(Care and treatment)
Patients (Health aspects)
Physical therapists (Services)
|Publication:||Name: New Zealand Journal of Physiotherapy Publisher: New Zealand Society of Physiotherapists Audience: Academic Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2010 New Zealand Society of Physiotherapists ISSN: 0303-7193|
|Issue:||Date: Nov, 2010 Source Volume: 38 Source Issue: 3|
|Topic:||Event Code: 310 Science & research; 360 Services information|
|Product:||Product Code: 8043600 Physical Therapists NAICS Code: 62134 Offices of Physical, Occupational and Speech Therapists, and Audiologists SIC Code: 8049 Offices of health practitioners, not elsewhere classified|
|Geographic:||Geographic Scope: New Zealand Geographic Code: 8NEWZ New Zealand|
Controversy over the pathology and treatment of low-back strain
continues. Strong and diverse views are put forward by different
sections of the medical community. From the conflict one fact emerges.
No concept of pathology and no treatment routine has gained the
authority of universal acceptance.
There is, however, one aspect of the treatment of low-back strain on which there is general agreement. It is frequently mentioned, but rarely carried out with the thoroughness it warrants. This aspect concerns the management of the back by the patient himself. It is virtually axiomatic that forward flexion of the spine causes pain and deterioration in either acute or chronic back strain. The stress of lifting or other strain falling on the lumbar spine in this position is notorious for its potential damage effect. Plaster jackets and lumbo-sacral corsets are used in recognition of the need to avoid flexion. In cases where they are not prescribed the need to maintain a lumbar lordosis still exists and this can only be achieved by the patient's voluntary effort. The constant maintenance of this posture under all circumstances for any length of time may seem at first glance an impossible demand to make of any patient. Admittedly there are patients to whom it is impossible. There are, however, a surprising number of people who will observe the routine if they fully understand its necessity, and are helped and encouraged over a period of a few weeks.
Physiotherapists too often make the gesture of a brief explanation of back strain, and a cursory warning that the patient should bend from the knees instead of from the waist. There is a tendency to become cynical about the likelihood of the patient's co-operation. Failure to emphasise the importance of back management is denying the patient his best chance of permanent recovery, and the value of any other treatment is seriously depreciated.
In the welter of argument over pathological changes and different methods of treatment the simple facts of back strain tend to be forgotten. In the position of forward flexion the lumbar spine is basically unstable, and stresses accepted in this position are nearly always the immediate cause of damage. Such damage can occur in young people of excellent physique with no evidence of structural abnormality. It is apparent that no back is immune if the stress is greater than the ability or readiness of the stabilising spinal musculature to cope with it. The back in which damage has already occurred, or which has some congenital or degenerative effect, is obviously more vulnerable to flexion strain. The more recent the damage or the more severe the degenerative changes, the smaller is the strain that will be harmful. The aim should be to eliminate all strain during recovery. To achieve this the patient must maintain a lumbar lordosis at all times when weight-bearing, regardless of the activity of the moment. Difficult as this may seem, it is, in fact, only a matter of habit, and habit can be formed by persistent application. If a patient is to make the considerable effort needed to form the habit he must have a clear mental picture of the mechanical reasons for doing so. It must be remembered that the average layman's knowledge of spinal structure is negligible. If he does have some ideas about it they are probably highly erroneous. In trying to build up a picture for him, the anatomical concepts must be reduced to their simplest and least technical form. As he is unfamiliar with the appearance and function of the structure involved, they must be likened to structures and actions which are within his experience. With the aid of models or drawings, or through analogy with more familiar joints he must be made to really "feel" the instability of the spine in flexion. Equally he should "feel" the stability of the lumbar spine when it is locked into a solid column in the lordosed position. Many people have great difficulty in voluntarily tilting the pelvis forward to lordose the lumbar spine. The physiotherapist should ensure that the patient can do so, and emphasise that a merely straight back is insufficient; the lordotic curve must be present. It is advisable to demonstrate by drawings that the wedge shaping of the lumbar vertebrae and discs implies a curve if they are to be locked into a solid column.
One of the difficulties of educating a patient is that he does not normally think in terms of joints and discs when he bends his trunk in any direction. His sense of bending covers the full column of the trunk moving on the full column of the hips. He is unconscious of the relatively tiny skeletal surfaces at which pivoting occurs. He should be made to realise this very clearly, and then be led on to an understanding of the leverage factor which so greatly multiplies the forces acting on these small stress-bearing surfaces. In this way he develops a consciousness of the potential weakness of the spine in the flexed state. It may be felt that it is unwise to induce a lack of confidence in the patient regarding the strength of his back. The objection is not valid if the patient understands that the same considerations apply to all human backs. A healthy fear of the consequences of misusing his back is his best safeguard against recurrence.
