Low back pain: A physical therapist’s perspective

When patients who are suffering from low back pain come to physical therapy for the first time, the two most frequently asked questions are, “Why was I referred to physical therapy when my MRI shows joint or disc abnormalities?” and “Don’t I need an MRI so you know what is going on?”

Both questions are very reasonable. After an MRI reveals a disc bulge or protrusion, many patients feel that a referral to a physical therapist is the equivalent of having your mechanic tell you to continue to drive your car and see if your flat tire improves. Frankly, both scenarios can feel ridiculous.

Thankfully, the human body is not like a car. Multiple studies in the last few years have shown that the farther a disc extrudes or protrudes, the more likely your body is to reabsorb the disc with time.(1,2) In other words, disc healing is a very real and normal occurrence.

MRI and X-ray Abnormalities

As we age, we can develop abnormalities that can be seen on MRI and X-ray. For example, in studies of patients without low back or neck complaints, about 30 percent of patients in their 20’s have disc bulging and degeneration.

The percent of abnormalities increases with age and by the time an individual is in his or her 80’s the prevalence of these abnormalities is greater than 80 percent.(3) Remember, these abnormalities are in patients without pain.

While there are times when surgery is needed to address low back pain, outcomes are significantly improved when abnormalities in imaging correspond with the expected complaints of the patient and positive clinical findings.

Low Back Pain Treatment

When developing a treatment plan for low back pain, it is important to realize that a one-size-fits-all approach is not appropriate. In other words, some movements and treatments that help one patient may not be effective for treating your low back pain.

Research has shown that subgrouping patients based on their history and clinical findings improves outcomes.(4) We do this first by getting a good history of the patient’s symptoms, screening for potential red flags, assessing neurologic involvement (how is his or her sensation and strength), and then determining movement or directional preference.

Movement preference is part of a spine examination where you complete range-of-motion exercises in particular planes of movement to determine how these motions affect your pain sensitivity or symptom location. Once movement preference has been determined, evidence-based therapeutic exercise and manual therapy are used to reduce pain sensitivity and restore previous mobility.

After the first visit to physical therapy, you should have a better understanding of what movements or postures are affecting your pain and what you can do immediately to improve symptoms. In each subsequent visit, response to treatment is reassessed and joint mobilizations, manipulation, soft tissue mobilization, and other various manual techniques along with progressive therapeutic exercises are utilized to further decrease pain sensitivity and movement limitation.

While the time it takes for symptoms to resolve varies, most patients should be able to see a benefit in their pain with physical therapy after the first few visits.

By Nelson Caudill

Nelson Caudill is a physical therapist with CHI Saint Joseph Health.

1. Zhong M, Liu JT, Jiang H, et al. Incidence of Spontaneous Resorption of Lumbar Disc Herniation: A Meta-Analysis. Pain Physician. 2017;20(1):E45-E52.
2. Chiu CC, Chuang TY, Chang KH, Wu CH, Lin PW, Hsu WY. The probability of spontaneous regression of lumbar herniated disc: a systematic review. Clin Rehabil. 2015;29(2):184-95.
3. Brinjikji W, Luetmer PH, Comstock B, et al. Systematic literature review of imaging features of spinal degeneration in asymptomatic populations. AJNR Am J Neuroradiol 2015;36:811–6
4. Fritz JM, Cleland JA, Childs JD. Subgrouping patients with low back pain: evolution of a classi?cation approach to physical therapy. J Orthop Sports Phys Ther. 2007;37(6):290-302.