Physical Therapy For Lower Back Pain: Best Modalities and Exercises

Back pain affects primarily the lower back and the good news is, that in most cases, the cause of pain is not serious and can be resolved in a few days or weeks. However, some symptoms can be more serious requiring a full assessment and diagnosis by an experienced Physiotherapist or GP. This article will help you to determine when self-help is enough or when it is best to seek further advice.

PT for Back Pain

In general, the goals of physical therapy are to decrease pain, increase function, and provide education on a maintenance program to prevent further recurrences.

Physical Therapy - Modalities

Acutely, the physical therapist may focus on decreasing pain with passive physical therapy (modalities). These therapies are considered passive because they are done to the patient. Examples of modalities include:

Physical Therapy - Back Pain Exercises

In addition to passive therapies, active physical therapy (exercise) is also necessary to rehabilitate the spine. Generally, a patient's back exercise program should encompass a combination of the following:

Stretching for back pain exercises

Streching Back

Almost every individual who has suffered from low back pain should stretch their hamstring muscles once or twice daily. Simple hamstring stretching does not take much time, although it can be difficult to remember, especially if there is little or no pain. 

Therefore, hamstring stretching exercises are best done at the same time every day so it becomes part of a person's daily routine. There are many more stretches that can be done to alleviate lower back pain.

Low-impact aerobic conditioning

Aerobics

Low impact aerobics are important for long term pain reduction. There are many options available, such as walking, bicycling swimming or water therapy. 

Aerobic exercise of often best done for 30 to 40 minutes three times weekly, on alternate days from the strengthening exercises.

Even patients with a very busy schedule should be able to maintain a moderate back pain exercise regimen that encompasses stretching, strengthening, and aerobic conditioning. These exercises suffice as physical therapy for back pain relief.

Multiple modalities are commonly employed to reduce low back pain. They are especially useful in alleviating acute low back pain (e.g. an intense, debilitating episode of low back pain) for the patient. Physical therapists or chiropractors usually use passive modalities.

Heat and Cold Therapy

Hot vs Cold


Heat and/or ice are easily available and are the most commonly used type of modality. Each type of therapy helps reduce muscle spasm and inflammation.

Some patients find more pain relief with heat therapy using heat packs and others with cold therapy such as ice massage. The two may also be alternated. 

They are generally applied for 10-20 minutes once every two hours, and are more useful early on (the first few days) in the course of an episode of pain.

Iontophoresis

Iontophoresis

Iontophoresis is a means of delivering steroids through the skin. The steroid is applied to the skin and then an electrical current is applied that causes it to migrate under the skin. 

The steroids then produce an anti-inflammatory effect in the general area that is causing pain. This modality is especially effective in relieving acute episodes of pain.

TENS Units for Electrotherapy

TENS

A transcutaneous electrical nerve stimulator (TENS) unit uses electrical stimulation to modulate the sensation of low back pain by overriding the painful signals that are sent to the brain. 

A trial of electrotherapy with the TENS unit is usually done first, and if the patient experiences substantial pain relief, a TENS unit may be used at home for low back pain relief on a long-term basis.

Ultrasound

Ultrasound is a form of deep heating in which sound waves are applied to the skin and penetrate into the soft tissues. Ultrasound is especially useful in relieving acute episodes of pain and may enhance tissue healing.

Therapeutic Ultrasound

Specific Low Back Pain Exercises

There is a substantial amount of medical literature supporting specific physical therapy exercises for the treatment of low back pain. 

While most episodes of low back pain are self limiting and will get better on their own, active exercise plays an important role in helping reduce the patient's pain and improving subsequent function in patients with low back pain. 

An ongoing exercise program also reduces the likelihood and severity of future occurrences of low back pain.

Stretching

Streching

Proper stretching of the muscles along with active exercise will help maintain normal range of motion and provide relief for muscles that are often suffering disuse atrophy (shrinking muscles from lack of use) or in spasm from inappropriate posture or nerve irritation. 

For many patients it is best to follow a stretching routine that has been individually designed for them by a physical therapist or a spine physician. 

As a general rule, low back pain patients should focus on stretching the lower back muscles, abdominal muscles, hips, and legs. 

The patient should never bounce during stretching, and all stretches should be slow and gradual.

Dynamic stabilization exercises

Stablization Exercise

These exercises involve the use of a variety of exercises and may include use of exercise balls, balancing machines or specific stabilizing exercises. 

The point of dynamic stabilization exercise is to strengthen the secondary muscles of the spine and help support the spine through various ranges of motion

Core strengthening exercises

These are specific exercises to strengthen the abdominal muscles and low back muscles (erector spinae) to provide the aforementioned 'belt of muscle' around the spine. These exercises typically include:

Specific abdominal strengthening, such as sit-ups, crunches, abdominal machines, and leg raises.