It must constantly be pointed out that correct management of the back does not eliminate any normal activity. In the beginning it makes some actions slow, awkward and difficult, requiring care and thought. With practice the correct methods becomes easier, and finally is employed unconsciously. This is the ultimate goal of the physiotherapist's teaching. Until it is achieved, the patient is in danger of fresh injury all his waking hours. Once established, the habit reduces the risk to the point where only some unusual accident can cause damage. It encourages the patient to learn that correct use of his body in taking strains actually enhances his power. The more robust hip and knee joints make sturdier fulcra than the interlaminar joints in performance. The example of the weight-lifter drives this home.
The patient will fairly readily learn to stabilise his back correctly for the more obvious stresses, such as lifting, pulling and pushing. Difficulties arise in getting him to recognise the lesser strains occurring with innumerable small everyday actions. He must be shown that gravity alone acting on this truck constitutes a stress if he bends forward at the lumbar joints. In this position a cough or sneeze can be disastrous. Strains that seem quite trivial to the patient can produce disproportionately severe results. It cannot be repeated too often that such incidents cannot occur if the lumbar lordosis is firmly maintained.
In teaching the patient to know his back, the ankle joint can be used to advantage. Everybody is familiar with a sprained ankle. Everybody knows that it is unstable if it bears weight in reversion. It can be shown that the leg muscles can stabilise the joint even if it bears weight in the maximum inversion position, but it is obvious what happens to the joint in this position if the muscles fail through weakness or unreadiness. It is equally obvious that the ankle cannot be sprained when it is held firmly in the central position. The analogy of the lumbar spine on flexion with the ankles in inversion is shown. The patient will appreciate, too, that if he had sprained his ankle he would be very careful not to take weight on it in inversion. He would be at pains to hold it rigidly against accidental inversion when walking, because it would be obviously foolish to invite further strain in the direction in which damage had already occurred. All this is quite apparent to a patient because he can see his ankle joints and understand the simple mechanics of strain without difficulty. If he can be taught to have a similar concept of his spinal movement he will realise the equal foolishness of bending over in the same direction in which injury has occurred. He will be willing to lock his back into the same position before accepting any strain at all. At some stage the patient will ask how long he must continue such deliberate precaution. The answer is that he must do so until the action becomes pure habit. The more thoroughly he attempts to observe the routine, the sooner the habit is acquitted. Another query is usual. The patient may worry about becoming stiff if he constantly avoids forward bending. Generations of people have been brought up in the belief that there is some virtue in being able to touch their toes, and that inability to do so indicates some defect. It should be explained that such ability varies with body types. Attempting to force the movement past the point where hamstring length limits it achieves nothing but harm through overstrain of the spinal articulations which must provide the extra movement. The physiotherapist should point out that the important movement to retain is freedom of extension of the back. The tendency with increasing age and weakness is to become stooped and to stiffen in this position. The ability to retain an erect and correctly curved spine through life is to be treasured. The only stiffness the patient need fear is that which limits free extension.
Once the patient sees the need for maintaining his lordosis he can be helped to do so by demonstration of the technique needed to carry out various everyday actions. The housewife, particularly, needs this assistance. Nearly all her work involves bending. Bedmaking, cleaning, ironing, lifting the baby--all these and innumerable other duties need discussion and demonstration. The physiotherapist must, of course, be capable of demonstrating personally that this apparently difficult business is in reality quite easy once the knack is acquired. It is a distinct advantage for him to have suffered a low-back strain in the past. His enthusiasm for the policy he is advocating will be genuine, and his mastery of the technique will show the patient that it is quite possible to acquire it. Posture in walking, standing and sitting must be corrected. For quite some time after a low-back strain the patient must support his lumbar lordosis with a properly positioned cushion when seated in a soft chair or a car. This will obviate the old complaint that the patient's back hurts when he stands up after being so seated. Again this should be pointed out that he wouldn't hold a sprained ankle over in inversion for lengthy periods, or that, if he did, it would hurt when he straightened it again. Similarly, the comparable position for his back is to be avoided in sitting. People with a long history of recurrent strain will usually be found to have a still, flat lumbar spine. They cannot achieve a lordosis, let alone maintain it, until the necessary measures have been taken to mobilise it. Once mobilised, it will still be held flat from habit unless the lordosis habit is inculcated. Enquiry should, of course, be made about the type of bed the patient uses, and any necessary alteration advises.
When all these measures have been taken, the subject of back management can be said to have been covered.
Any form of treatment of low-back stain will probably fail, or, at best, give only short-term results, unless the patient is taught to guard against further strain. The guarding habit does not restrict normal activity, nor does it induce loss of spinal mobility. It is not sufficient to give the patient cursory tuition in back management. It must be treated as of major importance to long-term recovery. The patient must be made to understand fully the reason behind it, and taught in detail how to achieve it. The physiotherapist must serve as an example. Regardless of controversy over the pathology, the physiotherapist's job is to relieved the patient of his complaint. His effects will produce superior results if he will take great pains to teach back management thoroughly.
By IA Tayler, Whangarei
Published in the New Zealand Journal of Physiotherapy, November 1960
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