Physiotherapy in Toronto for Lower Back
Welcome to In Balance Physiotherapy's patient resource about low back pain.
Low back (lumbar) pain is one of the main reasons people visit their doctor. For adults over 40, it ranks third as a cause for doctor visits, after heart disease and arthritis.
Eighty percent of people will have low back pain at some point in their lives. And nearly everyone who has low back pain once will have it again.
Very few people who feel pain in their low back have a serious medical problem! Ninety percent of people who experience low back pain for the first time get better in 2-6 weeks and having a bout of back pain does not mean you will go on to develop chronic back issues.
This guide will help you understand:
- the anatomy of the spine and low back
- what causes low back pain, and what the most common symptoms are
- how health care professionals diagnose back pain
- how to manage your pain and prevent future problems
Which parts make up the lumbar spine, and how do they work?
The human spine is made up of 24 spinal bones, called vertebrae. Vertebrae are stacked on top of one another to create the spinal column. The spinal column gives the body its form. It is the body's main upright support.
From the side, the spine forms three curves starting at the top. The neck, called the cervical spine, which curves slightly inward, the mid back, or thoracic spine, which curves outward, and the lumbar spine, which again curves slightly inward.
The lumbar spine is made up of the lowest five vertebrae of the spine. Doctors often refer to these vertebrae as levels L1, L2, L3, L4 and L5; the ‘L’ refers to ‘lumbar’. The lowest vertebra of the lumbar spine, L5, connects to the top of the sacrum, which is a triangular bone at the base of the spine that fits between the two pelvic bones. Some people are born with an extra, or sixth, lumbar vertebra (L6). Having an extra vertebrae doesn't usually cause any specific problems.
Each vertebra is a round block of bone, called a vertebral body. The lumbar vertebral bodies are taller and bulkier compared to the rest of the spine because the low back is designed to withstand pressure from body weight and from daily actions like lifting, carrying, and twisting. The bulkier vertebral bodies also provide support to allow the large and powerful muscles attaching on or near the lumbar spine to work effectively.
The very back of the vertebrae has a bony outcropping called the spinous process; this is what you feel when you run your fingers down the back of your spine. A bony ring attaches between the body of the vertebrae and the spinous process. When the vertebrae are stacked on top of each other, the vertebral rings form a hollow tube. The spinal cord passes through this bony tube. Just as the skull protects the brain, the bones of the spinal column protect the spinal cord.
The spinal cord extends down to the L2 vertebra. Below this level, a bundle of nerves extend down from the spinal cord (still within the bony canal) and go to the lower limbs and pelvic organs. This bundle of nerves is called the cauda equina. In Latin this term means ‘horse’s tail’ as it resembles the strands of a horse’s tail in its appearance.
As the spinal cord travels from the brain down through the spine, it sends out nerves on the sides of each vertebra called nerve roots. These nerve roots join together to form the nerves that travel throughout the body and form the body's electrical system. The nerve roots that come out of the lumbar spine form the nerves that go to the lower limbs (right down to the feet) and the pelvis. The thoracic spine nerves go to the abdomen and chest. The nerves coming out of the cervical spine go to the neck, shoulders, arms, and hands.
It is sometimes easier to understand what happens in the spine by looking at a spinal segment. A spinal segment includes two vertebrae separated by an intervertebral disc, the nerves that leave the spinal cord at that level, and the small facet joints that link each level of the spinal column together.
The intervertebral disc normally works like a shock absorber. It protects the spine against the daily pull of gravity. It also protects the spine during heavy activities that put strong force on the spine, such as jumping, running, and lifting.
An intervertebral disc is made up of two parts. The center, called the nucleus pulposus, is spongy. It provides most of the disc's ability to absorb shock and is designed to transmit force and resist rotation. The nucleus is held in place by the annulus, which is on the outside of the disc. The annulus is a series of strong ligamentous rings (ligaments are strong connective tissues that attach bones to other bones). These ligaments are laid in a criss-cross fashion around the middle of the disc (the nucleus). This criss-cross fashion of the anatomy is significant as only half of the ligaments are active and providing maximum support and resistance when the spine rotates to one side and half are active when it rotates to the other side.
Between the vertebrae of each spinal segment are two facet joints. The facet joints are located in a line on the back of the spinal column from the neck down to where the lumbar spine attaches to the sacrum. There are two facet joints between each pair of vertebrae, one on each side of the spine. The design and alignment of the facet joints of the lumbar spine allow the spine to bend forwards and backwards easily. The lumbar spine anatomy also allows some rotation, but not nearly as much as occurs in the cervical or thoracic spine. As the lumbar spine rotates the facet joints are pushed into each other on one side and open up away from each other a little bit on the other.
The surfaces of the facet joints are covered by articular cartilage. Articular cartilage is a smooth, rubbery material that covers the ends of most joints. It allows the bone ends to move against each other smoothly without bone rubbing directly on bone.
Two spinal nerves exit the sides of each spinal segment, one on the left and one on the right. As the nerves leave the spinal cord, they pass through a small bony tunnel on each side of the vertebra, called a neural foramen.