Low back exercises (hyperextensions), which can be performed on machines or by simply lying on the stomach and slowly raising the chest off the ground. This exercise utilizes the lower back muscles to 'hyperextend' the spine.

'Good-mornings' are also an exercise to strengthen the lower back muscles. This exercise requires the patient to stand with legs straight and shoulder width apart, with a broom-stick or weighted bar across the shoulders. The patient then slowly bends forward until the face is parallel to the floor and then raises back up. Very similar to just bending to touch the toes except there is weight across the shoulders.

Some physical therapy centers may also provide aquatic (water) physical therapy. Water supports the body and minimizes the effect of gravity, making it easier for patients to start an exercise program. Aquatic therapy can be very helpful for elderly patients and disabled patients who may not have the strength to do some of the exercises outside the aquatic pool.

Another aspect of physical therapy program may include lumbar traction. With lumbar traction, the patient lies on his back and is secured on a special table with a cable coming from the foot-end of the table that attaches to a strap that has been placed around the patient's hips. 

The cable is attached to weights at the foot-end of the table that provide a continuous and gentle pulling force on the hips toward the foot-end of the table. 

The goal of traction is to unload the disc space and muscles in the lumbar spine. This unloading is thought to provide a recuperative period which allows the muscles to rest and takes pressure off the disc space. 

Research about the effectiveness of traction is controversial, with some studies showing that it adds value and other studies showing that it is of little or no value for patients with low back pain.


Physical Therapy Before and After Back Surgery

There is substantial evidence supporting the benefits of physical therapy and exercise both before and after back surgery. 

The strength and stability that physical therapy provides can significantly shorten a patient's recovery time after surgery. Physical therapy and exercise is considered an important part of most back pain patients' treatments, including those undergoing non-surgical and surgical care. 

This is because patients with low back pain are most likely to recover when the patient is in optimum physical condition.

Unless there is a contraindication for physical therapy or a patient requires emergency surgery, most patients are advised to undergo a trial of physical therapy prior to considering back surgery.

For many patients with low back pain, it is usually advisable to first consult a physician who can diagnose the patient's condition and rule out any serious contraindications for physical therapy, such as a fracture or tumor. 

Many patients find it most helpful to be monitored by a physical therapist to ensure follow through and avoid problems. 

Once the initial phase of therapy is complete, those patients who continue to follow an exercise program are often the most successful in managing their low back pain.

Most physical therapy programs that are designed to treat low back pain and some radicular pain (pain radiating down the leg) will include a combination of the following types of exercise: 

When Exercise Doesn't Work

Exercise

All too often, spine practitioners refer patients for physical therapy and the patients return to the doctor stating they stopped the therapy because it hurt their backs or they just weren't getting adequate low back pain relief for their efforts. While this is by no means an exhaustive list.

Here are a few reasons physical therapy rehabilitation may not alleviate back pain:

The program prescribed does not include active exercise

This occurs when a patient's physical therapy program includes very little muscle training and focuses more on the use of hot packs, cold packs, and stimulation therapy. While hot/cold packs and deep tissue massage can often provide immediate pain relief, they are best used in conjunction with active exercise as opposed to replacing it.

Patients do the exercises incorrectly

Patients may not have a thorough understanding of how their exercises should be performed to bring about desired benefits. If this is the case, then the patient may benefit from a more thorough explanation of the exercise by a spine specialist and/or supervision and guidance by a qualified physical therapist who could correct possible errors in exercise performance.

Patients don't stick to the prescribed exercise program

Physical therapy is not likely to alleviate pain if patients do not perform all recommended exercises or do not devote enough time to their program. Continued exercise beyond the assigned therapy time may further strengthen the back and help maintain better posture and prevent recurring pain.

Patients don't keep up with exercise long term

It is best for patients to continue with the prescribed physical therapy exercises and/or a self directed exercise program following the initial course of physical therapy. 

Typically, it is recommended that the patient maintain the basic core and dynamic stabilization exercises and may slowly transition into a more extensive exercise program including low impact aerobic exercise and specific weight-lifting exercises that will not load the spine.

Some patients with low back pain are successfully treated with physical therapy but then return a year or two later with the exact low back problem. 

Most often the patient strengthens the abdominal muscles and low back muscles during physical therapy and subsequently takes the stress off the low back. 

After physical therapy, the patient does not maintain the abdominal and low back exercise program at home, leading to a slow loss of fitness in the trained muscles and possibly eventual low back problems. 

Thus, it is highly recommended that once a patient is treated successfully with physical therapy, he/she develops an exercise maintenance program at home to help sustain the strength and muscle mass that was developed in physical therapy.

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