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Low back pain is very common and most people have some experience of a back pain episode at some time of life. Attendances at physiotherapy clinics for low back pain are very high so physios have a variety of assessment and treatment techniques to manage spinal pain and improve patients' function.

Many people self refer for their back pain and so the physio has a responsibility to ensure the patient has not got a serious underlying condition. The physiotherapist goes through the patient's presenting condition and asks specific questions to rule out medically serious matters. Typical questions include a history of cancer, control of bladder and bowel, arthritic disease, epilepsy, diabetes, appetite loss, weight loss, sleep problems and night pain.

The physio is looking for the patient to react as if they have mechanical spinal pain, a condition where normal physical stresses such as sitting or walking have a worsening or easing affect on the pain. The examination starts by observing the posture and movement of the patient during the questioning and the physio follows this by examining the spinal posture and ranges of movement. Abnormalities of posture are common and not always important, with leg length differences, a reduction or increase in the back curves and a scoliosis being common findings.

The physiotherapy diagnosis is based on the changes in normal spinal movements. Limitation of spinal flexion (bending forward) is common with reduced range, guarding and some worsening of the pain during or at the end of this movement and other spinal movements. The physiotherapist may test the strength of the muscles and reflexes, the ability to feel sensations in the legs, hip movements and the sacro-iliac joints. Testing of the movements between the individual spinal joints can indicate where the pain, instability or stiffness might be produced.

Once the therapeutic diagnosis is made the physio will set the treatment goals and plan of treatment. If stiffness is a problem, mobilisation techniques can be used and the patient taught mobilising exercises as a home programme. If pain is the main issue then analgesia might be recommended with gentle mobilising and exercise techniques to ease the joints.

Lumbar stability has been a controversial and exciting development over the last 20 years with much research into the role of the abdominal and pelvic muscle groups in providing stability control to the lumbar spine. Patients are taught to maintain a neutral lumbar posture whilst recruiting their abdominal and spinal stabilisers and then move on to exercises with more resistance involved, eventually performing more functional exercises using the same principles.

Spinal joints do not appreciate being at end of their range for too long such as remaining slumped in sitting for a long period. This stretches the ligaments and can cause and maintain a pain problem. Physios teach patients to understand the new strange posture they are being asked to perform is the norm and that they need to perform it regularly until they do it naturally.

McKenzie technique is followed by many spinal physiotherapists. This therapy holds that certain postures and movements affect the central disc material, the nucleus pulposus, either causing it to increase pressure on the posterior wall of the intervertebral disc or to reduce the pressure. The physiotherapist asks the patient to do repetitive movements in one direction to establish a "directional preference" which either worsens or improves the symptoms. From this the physio forms a treatment plan based on which direction of movement causes the desirable disc changes which alter the symptoms in the desired manner.

The treatment from the physio is backed up by advice to the patient to reduce the aggravating stresses on their back by pacing their activity to avoid overdoing. This gives the problem an opportunity to settle and allows the person to get themselves fitter with weight training and aerobic exercise such as swimming or cycling. Many therapies have no supporting evidence, but increasing our fitness has been shown to reduce both the severity and impact of low back pain.

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Jonathan Blood-Smyth is a Principal Physiotherapist at a prominent NHS teaching hospital in South-West England. He publishes articles on injuries and mishaps in periodicals and on his website for physiotherapists. If you are looking for local physiotherapy after an mishap or injury, visit his website for physiotherapy practitioners around the United Kingdom.
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