The lumbar spine is heavily supported by ligaments and muscles which adds tremendously to its strength capabilities. Ligaments attach bones to bones to keep them stable. The ligaments are arranged in various layers and run in multiple directions. Thick ligaments connect the bones of the lumbar spine to the sacrum (the bone below L5) and pelvis.
The muscles of the low back are also arranged in layers. The deepest layer of muscles connects along the back surface of the vertebrae. These deepest muscles coordinate their actions with the muscles of the abdomen (the core) to help hold the spine steady during activity.
The erector spinae muscles also make up one layer of the low back muscles. These long muscles run up and down all the way from the lower ribs and chest right down to the bottom of the back. You can easily feel your erector spinae muscles at the bottom of your back pop out if you stand on one foot and then lift one leg backwards. These long muscles blend together in the lumbar spine to form a thick wide tendon near the bottom of your back (fascia) that binds together the bones of the low back, pelvis, and sacrum. This fascia heavily assists in supporting the lumbar spine especially when it is in a bent forward position.
Why do I have low back pain?
There are many causes of low back pain and health care professionals are not always able to pinpoint the exact source of each patient's pain. Despite not knowing the exact cause of the pain, most back pain can still be very effectively treated based on symptoms and knowledge about how backs usually respond to certain activities.
Acute tissue damage, such as a torn muscle, an irritated disc, a pulled ligament or a fracture will cause acute back pain. Most back pain of this nature will heal up within 6-12 weeks of the injury or less. Repetitive activities of daily living, when done well, actually keep the spine strong! However, inactivity, prolonged sitting, or repetitive heavy loading with poor mechanics or poor efficiency can mean the lumbar spine takes more load, rotation, or strain than it should and can result in an acute injury, or more localized degeneration than would normally occur with. Aging, by itself does not directly cause back pain, and all back pain is not necessarily related to degeneration. Persistent or chronic back pain may also be affected by other contributing factors such as systemic inflammation, stress, tension or fatigue.
There is strong evidence that cigarette smoking for example expedites degeneration of the spine, specifically the flat part of the vertebrae called the vertebral endplate. This can cause a vacuum type phenomena of the disc sinking into the vertebrae and causing decreased disc height between the vertebrae. Scientists have also found links among family members showing that genetics plays a role in how fast degenerative changes in the spine occur.
The intervertebral disc changes over time. The disc is spongy and firm and like most cartilage, actually gets stronger with load! We used to believe that cartilage damage was a “wear and tear” issue, but we now know it is actually a “wear and repair” phenomenon. This means you should not be afraid to load your spine well and often. The nucleus in the center of the disc contains a great deal of water. This gives the disc its ability to absorb shock and help the spine withstand heavy and repeated forces.
Normal change in the disc does occur with age but this does not correlate to pain. The annulus around the nucleus weakens and begins to develop small cracks and tears and the disc begins to lose water, causing it to lose some of its fullness and height. As the disc continues to degenerate, the space between the vertebrae shrinks. This compresses the facet joints along the back of the spinal column. As these joints are forced together, extra pressure builds on the articular cartilage on the surface of the facet joints. In the presence of local or systemic inflammation this extra pressure can damage and sensitize the facet joints. Over time, this may lead to arthritis in the facet joints.
These degenerative changes in the disc, facet joints, and ligaments may cause the spinal segments to move more than they usually do, requiring the muscles to do more to distribute force and keep the spinal column supple and strong. Extra movement is not always an issue - think of a gymnast’s or circus performer’s amount of spinal mobility! However, extra movement within the bones and ligaments without strong, supple conditioned muscles may lead to poor force distribution and more repeat episodes of muscle, joint or ligament sprain.
In some cases of degeneration the nucleus of the disc may push through the torn annulus and towards or into the spinal canal or into the space where the spinal nerves lie. This is called a herniated or ruptured disc. Sometimes patients refer to this as a slipped disc. The disc material that squeezes out may be enough that it directly presses against the spinal nerves. The disc tissue that pushes through also releases enzymes and chemicals that produce inflammation in the area. The inflammation caused by the chemicals released from the disc often (but not always) causes the brain to produce pain. Pressure on the nerves may cause additional sensitization or breakdown of the protective sheath around the nerve.
As the degeneration continues, the body naturally tries to contain the disc as well as the extra motion the degeneration is causing. In response to the extra movement the body may develop boney outgrowths around the edges of the disc and facet joints to try to share the load and make the joint more stable. These boney outgrowths are called bone spurs, or on an x-ray report may be referred to as osteophytes or facet hypertrophy. These bone spurs may cause no issue whatsoever or they may create nerve sensitivity by pressing on the nerves and blood vessels of the spine as they pass through the opening in the vertebra (neural foramina) or by limiting normal motion. This pressure around the nerves can cause pain, numbness, and weakness in the low back, buttocks, lower limbs and feet.
Over time a spinal segment that has degenerated and become more mobile as described above eventually becomes stiffer and less mobile. The ligaments thicken, facet joints enlarge, and disc tissue dehydrates and scars in a continued attempt to distribute force well. Typically, a stiff joint doesn't cause as much pain as one that moves around more than it should and as a result, this stage of degeneration may actually lead to pain relief for some people.
