Physical Therapy for Low Back Pain

Low back pain continues to dominate as the single leading cause of disability worldwide, and the data suggests that it won’t be dethroned anytime soon. Knowing that stat, we could argue that being armed with the skill set to confidently manage low back pain could be your single greatest weapon as a physical therapist. However, with thousands of research articles dropping every year on the topic, it can be challenging to sift through all the noise.

Allow us to summarize the three major components of what we believe to be comprehensive and effective management for low back pain.

 

Top Three Components to Effectively Managing Low Back Pain

1: Psychologically Informed Education

With so much evidence demonstrating the relationship between beliefs and pain, a psychologically informed approach has to be at the center of your rehab plan when experiencing low back pain. Whether it’s reducing fear, gaining trust, or building patient self-efficacy, this is the overall foundation that all other treatments are built around. But what does “psychologically informed” actually mean? Here are a few main topics to cover throughout the rehab journey:

  • Guidance to stay active, avoid rest, and return to activities you enjoy ASAP
  • Avoiding pathoanatomical explanations
  • Lack of correlation between pain and tissue damage
  • Lack of correlation between pain and imaging findings
  • Addressing lifestyle factors that can impact pain and disability (sleep, diet, stress, social connection, etc.)

 

2: Manual Therapy

We believe that a combination of manual therapy techniques, especially those used early in the plan of care, can have a significant effect on mitigating low back pain and disability. Nobody is arguing that manual therapy in isolation has long-term effects, but when used in combination with exercise and progressive loading, the effects can be extremely powerful. With the newest physical therapy clinical practice guidelines strongly recommending manual therapy for acute, subacute, and chronic low back pain, it’s hard to argue that it shouldn’t be a part of the package. Here are a few examples:

  • Spinal manipulation and mobilization
  • Soft tissue mobilization
  • Dry needling
  • Neural mobilization

 

3: Progressive Resistance Training

Although the initial goal might be to reduce someone’s low back pain, the long-term goal should always be life change. We want every patient to walk out of their treatment session not only feeling stronger, but literally becoming stronger. The research is very clear that general exercise is just as effective as specific exercise (low-load motor control) for reducing low back pain. With that being said, maybe there are factors beyond pain reduction that we need to consider when selecting our exercise program, such as the ability to build legitimate strength.

With progressive resistance training and aerobic exercise showing the ability to improve metabolic health, improve mental health, and reduce all-cause mortality, it’s hard to argue that building legitimate strength shouldn’t be a foundation in the comprehensive management of low back pain. Here are a few of our favorite exercises:

  • Deadlift
  • Reverse Hyper
  • Back Extension
  • Good Morning
  • Bent Over Row
  • Reverse Plank

 

Incorporate Various Strategies to Manage Patient Low Back Pain

It’s never one specific skill or technique that solves musculoskeletal pain, and low back pain is no exception. This is why we use an “And Not Or” approach in the clinic: Take all of the most evidence-based recommendations and package them together during each and every physical therapy session.

If you are interested in learning how to package all of these skills up, check out our Lumbar Spine Management weekend seminar. This two-day course covers manual therapy, including spinal manipulation and mobilization, progressive strengthening, and clinical reasoning to maximize your effectiveness and outcomes in the clinic.

 

References

Bakker EA, Lee DC, Sui X, Artero EG, Ruiz JR, Eijsvogels TMH, Lavie CJ, Blair SN. Association of Resistance Exercise, Independent of and Combined With Aerobic Exercise, With the Incidence of Metabolic Syndrome. Mayo Clin Proc. 2017 Aug;92(8):1214-1222. doi: 10.1016/j.mayocp.2017.02.018. Epub 2017 Jun 13. PMID: 28622914; PMCID: PMC5546793.

GBD 2021 Low Back Pain Collaborators. Global, regional, and national burden of low back pain, 1990-2020, its attributable risk factors, and projections to 2050: a systematic analysis of the Global Burden of Disease Study 2021. Lancet Rheumatol. 2023 May 22;5(6):e316-e329. doi: 10.1016/S2665-9913(23)00098-X. PMID: 37273833; PMCID: PMC10234592.

George SZ, Fritz JM, Silfies SP, Schneider MJ, Beneciuk JM, Lentz TA, Gilliam JR, Hendren S, Norman KS. Interventions for the Management of Acute and Chronic Low Back Pain: Revision 2021. J Orthop Sports Phys Ther. 2021 Nov;51(11):CPG1-CPG60. doi: 10.2519/jospt.2021.0304. PMID: 34719942; PMCID: PMC10508241.

Gordon BR, McDowell CP, Hallgren M, Meyer JD, Lyons M, Herring MP. Association of Efficacy of Resistance Exercise Training With Depressive Symptoms: Meta-analysis and Meta-regression Analysis of Randomized Clinical Trials. JAMA Psychiatry. 2018 Jun 1;75(6):566-576. doi: 10.1001/jamapsychiatry.2018.0572. PMID: 29800984; PMCID: PMC6137526.

Oliveira CB, Maher CG, Pinto RZ, Traeger AC, Lin CC, Chenot JF, van Tulder M, Koes BW. Clinical practice guidelines for the management of non-specific low back pain in primary care: an updated overview. Eur Spine J. 2018 Nov;27(11):2791-2803. doi: 10.1007/s00586-018-5673-2. Epub 2018 Jul 3. PMID: 29971708.

Shipton EA. Physical Therapy Approaches in the Treatment of Low Back Pain. Pain Ther. 2018 Dec;7(2):127-137. doi: 10.1007/s40122-018-0105-x. Epub 2018 Sep 18. PMID: 30229473; PMCID: PMC6251828.

Smith, B.E., Littlewood, C. & May, S. An update of stabilisation exercises for low back pain: a systematic review with meta-analysis. BMC Musculoskelet Disord 15, 416 (2014). https://doi.org/10.1186/1471-2474-15-416

Stamatakis E, Lee IM, Bennie J, Freeston J, Hamer M, O’Donovan G, Ding D, Bauman A, Mavros Y. Does Strength-Promoting Exercise Confer Unique Health Benefits? A Pooled Analysis of Data on 11 Population Cohorts With All-Cause, Cancer, and Cardiovascular Mortality Endpoints. Am J Epidemiol. 2018 May 1;187(5):1102-1112. doi: 10.1093/aje/kwx345. PMID: 29099919.