|
Low Back Pain: Why it Matters
Mechanical low back pain is the
second most common symptom-related reason for seeing a healthcare
provider in the U.S. 50% of Americans have low back pain annually,
and 85-90% of Americans have low back pain in their lifetime (1).
The peak age for low back pain is 25 to 45 years, and low back pain
is the number one cause of disability in people under age 45 (1).
Furthermore, treating low back pain is expensive. In the U.S. in
2008, over $33.4 billion was spent on direct medical costs
associated with low back pain, and over $66.6 billion was lost as a
result of lost wages and decreased productivity (1).
Bracing
Lumbar supports are often used in the management of low back pain,
as well as in the workplace to prevent low back pain (2). Lumbar
supports may be rigid or flexible, may be worn over or under
clothing, may or may not have shoulder straps, and may be worn all
day, part of the day, or only during certain activities. There has
been many advances in the design and technology of the lumbar
support compared to even a few years ago. Variations on how the
supports compress and unload the spine and the flexibility from one
brace to another may vary greatly as well.
Bracing: Pros
In 1987, Nachemson reported in a study that lumbar supports have
five desired functions (3):
1. correct deformity
2. limit spinal motion
3. stabilize part of the spine
4. reduce mechanical uploading
5. miscellaneous effects, including massage, heat, and placebo
If and how lumbar supports do indeed accomplish the aforementioned
functions is under debate (4).
Bracing - Cons
Studies to date have shown that wearing a lumbar support may result
in (5, 6):
1. skin lesions
2. gastro-intestinal disorders
3. muscle wasting
4. higher blood pressure
5. higher heart rates
Bracing - Current Research
Research by Van Poppel et al. has confirmed that wearing lumbar
supports affect trunk motion (4). A study by Cholewicki et al. also
demonstrated that wearing lumbar belts increases lumbar stability,
and the researchers proposed that this increased stability may
explain the possible preventative and therapeutic properties of
lumbar belts (7).
While the aforementioned research has demonstrated that lumbar
stability is increased while wearing lumbar belts, other research
has shown a decrease in core stability when the lumbar belts are
taken off after being worn for extended periods of time. A study by
Rostami et al. allocated sixty healthy volunteers into two groups: a
belt group that wore lumbar belts during waking hours and a control
group who wore no belt (8). Researchers measured the thickness of
the lateral abdominal muscles and the cross sectional area of the
lumbar multifidi muscles using ultrasound at baseline, 4 weeks, and
8 weeks, finding significant differences in thickness and cross
sectional area of the muscles of the participants in the belt group
after 8 weeks (8). Researchers discussed that wearing the lumbar
belt may have resulted in inaction of the abdominal and trunk
muscles, which may have lead to a decrease in muscle size, which may
indirectly lead to a decrease in core stability (8). Core stability
and core strengthening, particularly transverses abdominis
strengthening exercises, have been shown to decrease the pain
intensity of patients with LBP (8).
A Cochrane review published in 2008 that included studies with
acute, subacute and chronic low back pain concluded that there is
"moderate evidence that lumbar supports are not more effective than
no intervention or training in preventing low back pain," and "it
remains unclear whether lumbar supports are more effective than no
or other interventions for treating low-back pain (4).”
Clinical Relevance
As physical therapists, we often see patients that present with acute, subacute, and chronic low back pain. They may be able to
tolerate physical therapy treatment and obtain some relief from the
physical therapy interventions. However, this relief of symptoms can
sometimes be short lived and symptoms return once they return to
their job or activity despite making modifications. Depending on the
condition that the patient may be experiencing, the utilization of a
lumbar support for a limited basis in coordination with other forms of
treatment may allow for achieving the best overall results.
For patients with chronic pain, they may have insurance limitations
for participation in physical therapy and rely on long acting
narcotics such as Oxycontin that have very significant side effects.
Furthermore, invasive procedures and injections may also be
performed on these patients which can be costly and are not a
guarantee to alleviate the pain. Given the many obstacles that may
face patients with chronic pain,
the utilization of a lumbar support may help the patient with
chronic pain to get up and move instead of being sedentary. The
utilization of the support could play a role with helping the
patient take a step in the right direction.
More up to date and further research is warranted to address the
utilization of a lumbar support in conjunction with physical
therapy, along with the gradual weaning off from the lumbar support
with participation in physical therapy. Conducting a risk versus
reward analysis for patients with chronic pain and the use of a
brace when compared to other options will also be essential to
determining if a patient with chronic pain would benefit from a
support or not.
Last revised: February 22, 2014
by Michelle Kornder, SPT & Chai Rasavong, MPT, MBA
References
1) Hallisy, Thein-Nissenbaum. PT 676 -MS Dysfunction:
Examination, Diagnosis, & Management I. Madison, WI: Department of
Physical Therapy; 2012.
2) Wassell JT, Gardner LI, Landsittel DP, JohnstonJJ, Johnston JM. A
prospective study of back belts for prevention of back pain and
injury. JAMA 2000; 284(21):1-10.
3) Nachemson AL. Orthotic treatment for injuries and diseases of the
spinal column. Physical Medicine and Rehabilitation: state of the
art reviews 1987:1(1):11-24.
4) van Duijvenbode I, Jellema P, van Poppel M, van Tulder MW. Lumbar
supports for prevention and treatment of low back pain (Review).The
Cochrane Library 2008, Issue 2.
5) Calmels P. Fayolle-Minon I. An update on orthotic devices for the
lumbar spine based on a review of the literature. Rev Rhum
1996:63(4):285-291.
6) McGill SM. Abdominal belts in industry: a position paper on their
assets, liabilities and use. American Industrial Hygiene Association
1993:54(12):752-754.
7) Cholewicki J, Juluru K, Radebold A, Panjabi MM, McGill SM. Lumbar
spine stability can be augmented with an abdominal belt and/or
increased intra-abdominal pressure. Eur Spine J 1999;8:388-395.
8) Rostami M, Noormohammadpour P, Sadeghian AH, Mansournia MA, Kordi
R. The effect of lumbar support on the ultrasound measurements of
trunk muscles: a single-blinded randomized controlled trial. PM&R
2013; 1-7.
|