Understanding Types of Pain
Pain research is ever-evolving. The most current guidelines divide pain into a few key categories. The key message is that all pain is real. Pain is a complex perception. It’s an output of the brain in response to messages from the body. The full definition states that pain is an unpleasant sensory and emotional experience, associated with, or resembling that associated with actual or potential tissue damage. Back pain commonly falls into all the categories below which can help reassure us when we are trying to makes sense of why it may be behaving as it does, why back pain is so intense at times, or why it lingers.
This is pain that is produced in proportion to the messages coming to the brain from the tissues that are irritated, damaged, have inflammation, or are in mechanical overload. For example, you would expect to feel immediate pain after dropping something heavy on your foot but it would resolve in a reasonable amount of time. This pain also generally follows a predictable pattern such as the pain you feel after an acute back muscle spasm - it may feel ok sitting down but hurts when you transition to standing. It may be better in the morning and predictably sorer in the evening or after certain activities. The key feature of this type of pain is that it doesn’t last beyond 12 weeks - even though that might not be what your experience feels like.
This pain comes from specific damage or disruption to the somatosensory systems which is the network of nerves throughout the brain and body that allow you to sense touch, temperature, muscle stretch, body position, and also includes taste, hearing, vision and smell. In this type of pain there can be a prolonged experience beyond 12 weeks wherein the messaging to and from the brain gets disrupted, or can be stimulated without new tissue damage. Our fears and emotions can play a part in type of pain, but that isn’t always the case. It’s more like the wires are faulty. In back pain, this type occurs when a nerve exiting the spinal column gets inflamed or damaged. Often it will be felt down the legs along the path of the nerves involved.
Central Sensitivity or (Nociplastic Pain)
This type of pain arises from altered perception of the messages coming from the body despite there being no clear evidence of actual or threatened tissue damage or evidence of a disease or disruption to the body’s sensory system (the somatosensory system). This pain is very real, it’s just not necessarily coming from a new damaged tissue or an area that hasn’t healed. This type of pain features strongly in back pain lasting longer than 12-16 weeks. It’s like messages from the body that wouldn’t normally create a response get amplified within the central nervous system and are strongly influenced by thoughts, fears, perception, environment and emotions. There is also strong evidence that individuals with neuropathic pain will have elements of central sensitization as well.
Many patients with back pain may have a mix of two or more of the types above.
The good news is that all types of pain respond to treatment, it just needs to be the appropriate treatment for the types of pain you are experiencing!
The effects of spine degeneration or back injury can lead to specific spine conditions. These include:
- annular tears
- internal disc disruption
- herniated disc
- facet joint arthritis
- segmental instability
- spinal stenosis
- foraminal stenosis
Our intervertebral discs change with age, much like our hair turns gray. Perhaps the earliest stage of degeneration occurs due to tears that occur in the annulus. These tears can result from natural tissue changes over a period of time or they can be the result of a sudden injury to the disc due to a twist or increased strain on the disc that overpowers the strength of the annulus. These annular tears may cause pain in the back until they heal with scar tissue.
Internal Disc Disruption
Multiple annular tears can lead to a disc that becomes weakened. The disc, which sits between the two vertebrae, naturally over time dehydrates and loses height. This process can be accelerated with cumulative injury. The loss of disc height causes the vertebrae to start to compress closer to one another. The collapsing disc itself can be a source of pain because it has lost the ability to be a shock absorber between the vertebrae. This condition is sometimes referred to as internal disc disruption. This type of problem causes primarily mechanical back pain due to inflammation of the disc and surrounding structures, however the disruption of the normal disc anatomy can also add pressure to the nerves in the area and may result in neurogenic pain. In many cases the body reacts to a collapsed disc by growing small bony outgrowths (spurs) near the edge of the disc or the nearby small joints (facets joints) in order to contain the splaying of the disc. Bone spurs can cause pain by pressing on nearby nerves or getting in the way and being compressed when the back tries to move naturally.
A disc that has been weakened may rupture (herniate). If the annulus ruptures or tears, the material in the nucleus can squeeze out of the disc, or herniate. A disc may herniate a little or a lot, and symptoms will vary accordingly. A disc herniation usually causes compressive problems if the disc presses against a spinal nerve. The chemicals released by the disc may also inflame the nerve root causing pain in the area where the nerve travels to (somewhere down the leg). If this type of pain travels down the back of the leg it is referred to as sciatica.
Disc herniation occurs more often in younger populations (20-50 years old) when the disc is plump and well hydrated. Poor efficiency with heavy, repetitive bending, twisting, and lifting can place too much pressure on the disc, causing the annulus to tear and the nucleus to rupture into the spinal canal.
Facet Joint Arthritis
The facet joints along the back of the spinal column link the vertebrae together. They are not meant to bear much weight but rather act to allow free but coordinated movement of the spine. If a disc loses its height as it degenerates, the vertebra above the disc begins to compress toward the one below. This causes the facet joints to press together and bear weight. Joint (articular) cartilage covers the surfaces where these joints meet. Like other joints in the body that are covered with cartilage such as the hip and knee, the facet joints can develop osteoarthritis (the articular cartilage wears away over time due to systemic or local inflammation). Extra load and localized inflammation of the facet joints, such as that from a collapsing disc, can speed the degeneration in the facet joints. The swelling and inflammation from an arthritic facet joint can be a source of low back pain.
