The aim of treatment is to re-establish normal movement at both a physiological and accessory level, while desensitising the nervous system and resolving pain. The physiotherapist must take into account the full picture of the patient’s symptoms. Critical to this is an accurate assessment. While it is not always possible to ascertain the exact cause of LBP the assessment should provide a reasonable theory as to the cause of the pain and aim to target the offending tissues or indeed pain syndrome.
Imaging may be used to help in the diagnosis but should not be relied upon to explain the whole picture as to why symptoms occur.
Manipulation, acupuncture, mobilisations, soft-tissue-release, nerve glides and rehabilitative exercises are among the techniques used. Should the therapist find that a certain level of the spine, a particular muscle or nerve are the root of the pain, the treatment can focus on returning normal movement and function to these areas. Here we discuss the first two interventions:
Manipulation may take place at the end or mid-range of a joints movement. What all manipulations have in common is that they are a high velocity and low amplitude thrust. While most of us would associate manipulation with an audible click or ‘cavitation’ of the joint, this is not a requirement in order to gain the effects. As with all manual therapy manipulations should never be seen as the sole treatment, rather they provide a window of opportunity during which rehabilitation exercises can take place. The three main mechanisms of manipulations are:
– Biomechanical effects – joint gapping leading to possible improved available accessory movements and therefore range
– Muscular reflexogenic effects – a reflex reduction in pain and muscle hypertonicity leading to improved functional ability
– Neurophysiological effects – pain-gating may occur through a barrage of non-nociceptive input. Opioid release has been shown to take place through stimulation of the periaqueductal grey matter in the brain leading to descending inhibition. The effectiveness of the neurotransmitter Substance P is decreased by the release of β-endorphins
(Potter et al 2005).
Western Acupuncture is known to help with pain relief and muscle tension, which itself is often the cause of LBP. The National Institute of Care Excellence (NICE) recommend acupuncture as a possible treatment in the management of non-specific LBP. Possible mechanisms of therapeutic acupuncture pain relief include:
– Through axon reflexes, the release of neuropeptides with trophic effects, dichotomising nerve fibres and local endorphins
– Spinal mechanisms, for example, gate-control, long-term depression, propriospinal inhibition and the balance between long-term depression and long-term potentiation.
– Supraspinal mechanisms through the descending pain inhibitory system, the sympathetic nervous system and the HPA-axis.
– Cortical, psychological, “placebo” mechanisms from counselling, reassurance and anxiety reduction.
Pain relief has been shown to facilitate muscle function and with it tissue healing. If acupuncture can decrease the discomfort felt, through any mechanism, then a functional improvement should be seen. (Furlan et al 2005)
Furlan AD, van Tulder MW, CherkinD, Tsukayama H, Lao L, Koes BW, Berman BM. Acupuncture and dry-needling for low back pain. Cochrane Database of Systematic Reviews 2005, Issue 1.
Potter L, McCarthy C, Oldham J. Physiological effects of spinal manipulation: a review of proposed theories. Physical Therapy Reviews 2005; 10:163-170