What is the recommended physiotherapy approach for patients with back pain?

Recommended Physiotherapy Approach for Back Pain

Exercise therapy should be the cornerstone of physiotherapy treatment for patients with back pain, with specific interventions tailored based on the duration and severity of symptoms using tools like the STarT Back screening tool. 1

Assessment and Classification

1. Initial Assessment (within 2 weeks of pain onset)

   • Use the STarT Back tool to stratify patients into low, medium, or high risk for developing persistent disability 1
   • Determine pain duration: acute (<4 weeks), subacute (4-12 weeks), or chronic (>12 weeks) 1

2. Risk-Based Treatment Pathway:

   • Low risk: Self-management with education and advice
   • Medium risk: Standard physiotherapy with patient-centered management plan
   • High risk: Intensive physiotherapy with comprehensive biopsychosocial assessment 1

Evidence-Based Interventions by Pain Duration

For Acute Low Back Pain (<4 weeks)

• First-line approaches:

  • Advice to remain active and avoid bed rest 1
  • Spinal manipulation (small to moderate short-term benefits) 1
  • Superficial heat (moderate improvement in pain relief and disability) 1

• Not recommended:

  • Supervised exercise therapy (not effective for acute pain) 1
  • Traction (not proven effective) 1
  • Bed rest 1

For Subacute Low Back Pain (4-12 weeks)

• Effective interventions:
  • Intensive interdisciplinary rehabilitation (moderately effective) 1
  • Functional restoration with cognitive-behavioral components (reduces work absenteeism) 1
  • Exercise therapy (gradually introduced) 1
  • Massage therapy (moderately improved short-term pain relief) 1

For Chronic Low Back Pain (>12 weeks)

• Moderately effective interventions:
  • Exercise therapy (small improvements in pain and function) 1, 2
  • Motor control exercise (moderately decreased pain scores) 1
  • Massage therapy (improved short-term pain relief) 1
  • Spinal manipulation (slight improvement in pain) 1
  • Multidisciplinary rehabilitation (moderately reduced short-term pain) 1
  • Acupuncture (moderate improvement in pain relief) 1
  • Cognitive-behavioral therapy (moderately improved pain intensity) 1
  • Yoga (improved pain and function) 1

Specific Exercise Recommendations

1. Core stability and strengthening exercises 3

   • Focus on muscles that control and support the spine
   • Gradually progress intensity and complexity

2. Individualized exercise programs with these components 1:

   • Individual tailoring
   • Supervision
   • Stretching
   • Strengthening

3. Back School programs for occupational settings 4

   • Ergonomics training
   • Education on proper body mechanics
   • Particularly effective for healthcare workers

Combination Approaches

• Most effective combinations:
  • Spinal manipulation + active treatment (greater pain relief and improved function) 1
  • Massage + exercise (superior to either intervention alone) 1
  • Heat + exercise (greater pain relief than exercise alone) 1

Return to Physical Activity

• Recommended moderate-intensity activities 5:

  • Swimming
  • Walking
  • Cycling

• Sports that can be resumed with modifications 5:

  • Tennis
  • Golf
  • Running (at lower intensity)
  • Gymnastics
  • Martial arts
  • Horse riding

Common Pitfalls to Avoid

1. Passive approaches only

   • Relying solely on passive treatments (rest, medications) is associated with worsening disability 2
   • Always incorporate active strategies

2. One-size-fits-all approach

   • The traditional "physical therapy for all" approach is not effective 1
   • Use risk stratification tools to guide treatment intensity

3. Delayed intervention

   • Early non-pharmacological treatment is endorsed 2
   • Don't wait for pain to become chronic before implementing active approaches

4. Neglecting psychosocial factors

   • For high-risk patients, address psychological factors that may contribute to pain persistence 1
   • Consider cognitive-behavioral approaches for chronic pain

5. Ineffective modalities

   • Transcutaneous electrical nerve stimulation (TENS) has not been proven effective for chronic low back pain 1
   • Continuous or intermittent traction is not effective for sciatica 1
   • Ultrasound shows no difference compared to sham ultrasound 1

By following this evidence-based approach to physiotherapy for back pain, clinicians can optimize outcomes related to pain reduction, functional improvement, and quality of life for their patients.