Segmental instability means that the vertebral bones within a spinal segment move more than they should. This movement can develop if the disc or the facet joints have degenerated and the neuromuscular system wasn’t able to adequately compensate. Usually the supporting ligaments around the vertebrae have also been stretched over time, and fail to support the joint as it normally would.
One form of segmental instability is a condition called spondylolisthesis, where one vertebral body begins to slip forward over the one below it. Evidently when a vertebral body slips too far forward it can cause problems. Firstly, slipping of a vertebrae can lead to mechanical pain simply because the structures of the spine move around more than they should and they can become inflamed. The extra movement can also cause nerve pain symptoms if the spinal nerves are pressured as a result of the extra movement. This is common in young athletes like gymnasts that train hard without ideal efficiency while their skeleton is immature. Spondylolisthesis can be a condition people are born with that doesn’t present until adulthood, or can occur from repetitive microtrauma or a larger sudden trauma.
Stenosis means narrowing. Spinal stenosis refers to a condition in which the tube-like area where the spinal cord inside the spinal canal is narrowed, or closed in. This usually occurs from bony spurs encroaching on the area but can also occur from other matters such as cysts or tumours. The spinal cord itself ends at L2. Below this level, the spinal canal contains only the spinal nerves that come off of the spinal cord. These nerves travel to the pelvis and legs. When stenosis narrows the spinal canal, either the spinal cord itself or the spinal nerves coming from the cord are squeezed inside the canal. This pressure on the nerves or spinal cord can cause problems in the way the nerves work. Depending on whether it is the spinal cord being compressed or the nerves, and which nerves are being compressed, resulting problems can include pain and numbness in the buttocks, genitalia and legs, as well as weakness in the muscles of the lower body that are supplied by those nerves.
Spinal nerves leave from the spinal cord between the vertebrae in a boney tunnel called the neural foramen. Stenosis can also occur here and cause this tunnel to become smaller due to disc degeneration and collapse or bone spurs forming in the area. This subsequently squeezes the spinal nerve as it passes through this tunnel. This condition is called foraminal stenosis.
Symptoms from low back problems vary. The pain or symptoms they experience depend on a person's overall health condition, which structures are being affected, and many other factors like stress, sleep, diet, mood and their beliefs about their pain or condition. Some of the more common symptoms of low back problems are:
- low back pain
- pain spreading into the buttocks and thighs
- pain radiating from the buttock to the foot
- back stiffness and reduced range of motion
- muscle weakness in the hip, thigh, leg, or foot
- sensory changes (numbness, prickling, or tingling) in the leg, foot, or toes
In some rare cases, symptoms may involve changes in bowel or bladder function. These symptoms are caused by a large disc herniation or tumor that pushes straight back into the spinal canal and puts pressure on the nerves that go to the bowel and bladder. In addition to loss of control of the bowel and bladder, the pressure on these nerves may cause symptoms of low back pain, pain running down the back of both legs, and numbness or tingling in the saddle/genitalia area. Pressure on these nerves is considered a medical emergency as it can lead to permanent paralysis of the bowel and bladder. This condition is called cauda equina syndrome. Immediate surgery to remove pressure from the nerves is required.
How will my health care provider find out what's causing my problem?
The diagnosis of low back pain begins with a thorough history of your condition. Your physiotherapist will ask you questions to find out when you first started having problems, what makes your symptoms worse or better, and how the symptoms affect your daily activity. Your answers will help guide the physical examination. They may also ask you to fill out a questionnaire describing your back problems.
After taking your history your physiotherapist will then physically examine the muscles and joints of your low back and ask you to move in different directions to determine how your pain is affected. It is important that your physiotherapist understands how your back is aligned, finds out where it hurts, and checks which movements make it better or worse.
Your physiotherapist may do some simple tests to check the function of the nerves in your back. These tests are used to measure the sensation, reflexes and strength in your legs or feet. The information from your medical history and physical examination will help your physiotherapist decide what else needs to be looked at in the examination.
Most people with back pain will NOT need x-rays or other tests in order to diagnose and treat their pain. In some cases if an x-ray or other diagnostic could be helpful, then your physiotherapist will refer you to a doctor for further diagnostic imaging.
Once your physical examination is complete, your physiotherapist at In Balance Physiotherapy will discuss treatment options with you that will help speed your recovery so that you can return to your normal lifestyle as quickly as possible. It should be noted again that in many cases an exact single structure causing your back pain won’t be specifically identified. Back pain is rarely that simple. Not specifically identifying a single structure causing your issue does not preclude physiotherapy treatment from helping; most cases of low back pain can be resolved or managed very well with consistent physiotherapy treatment. Treatment will be very individual to you - who you are, how your body moves, what your health beliefs are, and what kind of life you live.
In Balance Physiotherapy provides physiotherapist services in Toronto.
What can be done to relieve my symptoms?
Physiotherapy can be very effective to ease your current pain and get you back to your normal everyday activities. Physiotherapy has been proven to be effective in both acute and chronic back pain. Physiotherapy can assist patients of all ages as well as all stages of back pain, whether this is your first bout of pain or whether you have had several bouts and you are dealing with chronic pain. Physiotherapy can also help by educating you about how to prevent back pain flare ups in the future.
