, and movements than can be related to guide my evaluation. 90% of my work is done simply by listening to what the patient has to say. The rest of my exam will be to confirm or deny suspicions I have about the patient’s movement profile. Our exam at Chandler Physical Therapy is always the same, regardless of onset of low back pain. Why? This gives us a measurable baseline to which we can return to and compare in future session. For us, we use the Selective Functional Movement Assesment (SFMA). This exam breaks down developmental movement patterns into pieces so that we can pin point exactly what is dysfunctional and causing the patient pain. Often, this isn’t an ‘AHA!’ one and done dysfunction but rather a multifactorial combination of factors leading to an undesirable outcome (back pain). This exam will then guide my treatment based off it’s findings. My treatment will vary widely depending on my findings. Consider these two patients.
Patient #1: 28 y.o. female with 2 year history of low back pain. Former gymnast. Pain described as achy, and diffuse throughout the low back and into the buttocks with standing > 30 minutes.
Patient #2: 68 y.o. retired male. 28 year history of low back pain. Former insurance salesman. Describes pain as achy, and diffuse throughout the low back and into the buttocks with standing > 30 minutes.
While both present with the same symptoms and pain locations, I want to share my findings from my evaluation to illustrate why all low back pain is not the same.
Patient 1#: Normal toe touch without pain – remains normal when reaching for toes while sitting. Very painful backward lean which replicates symptoms, very poor spinal rotation with pain at end range. Pain of backward lean was not painful in a prone press up. Seated rotational assessment of the spine was normal and without pain.
Patient #2: Unable to touch toes, painful, and replicated familiar symptoms- seated toe touch was the same, painful. Backward lean was non-painful – limited in upper spine and hips, but did not aggravate low back pain. Prone press up on a table demonstrated similar restrictions as in standing no low back pain. Patient demonstrates marked reduction of hip inward rotation. Significant restriction of rotation both in standing and seated.
Both patients came in with the same report of pain. But both were very different in their presentation. It doesn’t make sense to treat these two patients the same. So, from my exam, how were these patient’s treated?
Patient #1: Because of the absence of pain with testing on the table and pain with standing, we see that the patient had marked stability deficits in the hips and lumbar spine. The patient was certainly able to get where she needed to go, but when loaded in standing, could not control it, causing pain. This patient was treated with hip mobilizations, dry needling to the lumbar spine and hips for muscular trigger point management, and given lots of lumbar and hip stability exercises to work on at home.
Patient #2: This patient demonstrated marked mobility restrictions in standing which did not resolved once on the table. This would suggest that the patient was lacking more mobility of the hips, lumbar spine and thoracic spine. This patient was treated with lumbar spine and thoracic spine manipulation, dry needling to the hips and lateral legs, and given hip and spinal mobility drills to work on at home.
Both patients responded favorably – discharge outcome measures demonstrated 90+% resolution of pain and dysfunction and both had returned to normal activities without limitation.
While presenting the same, these patients were treated very differently. When it comes to back pain, why settle for a once size fits all treatment? No two cases of low back pain are alike. If you, or someone you know and love is suffering from low back pain, please, get evaluated by a physical therapist, a movement expert.
Back pain is a symptom, not a condition. Why allow yourself to be limited by disability when a treatment option is out there?