LOW BACK PAIN

the first instance, the use of postural and movement re-education is important in the treatment of low back pain. It’s important to understand that any postural or movement strategy must begin with awareness of the non-optimal strategy, and how this strate- gy is contributing to the pain pattern. Knowledge, movement and awareness can empower the patient to take control of their back pain. The term ‘re-education’ rather than treatment can also serve as a strong motivator for the patient, in as much as it assumes that the patient is already capable of achieving good posture or movement.

Exercise therapy Exercise is now recognised as an all-important part of low back pain rehabilitation since the publication of the first trial to demonstrate it’s efficacy in 1988 (4). Exercise is also the primary means by which patients can be restored to normal function. Stability exercises can help to increase spinal and pelvic stability, although it is important to get the correct balance of stability and mobility appropriate to the patient. The use of Pilates-evolved exercise methods has significantly raised the awareness of such approaches in the treatment of low back pain. Within the context of stability it is important not to forget stability training of other major joints such as the ankle joint, and how instability in the distal segments may contribute to low back pain.

Functional movement patterning may help integrate patients back into the demands of daily living following low back pain. Although these movements are generally more effective once the objectives of awareness and stability are realised, they can be introduced almost immediately for the majority of low back pain sufferers. The primary focus of these programmes is the mainte- nance of good postural control while performing useful move- ments such as bending and lifting, pushing and pulling, twisting, balance and gait patterns.

Lifestyle management Effective lifestyle management can help patients to confidently address nutrition, stress and psychological factors that may affect both the treatment of low back pain and preventative back health. Optimal nutrition in itself may form part of an overall plan to provide the body with adequate nutrients for healing tissue; stress management techniques can help to off-set occupational pressures that may contribute to back pain; and psychological techniques such as cognitive behavioural therapy and counselling may yield significant results in terms of pain control, weight management and the removal of muscular guarding patterns. All practitioners should play an active role in installing and maintaining motivation of their patients both during and after treatment. This is particularly useful when exercise is an important part of the treatment plan, as it doesn’t matter how effective an exercise may be if a patient is not motivated to do it.

WHAT ARE THE LIMITATIONS WITH THE TRADITIONAL TREATMENTS FOR LOW BACK PAIN, AND HOW COULD THESE BE ADDRESSED IN THE FUTURE? The past 25 years has seen a dramatic increase in the number and diversity of back care practitioners yet while many approaches work within a specific context, no single approach is adequate for all cases. All treatments for low back pain have some limitation,

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highlighting the need for a multidisciplinary approach to back care. All therapists should be aware of the limitations of their profession and more importantly not be afraid to try different treatment options, or refer to a different speciality where necessary. Meeting the needs of patients must always be first priority, there is no room for the ego of the therapist.

WHAT ROLE DO BACK CARE PRACTITIONERS PLAY IN THE MANAGEMENT OF LOW BACK PAIN OVER THE NEXT 5-10 YEARS? Based on the limitations of current approaches, by far the most important role of all back care practitioners over the next 5-10 years is to continue to build bridges between associated therapeutic disciplines. Indeed, much of the already growing success in current back pain management has not arisen from new methods, but the integration of existing models of diagnosis and treatment. This collaboration can only be a positive move, and one that should effectively become part of mainstream culture in the future.

Diversification within each profession is another shift that is already happening, and may also serve to increase specificity of knowledge in the area of low back pain. This can be bought about by better classification of low back pain and by appropriately developed randomised controlled trials to help better understand specific subgroups and optimum strategies for treatment. Although evidenced based medicine is an important driver of best practice, all therapists should bear in mind that lack of sound evidence doesn’t mean a treatment or approach doesn’t work in practice. There is along way to go in treatments for low back pain and research methodologies are still being developed to address some of the key questions in this area.

As well as looking for new ways of integrating resources, back care practitioners will do well to remember their central roles within their chosen profession:

■ To make a diagnosis that is based on the paradigms of their chosen field

TABLE 2. PATIENT CHECKLIST FOR LOW BACK PAIN

■ Take control of your low back pain: assume an active role in your own rehabilitation

■ Understand the postural and movement behaviours that bring on your back pain

■ Take the steps necessary to begin to make changes in your body. If necessary, seek the assistance you need to facili- tate those changes: spinal manipulation, physiotherapy, massage and exercise

■ If needed, apply pain relief through non-prescriptive med- ication

■ Develop a rehabilitative and preventative strategy with the guidance of your healthcare professional(s)

■ Be patient and persevere ‘ understand that you back pain is likely to have been an accumulative process, that make take a small amount of self-discipline and awareness to resolve

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