Although the time required for rehabilitation varies among patients, you should expect to engage in therapy for anywhere from 3 weeks to 4 months depending on if your problem has occurred for the first time or is a chronic issue for you, and depending on how painful and limiting your problem is.
Fortunately, although back pain can be scary and debilitating, it is very rarely a sign of a dangerous problem or serious tissue damage. In most cases, back pain responds very well to physiotherapy treatment. Each of our treatments are designed specifically for your individual types of back pain and work to ease your pain and to improve your mobility, strength, posture, function and perception of vulnerability. In addition, your physiotherapist at In Balance Physiotherapy will teach you how to control your symptoms and how to protect your spine for the years ahead.
If your back pain is in an acute flare of less than 2-3 weeks, your physiotherapist may initially use ice, heat, ultrasound, electric muscle stimulation, interferential current, laser, needling, or hands-on treatment to address your symptoms. These modalities may be particularly helpful in the early weeks to improve your comfort so you can more easily engage in your physiotherapy regime and get back to your normal activities. Pain education will be a big feature right from the start to help you understand the nature of your back pain, address your fears or beliefs about back pain, and give you a sense of your prognosis to improve self-empowerment and reduce the likelihood of developing chronic pain.
Your physiotherapist will teach you ways to position your spine for maximum comfort while you recover from your injury or flare up. Your back is designed to withstand a variety of postures and it is actually healthy for your back to frequently move into many different postures. As long as you are without pain at the time, slouched sitting and lifting items with a slightly rounded back are ok for your back! In fact, the back is designed such that the anatomical structures that support your spine can still work efficiently in these postures. You and your physiotherapist may explore your preferred directions of movement and how to use them to your advantage early on as you heal. As rehabilitation progresses, it will be very important to explore and practice all directions of movement, and your therapist will guide your individual journey to movement freedom. Your physiotherapist will also explore efficient sitting, standing and movement postures and techniques to help you rediscover the strength and resilience of your spine.
You may be tempted to stop all activity because of your back pain however there is a great deal of evidence that shows that aerobic exercise (walking, running, biking or anything that gets our heart rate up) helps in the treatment of back pain and that increased overall fitness also reduces the risk of developing back pain again. Having moderate to severe pain with activity should always be respected but some mild discomfort may occur as you start back into your activities and as your back recovers and gets used to taking on load again; this is ok! This ongoing mild discomfort as you begin back to activity does not mean you are further injuring structures in your back. Some intense activities may need to be fully curtailed temporarily but gradually returning to your regular activity will be good for your back and your health in the long run. Your physiotherapist can help you to determine the best activities to restart and when to start them with your particular injury. They can also assist you in determining how hard you should push your activity level at each stage of your rehabilitation.
In addition to getting back to regular aerobic exercise, your physiotherapist will give you specific strengthening and stretching exercises to help your back. Your hip range of motion and strength is particularly important in helping your back function well so they will assess your hips and your lower body alignment and give you the best strength and mobility exercises for your individual needs in order to address any tightness, weaknesses and side to side imbalances.
Your ‘core’ muscles are those around your abdomen and trunk that help to maintain supple (not rigid) stability in this area and ensure efficient load transfer to the low back and entire spine. Maintaining adequate core strengthening is important in everybody, but particularly in those with low back pain. Some patients with chronic back pain unintentionally ‘overuse’ or inappropriately use their core muscles, and this can be more detrimental to someone with back pain than not using them at all! Your physiotherapist will check your core activation and strength and teach you how to appropriately and efficiently use your core muscles to support your spine in daily activities. A key feature will be teaching you how to move without holding your breath to allow you to load through your core efficiently and with less pain. Remember that your back is anatomically designed to withstand the loads of everyday life such as bending, twisting, jumping and taking load; your physiotherapist will educate you on how to ensure you are doing all the right things to optimize your back’s abilities.
If you have severe back pain, our physiotherapist may choose to work with you in a pool or encourage you to do exercises in a pool on your own. Physiotherapy done in water puts less stress on your low back, and the buoyancy allows you to move easier during exercise. Clients consistently report how much easier it feels to move their back when they are in the water.
It is well known that other factors can drastically affect your chances of getting low back pain and also how quickly you heal from your low back pain. As mentioned previously, people who smoke have both a higher chance of getting low back pain and recover from it more slowly as smoking decreases the blood supply to tissues and bones which leaves them vulnerable to injury, quicker to degenerate, and slower to heal. Your physiotherapist will encourage you to stop smoking if you do; even temporarily stopping while you are dealing with your back pain helps, but evidently quitting for good is recommended.
Fears, emotions, and beliefs also heavily influence the experience of back pain and the recovery trajectory. If you believe your back is unstable, fragile or degenerated it will be hard to trust movement is safe. If someone in your family has lived with horrible back pain, you may be inclined to believe that is your fate too and this can influence your experience. Furthermore, if you have experienced back pain and recovered from it, you may feel similar sensations and pains again if you experience emotional trauma, loss, anxiety or overwhelm. Your physiotherapist is aware of these factors and may do some additional assessments to determine if your pain is being created by the brain first, rather than in response to tissue damage. In either case, your physiotherapist knows the pain you experience is real and you are not making it up. Treatment approaches for centralized (or nociplastic) pain may be targeted at restoring your sense of safety, exploring your beliefs about your back pain in a non-judgemental way, and possibly getting you additional support to help process the emotional loads.
