How do we treat back pain? That question, as simple as it sounds, can be one of the most controversial and divisive questions that anyone could ask a physical therapist. There are millions of people out there with low back pain (about 80% of adults have an episode of significant low back pain during their lifetime) and, it seems, a million different ways to treat it. Published research over the past 15 years or so (I’m speaking of serious research, peer-reviewed by experts in content and statistical analysis) has trended in a few general directions:
- Back pain is essentially normal, mostly related to psychosocial concerns (a.k.a. job and personal stress, etc.), and needs no special treatment by therapists, chiropractors, or surgeons – just a simple pamphlet with guidelines and encouragement will suffice.
- Back pain is due to a specific anatomical defect, and is best treated by surgery, but only when you can’t stand it any longer.
- Back pain is a large pool (garbage pail) of separate problems all mixed together. To effectively treat low back pain (and we’ll throw in sciatica – pain running down the leg past the knee with numbness/tingling) the treating clinician needs to be able to differentiate one type from another, and apply the correct treatment for that specific type.
The most promising, and clinical applicable work (meaning that clinicians can actually use something from the research) has been in third direction. Namely, the back problem that you or your patient (if you’re a physician reading this) is different from your next door neighbor’s or another patient’s. Getting effective treatment is dependent on correct classification based on the symptoms (what a patient relates or complains of) and signs (specific things the clinician finds) present at the time of examination. The other major revolution in this area was first observed in a clinical setting and reported decades ago, and finally accepted in the research realm in the early 1990s: Centralization
Centralization and Classification of Back Pain Syndromes
Centralization was recognized first in patients with pain that radiated from the back, into the gluteal area (butt) and down the thigh and leg. Reported as an accidental finding in the 1950s, centralization refers to the progression of symptoms (pain, numbness and tingling, weakness) back up the leg and thigh toward the back.
In the most famous written early account, a patient with sciatica was told to lie down on a treatment table prior to the start of his treatment. The treatment table had a joint that allowed half of it to be inclined nearly vertically. This patient (who the clinician thought was not too bright) laid face down on the treatment table, half of which was inclined, such that his back was severely extended at the waist with his upper body much higher than the lower half of his body. He fell asleep in this position waiting for the therapist, who forgot completely about him. The therapist found him a time later, still asleep, and was horrified – that position was thought at the time to be damaging to the spine. He gently aroused the patient, who got off the table and told him that he no longer had any pain down the leg or thigh, and felt better than he had in some time.
After decades of experimentation, a theory was made and an evaluation and management system for spinal disorders known as the McKenzie Mechanical Diagnosis and Treatment was published. Since that time, research has validated the general method of classification of patients into subgroups to gain more effective results, and specific studies suggest that specific tests and measures further aid in classification and management of spinal pain. Keep reading for future articles on this issue with more specifics about how your therapist can accurately classify and treat your spinal pain.