Low back pain is a common health care and social problem associated with disability and absence from work. One 2005 medical study of chronic spinal pain stated that the "lifetime prevalence of spinal pain has been reported as 54 to 80 percent, with as many as 60 percent of patients continuing to have chronic pain five years or longer after the initial episode."1 The long-term and disabling conditions of chronic and recurrent low back problems are of major concern, both from a cost perspective and in terms of morbidity.
Chiropractic care has been shown to compare favorably in many cases to medical care with respect to long-term pain and disability outcomes.2 However, the chiropractor should carefully consider the optimum treatment plan for each patient on an individual basis. For most cases of chronic low back pain, I recommend a three-step program of spinal adjustments, postural stabilization and rehabilitative exercise. Combining these three elements can make the difference between a successful care program and a lingering, recurring low back condition.
As far back as 1985, medical research was reporting that "a two- to three-week regimen of daily spinal manipulations by an experienced chiropractor" brought significant improvement in 81 percent of completely disabled patients with chronic low back and referred leg pain.3 The subjects in the study were from a university back pain clinic for patients who had failed to respond to previous conservative or surgical treatment. The researchers stated, "In our experience, anything less than two weeks of daily manipulation is inadequate for chronic back pain patients." In addition, several chiropractic research studies published between 1979 and 1993 described various procedures that assisted patients in regaining lumbopelvic structural function and alignment.4-6
A significant factor in reducing excessive biomechanical forces on the lumbar spine is frequently overlooked by practitioners - the use of external supports to decrease external forces. Positioning aids such as sitting postural supports (e.g., postural back rests or ischial lifts for chairs and car seats), standing postural supports (e.g., foot orthotics and heel lifts) and sleeping postural supports (e.g., mattresses and pillows) can all greatly assist in the long-term management of painful lumbar spine conditions.
During standing and walking (and for athletes, running), the lumbar spine and pelvis balance on the lower extremities. If leg or foot asymmetries or alignment problems are present, abnormal forces are transmitted along the closed kinetic/kinematic chain, interfering with spinal function.7 When excessive pronation and/or arch collapse is present, a torque force produces internal rotation stresses to the leg, hip and pelvis.8 These forces can be decreased significantly with the use of custom-made orthotics, which help to stabilize the spine and pelvis. In patients with degenerative changes in the lumbar discs and facets, the external force of heel strike may aggravate and perpetuate low back pain, and is easily reduced with the use of shock-absorbing orthotics.9,10
Home corrective exercises to strengthen supporting muscles are recommended as an adjunct to chiropractic adjustments and postural stabilization. Active involvement of the chronic low back pain patient in an appropriate exercise program has been found to be very beneficial,11 even for patients with herniated discs.12 Flexibility and strength exercises can bring about rapid improvements in lumbar spinal function, as well as decreases in pain levels.13 Activity should focus on developing strength in the abdominals and supporting pelvic and low back muscles. This also can enhance the shock-absorbing properties of the tissues.
Specific exercises must develop "dynamic control of lumbar spine forces in order to eliminate repetitive injury to the intervertebral discs, facet joints, and related structures."14 Recommending specific exercise(s) is not easy, as some research supports the need for abdominal strengthening,15,16 others advise pelvic tilts,17 and other reports focus on the importance of strengthening the lumbar extensor muscles.18,19 The bottom line is that patients' needs vary, and exercises that work for one patient will not necessarily work for the next.
The first step toward a solution is to use clinical testing, and postural evaluation in particular, to identify the most appropriate and effective lumbopelvic exercise routine. By evaluating a patient's three-dimensional posture in a reference frame and noting any specific deviations from the ideal intrinsic equilibrium, the doctor is able to identify the sources of excessive biomechanical stress and give specific corrective exercise recommendations. Of course, a general conditioning and flexibility program will complement the specific corrective postural exercises.
- Boswell MV, Shah RV, Everett CR, et al. Interventional techniques in the management of chronic spinal pain: evidence-based practice guidelines. Pain Physician, 2005;8(1):1-47.
- Nyiendo J, Haas M, Goldberg B, Sexton G. Pain, disability, and satisfaction outcomes and predictors of outcomes: a practice-based study of chronic low back pain patients attending primary care and chiropractic physicians. J Manip Physiol Ther, 2001;24(7):433-9.
- Kirkaldy-Willis WH, Cassidy JD. Spinal manipulation in the treatment of low back pain. Can Fam Phys, 1985;31:535-40.
- Mierau D, Cassidy JD. A comparison of the effectiveness of spinal manipulative therapy for low back pain patients with and without spondylolisthesis. J Manip Physiol Ther, 1987;10:49-55.
- Cassidy JD, Potter GE. Motion examination of the lumbar spine. J Manip Physiol Ther, 1979;2:151-8.
- Cassidy JD, Thiel HW, Kirkaldy-Wills WH. Side posture manipulation for lumbar intervertebral disk herniation. J Manip Physiol Ther, 1993;16:97-103.
- Keane GP. "Back Pain Complicated by an Associated Disability." In: White AH, Anderson R. eds. Conservative Care of Low Back Pain. Baltimore: Williams & Wilkins, 1991:307.
- Hammer WI. Hyperpronation: causes and effects. Chiro Sports Med, 1992;6:97-101.
- Light LH. Skeletal transients on heel strike in normal walking with different footwear. J Biomechanics, 1980;13:477-80.
- Faunø P. Soreness in lower extremities and back is reduced by use of shock absorbing heel inserts. Int J Sports Med, 1993;14:288-90.
- Mayer TG, Gatchell RJ. Objective assessment of spine function following industrial injury: a prospective study with comparison group and one-year follow-up. Spine, 1985; 10:482-93.
- Saal JA, Saal JS. Nonoperative treatment of herniated lumbar intervertebral disc with radiculopathy: an outcome study. Spine, 1989;14:431-7.
- White AA, Panjabi MM. Clinical Biomechanics of the Spine, 2nd ed. Philadelphia: J.B. Lippincott, 1990:429.
- Saal JA, Saal JS. "Rehabilitation of the Patient." In: White AH, Anderson R. eds. Conservative Care of Low Back Pain. Baltimore: Williams & Wilkins, 1991:31.
- Williams PC. Lesions of the lumbosacral spine: chronic traumatic (postural) destruction of the lumbosacral intervertebral disc. J Bone Joint Surg, 1937;19:690.
- Schmidt GL, Herring T. Assessment of abdominal and back extensor functions. Spine, 1983;11:19-27.
- Partridge MJ, Walters CE. Participation of the abdominal muscles in various movements of the trunk in man: an EMG study. Phys Ther Rev, 1959;39:791-800.
- Mayer TG, Smith SS. Quantification of lumbar function: sagittal plane trunk strength in chronic low back pain patients. Spine, 1985;10:765-72.
- Beinborn DS, Morrissey MC. A review of the literature related to trunk muscle performance. Spine, 1988;13:655-60.
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