Being overweight can affect your low back, particularly if you carry your weight around your abdomen which indicates a higher body fat percentage and therefore higher systemic inflammation. If appropriate your physiotherapist will help support you to lose weight and modify your eating, sleep, and exercise, which will help you recover quicker and avoid future flare ups.
Physiotherapy at In Balance Physiotherapy will focus on reassuring you that swiftly getting back to work and other normal activities won't cause you harm and can actually help improve your back’s tolerance for activity in the future. Nonetheless, back injury flare ups may occur in the future and are often related to a period of emotional trauma, low mood, poor mental health, poor sleep, stress, inactivity, or trying a new activity; your physiotherapist will discuss what to do if your back pain returns and how best to manage this.
Your physiotherapist can also show you how to keep you moving with efficiency during routine activities. You'll learn about healthy postures for your back and using the best body mechanics to assist your back while lifting and carrying, standing and walking, and performing work duties. As mentioned previously, your back is anatomically designed to be strong and do many things such as carry loads, as well as to sit and to stand for periods of time. Contrary to popular belief, a slouched sitting position and allowing your back to bend forward slightly while lifting items is actually conducive to how your back is designed and is considered proper body mechanics! These positions allow the layers of long and tough ligaments and muscles at the back of the spine to mechanically do their job in supporting the spine. All this being said, however, our bodies in general are designed to move and not stay still in one position for too long, especially when recovering from injury. Your physiotherapist can advise you on how much is too much for carrying, sitting, standing and other activities as you recover from your back pain.
Although ‘bed rest’ was a common prescription in the past for acute back pain, ‘bed rest’ or lying down and doing nothing is rarely prescribed to help back pain these days. Alternatively, in cases of severe pain, your physiotherapist may suggest a short period of ‘modified rest’ where you are encouraged to rest in a comfortable position (such as on your back with your knees supported or in a semi-reclined position in a chair), but also still continue to do some modified activities, such as gentle hip and back range of motion exercises or light walking in order to keep your back moving while allowing your acute pain to settle. Again, staying in one position for too long, although comfortable at the time, is actually detrimental to healing. For this reason, modified rest after an acute injury will only be recommended for no more than 2-3 days.
A back support belt is sometimes recommended when back pain first strikes. In many cases a back brace can help provide support by adding compression to your back and increasing your confidence to move. A brace can lower the pressure inside a problem disc, decrease pain, and allow you to engage in some activities longer than you could without the back brace. Gradually your physiotherapist will encourage you to discontinue wearing the brace as your pain improves and you can engage in more advanced back strengthening exercises. Using the brace routinely after recovering from acute pain is not recommended. Wearing a back brace all the time after your back has recovered may cause muscles to atrophy and some patients will psychologically begin to rely on the belt instead of on the strength of their own muscles.
Your physiotherapist will suggest that you consult with your doctor or pharmacist regarding the use of pain relief or anti-inflammatory medication for your acute back pain. Although there is no medication that will cure low back pain, short term medications to combat pain, inflammation, and muscle spasm and to assist sleep can be incredibly useful to supplement your rehabilitation program. Over-the-counter medication is sufficient in most cases of back pain.
In Balance Physiotherapy provides services for physiotherapy in Toronto.
In most cases of low back pain no special diagnostic testing is required to diagnose and treat your back pain. Your doctor or physiotherapist will be able to determine from the history of your injury, how you are moving, as well as the physical exam they do as to what the most likely cause of your back pain is. In many cases, the exact structure causing the pain in your back may not be known, but this does not preclude treatment to help your pain. A combination of irritation to your back’s connective tissues, muscles, joints, ligaments, discs and nerves are often the culprits, so ‘diagnosing’ or naming one single structure is often futile. Treatment to help your back problem can still be very effectively provided without knowing the exact anatomical cause of your pain.
When acute back pain occurs, diagnostic tests are not routine. In many cases where diagnostic tests are completed unnecessarily, misleading findings are found. In many interesting studies patients have had no back pain at all but when they had their backs x-rayed or other diagnostics completed, the diagnostics have shown major structural changes despite no pain!
Diagnostic testing for back pain is reserved for when the pain is not acting as your physiotherapist or doctor would expect, your symptoms aren’t resolving with the usual conservative treatment, your pain is intense and relentless affecting your normal functions, your symptoms include nerve pains into your leg and foot, or you have a suspected more serious problem, such as cauda equina syndrome (disc disruption affecting the nerves supplying your bowel and bladder).
If diagnostic tests are deemed necessary, there are several different tests that your doctor may suggest you have done. Radiological imaging tests allow your doctor to see the anatomy of your spine and assists them in determining what may be causing your back pain. Knowing what structures may be contributing to your back pain may help further direct the most appropriate treatment to assist you.
X-rays are usually the first test ordered before any of the more specialized tests are completed. X-rays use electromagnetic radiation to show problems with bones and can show problems such as fractures, infections or bone tumors. X-rays of the spine can give your doctor information about bone alignment, and can show them how much degeneration has occurred in the spine. Both alignment and degeneration can affect the amount of space in the neural foramina and between the discs, which subsequently impacts the nerves in the area, so this can be important information for your health care professional to know in order to assist you with your back pain.
