First off, most people in their lives will experience low pain. Low back pain is one of the most common health complaints in the world, affecting up to 80% of people at some point in their lives.
Low back pain can be caused by a variety of factors including poor posture, muscle strain, ligament or tendon sprains, disc herniation or degeneration, fractures, and kidney stones. Muscle strain occurs when muscles are overstretched or torn due to sudden lifting or movement. Ligament or tendon sprains are tears that occur in the soft tissue due to excessive stretching. Disc herniation is a displacement of the gel-filled discs between vertebrae which can pinch nerves and cause pain. Degeneration is the breakdown of spinal discs due to age with can lead to chronic inflammation. Fractures can occur from car crashes and falls while kidney stones are hard deposits that may form in the urinary tract and cause back pain. The very first step is to get into a professional that can help you identify the cause of the pain. The goal may not be to absolutely figure out exactly the structure because for physical therapy, we really just need to figure out if this is a musculoskeletal injury or if it is caused by something like a kidney stone or internal organ referred pain.
There are many clinical tests that a physical therapist can perform to help you determine the injured structure. This means you can start physical therapy in most cases without needing and MRI.
The type of low back pain we are going to discuss today is disc injuries. There are a variety of different types of disc injuries and there is different terminology for naming these different types of injuries. . Lumbar disc injuries can occur when spinal discs become herniated or torn. The injury occurs when the gel-filled disc between two vertebrae is displaced, pinching nerves and causing pain. This type of injury is commonly caused by poor posture, excessive lifting, or sudden movements. Symptoms include lower back pain that radiates down the legs and can range from mild to severe depending on the severity of the injury. Treatment for lumbar disc injuries typically involves rest, physical therapy, medications, and in some cases surgery.
Here is a great video describing the mechanism of a disc injury and how you can work to resolve the injury.
Compressions forces squeeze the disc material beyond the annular layer of the disc and can cause that material to touch a nerve. This will result in pain radiating down leg, usually the back of the leg. Depending which nerve is injured, the pain pattern will be different. Since L4/L5 and L5/S1 injuries are most common, we will refer to pain patterns with those lumbar levels.
Some people (like me) will not have any pain down into the legs with a disc injury. If the annular layer has a tear (fissure) and there is nothing touching the nerve, you may only have pain in the low back. This pain typically radiates to the sides along the belt line. If the nucleus has pushed out far enough to contact a nerve root, it will send pain down that nerve. The harder the nerve is pressed, the further and more intense the symptoms.
Typically, this pain is worse in the morning and made worse with bending, sitting, lifting, and twisting... but not always. In my case, my pain is worse with longer term standing or sitting. Bending is only painful in the morning but become less painful throughout the day. For me, twisting to the right hurts but to the left it does not. Every disc injury is different and will have a different presentation yet the main symptoms are often common. between patients.
Phases Of Treatment Of Disc Injuries
Phase 1
The main goal of phase 1 is to reduce the pain in and sensitivity of the disc. This is not a no pain, no gain time. This is time to treat the disc and try to get the nucleus to retract as much as possible to reduce the pain in the low back. There are several ways to do this but the best is to do light exercises to improve nerve mobility and retract the disc herniation and nuclear material away from the nerve and fissure.
This is typically accomplished with extension and nerve glides as well as decompression.
The nerve glide will help to reduce some of the symptoms in the legs if you are having any. This can also relieve some of the pain in the low back that is being cause by neural structures.
Here is a video of a prone press up. This is a common exercise performed inside of physical therapy. Dr. Tony (audio) describes the process of how we perform our prone press ups in clinic.
Lastly, some type of decompression of the lumbar spine (click here to see) may be useful during this phase of recovery to help relieve some of the pain and reduce the herniation and pressure posterior on the tear.
Phase 2
This is the phase where we can work on graded exposure to activities that were previously painful. The goal is to gradually increase strength of the low back, hip, and core muscles. We also want to work on improving range of motion of the spine and working to return it back to normal. This phase can be a bit tedious but with the right physical therapy clinic and the right physical therapist this phase can still be fun and challenging. You should come out of this phase feeling confident that you have restored your strength and range of motion. You may not yet be pain free and most likely won't have returned to most of your activities but you should be feeling better.
Phase 3
This is a phase in which we are going to take the training wheels off a bit and start letting you get back to some of the previous protected movement patterns. This phase you may end up going back to positions that caused the injury in the first place. In order to get back to full strength and activity your back will need to be able to do all movements that it was doing prior. That doesn't mean we need to start off with deadlifts at your previous weight, it just means that we need to very gradually increase load, volume, and time with exercises.
(Meakins A Road to recovery graph British Journal of Sports Medicine 2015;49:494.)
It is important to remember that during the recovery process you will likely not experience a linear recovery. There will be ups and downs, highs and lows. Some days you will feel a lot better than others. Some days will be frustrating and some will be filled with hope. What I had to do during my recover was zoom out and look at the bigger picture. Very much like the stock market. Is the trend upward? If yes, we can be happy. If no, we need to simply change the plan and continue to move forward.
Phase 4
This is the phase where we get you back to all prior activities. The goal is to get you back to 100% of the activities you did prior to your injury without fear and avoidance. Sometimes the mental aspect of this phase can be the most difficult. I remember the fear of returning to heavy lifting after I injured my back. It can be hard to get past the mental barriers that are holding you back. This is also the phase where maintenance is going to be very important. Honestly, if you are like me you will need to do some sort of maintenance the rest of your life, especially if you continue to do very physical activity.
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