Flexion and Extension X-rays
Special x-rays called flexion and extension x-rays may help to determine if there is a true instability between vertebrae. These X-rays are taken from the side as you bend as far forward and then as far backward as you can. Comparing the two x-rays allows the doctor to see how much motion occurs between each spinal segment.
Magnetic Resonance Imaging (MRI)
An MRI scan uses magnetic waves (not radiation) to create pictures of the lumbar spine in slices. The MRI scan shows the lumbar spine bones as well as the soft tissue structures such as the discs, joints, and nerves. MRI scans are painless and don’t subject you to radiation as an X-ray does. MRI scans are the most common test to look at the lumbar spine after an x-ray has been taken. These tests may be indicated if your healthcare provider is concerned that surgery may be necessary.
In some cases specialized MRIs that use an injection of contrast dye may be recommended by your doctor in order to see specific structures. These special MRIs are done with a gadolinium-based dye injected into you intravenously. The contrast enhances image quality and can define some structures more than a regular MRI.
Computed Tomography (CT) Scan
A CT scan is a special type of x-ray that lets doctors see slices of tissue. The machine uses a computer and a series of x-rays to create these slices. CT scans subject patients to significantly more electromagnetic radiation than a traditional x-ray so will only be ordered when truly necessary to help diagnose a problem. CTs can be useful to look at bone, soft tissue and blood vessels.
The myelogram is a special kind of x-ray or CT where a dye is injected directly into the spinal canal to look for problems in this area. Myelograms are used to help diagnose herniated discs, pressure on the spinal cord or spinal nerves, spinal tumor, or boney spurs that may be pressing on the spinal canal structures.
The discogram is another type of specialized x-ray. A discogram has two stages; firstly, a needle is inserted into the problem disc and then saline is injected to create pressure inside the disc. If this injection reproduces your pain, then it suggests that the disc is the source of your problem. During the second part of the test, dye is injected into the disc. The dye can be seen on x-ray. Using both regular x-rays and CT scan images, the dye outlines the inside of the disc. This can show abnormalities of the nucleus such as annular tears and ruptures of the disc.
A bone scan (skeletal scintigraphy) specifically diagnoses problems with your bones. During a bone scan a safe and small amount of radioactive tracer is injected into your veins. This tracer is taken up by your bones. The tracers then show up on special diagnostic images taken of your back. The tracers build up more in areas where bone is undergoing a rapid repair process, such as a healing fracture or the area surrounding an infection or tumor. A bone scan may be initially used to locate a problem then other tests such as a CT scan or MRI can be used to look at the area in more detail.
An EMG is a special test used to determine if there are problems with any of the nerves going from the spinal cord to the lower limbs. EMGs are usually done to determine whether the nerve roots have been pinched by a herniated disc or structurally damaged by inflammation. During the test, small needles are placed into certain muscles that are supplied by each nerve root. If there has been a change in the function of the nerve, the muscle will not fire as well as it normally would and this will be noted. An EMG can help determine which nerve root is involved. Often the nerve disruption has to be significant to show a change in EMG.
Not all causes of low back pain are from conditions within the spine itself. Other conditions, such as rheumatic arthritis, spondyloarthropathies or infection may cause a back problem or pain may be referred from problems such as gastrointestinal issues, stomach ulcers, kidney problems, and aneurysms of the aorta. Blood tests, urinalysis or other tests may be needed to rule out problems that do not involve the spine.
In some cases of back pain that don’t respond to physiotherapy other more aggressive forms of treatment may be required as a compliment to your active mobility and strengthening program. These are temporary measures and interventions, designed to provide short-term relief to allow you to move more and build up your conditioning and load tolerance.
Spinal injections are used for both diagnostic purposes as well as treatment. There are several different types of spinal injections that your doctor may recommend. Most injections use a mixture of an anesthetic and some type of cortisone (anti-inflammatory) preparation. The anesthetic is a medication that numbs the area where it is injected. If the injection takes away your pain immediately this provides important information suggesting that the injected area is indeed the source of your pain. The cortisone in the injection decreases inflammation and can reduce the pain from an inflamed nerve or joint for a prolonged period of time.
Some injections are more difficult to perform and require the use of a fluoroscope. A fluoroscope is a special type of x-ray that allows the doctor to see a real-time x-ray picture continuously on a TV screen during a procedure. The fluoroscope is used to guide the needle into the correct place before an injection is given.
Epidural Steroid Injection (ESI)
Back pain from inflamed nerve roots and facet joints may benefit from an ESI. During this procedure the medication mixture is injected under fluoroscopy into the epidural space around the nerve roots. Generally, an ESI is given only when other non-operative treatments aren't working. ESIs are unfortunately not always successful in relieving pain; if they do work, they may only provide temporary relief.
Selective Nerve Root Injection
This type of injection places steroid medication around a specific inflamed nerve root. A fluoroscope is used to guide a needle directly to the affected spinal nerve root which is then bathed with the medication. In difficult cases, the selective nerve root injection can also help surgeons decide which nerve root is causing the problem before surgery is planned.
Facet Joint Injection
If pain is thought to be coming from the facet joints of the back (the joints connecting two vertebrae), an injection into one or more facet joints can help to ease pain and more specifically determine which joints are causing the problem.
During this procedure a fluoroscope is used to guide a needle directly into the facet joint. The facet joint is then filled with a medication mixture. If the injection immediately eases the pain, it helps confirm that the facet joint is a source of pain. The steroid medication will reduce the inflammation in the joint over a period of days and may reduce or eliminate your back pain.
Trigger Point Injections
Injections of anesthetic medications mixed with a cortisone medication are sometimes given directly into the painful points of muscles, ligaments, or other soft tissues near the spine. These injections can help relieve back pain, muscle spasm and tender points in the back muscles.
Injections of a dextrose-based solution into joints that are considered to be moving too much can be used to stimulate a temporary, low-grade local inflammation at the problem area. This creates a subsequent healing and scarring up at the joint, which is thought to in turn ‘tighten’ the local area. Prolotherapy is not generally done under fluoroscopy.
Surgery for back pain is, in most cases, a last resort for treatment, except in the case of cauda equina. In most cases surgeons prefer patients to try nonsurgical treatments for a minimum of three months before considering surgery. Fortunately most people with back pain gradually get better with physiotherapy. Even people who have degenerative spine changes tend to gradually improve with time. Only 1-3% of patients with degenerative lumbar conditions typically require surgery. In some stubborn cases of severe pain that are not improving with physiotherapy, however, surgery may be recommended.
In some rare cases your doctor may need you to undergo immediate surgery if you are losing control of your bowels and bladder (cauda equina syndrome) or if your muscles are rapidly becoming weaker. In these cases, surgery is imminently required to remove pressure off of specific nerves in your lower back before they become permanently damaged.
There are many different operations that are done for back pain. The goal of nearly all spine operations is to remove pressure from the nerves of the spine, stop excessive motion between two or more vertebrae, or both. The type of surgery completed depends on each patient's conditions and symptoms.
The lamina is part of the bony ring of the spinal canal. It forms a roof-like structure over the back of the spinal column. When the nerves in the spinal canal are being squeezed by a herniated disc or from bone spurs pushing into the canal, a laminectomy removes part or all of the lamina to release pressure on the spinal nerves. This is sometimes called a posterior decompression surgery.
When the intervertebral disc has ruptured, the portion that has ruptured into the spinal canal may acutely inflame or compress the nerve roots. This may cause pain, weakness, and numbness that radiates into one or both legs. The operation to remove the portion of the disc that is pressing on the nerve roots is called a discectomy or microdiscectomy. This operation is performed through an incision in the low back immediately over the disc that has ruptured and is one of the most common types of surgeries used to alleviate back pain.
In the past spinal surgery required a large incision down the affected portion of the spine. Fortunately spine surgeons can now perform most discectomy procedures through very small incisions in the low back. These surgeries are called minimally-invasive surgeries. The obvious advantage of these minimally-invasive procedures is less damage to the muscles of the back and a quicker recovery. Many surgeons are now even performing minimally-invasive discectomies as an outpatient procedure (no hospital stay required).
When there is extra movement between two or more vertebrae, the excess motion can cause both pain due to the motion itself as well as irritation of the nerves of the lumbar spine. In these cases, if physiotherapy has not helped, a spinal fusion is usually recommended. The goal of a spinal fusion is to force two or more vertebrae to grow together, or fuse, into one bone. A solid fusion between two vertebrae stops the movement between the two bones and pain is reduced because the fusion stops movement and decreases the irritation of the nerve roots. There are many different types of spinal fusions performed.
In the past, the traditional operation to perform a fusion of the lumbar spine was done where surgeons ‘decorticate’ the back surface of the vertebrae. Decorticate means to remove the hard outside covering of a bone to create a bleeding bone surface. Once this was done, bone graft was taken from the pelvis and laid on top of the decorticated vertebrae. Just like a bone fracture would heal, the bone graft and the bleeding bone grow together and fuse to create one solid bone.
Unfortunately spinal fusions in the past were not always successful, mainly because the vertebrae failed to fuse together in up to 20 percent of cases. Due to this common failure, surgeons began looking for ways to increase the success of fusions. Being that metal plates and screws had been used to treat fractures of other bones for many years, surgeons explored the idea of using metal implants to help fuse spinal segments. The more rigid two bones can be held together while the healing phase occurs, the more likely the bones are to heal.
Major advances have been made in recent years in developing metal rods, metal plates, and special screws that are designed to hold the vertebrae together to aid spinal fusion. These new techniques of spinal fusion are referred to as instrumented fusions because of the special devices used to secure the vertebrae to be fused. Today the most common type of fusion is performed using special screws called pedicle screws that are inserted into each vertebra and connected to either a metal plate or metal rod along the back of the spine. The vertebrae are still decorticated as previously and bone graft is still used to stimulate the bones to heal together and fuse into one solid bone. Metal cages are sometimes used to create space in the spine and hold vertebrae in place while natural bone healing and fusion occurs. Depending on the problem, surgeons may need to make a surgical incision in your back or they may need to approach the surgery from your abdominal area.