Who among you has never had back pain? Like the common cold, back pain is one of the most common experiences. It seems that the vast majority of the population is affected by this type of pain sooner or later in life (about 80%). Only a small part of back pain becomes chronic, and then constitutes a major public health problem.
How to deal with chronic back pain in our healthcare system? In France, the recommendations of the Haute Autorité de Santé are clear: care must be multidisciplinary and individualized. Among the health actors concerned, we find physiotherapy (so called in France and Belgium, and physiotherapy in other countries).
My name is Eric and I am a physiotherapist. Back pain is an integral part of my daily life. Every day I work with patients who suffer from it, and fortunately it is one of the things that interest me the most in the world. Many of my patients have already consulted at least one of my colleagues before.
However, who can claim to clearly define what physiotherapy is? The entire profession and its practices are constantly evolving, and many different streams currently coexist. If you consult 10 different physiotherapists, it is very likely that you will not be offered the same treatment 10 times.
How to define the role of physiotherapy for back pain? What can we expect from treatment with a physiotherapist? In this article we are going to make an inventory of the different roles and tools of this profession of rehabilitation, in the context of low back pain. This article reflects my point of view as a physiotherapist trying to adopt a practice based on current scientific evidence.
Identify the elements that cause your pain to persist
If you come to see me for back pain, one of the first things I keep in mind is to look for chronicization factors. These are the elements that may cause your pain to persist longer than expected. Although the doctor started this work when you consulted him, all health professionals are involved.
If you feel a lot of anxiety and worry about your pain, whether this pain is related to personal or professional problems, these are important elements to identify. The physiotherapist is not qualified to treat all these things alone. This sometimes makes it possible to adapt the care and direct you to the right resources.
To enable this, the therapeutic relationship between you and your physiotherapist must be strong and caring. It seems essential to me to take the time to listen to you and to deepen your current situation with you. It's not always easy to describe how you feel to someone else, hence the need for good trust in your therapist.
Understand and manage the situation differently
My role as a physiotherapist is not only to make you do movements or exercises. How you understand and handle your situation is also important. Therefore, the physio provides you with important information. What's going on in your body? What can you do to improve this? How long can this take?
Every day, people consult me without having received a clear explanation of what is happening to them. The doctor sometimes did not have time to answer some of your questions. This leads to worry and anxiety, factors that tend to make pain persist! It therefore seems essential to discuss this subject from the start of treatment. What worries you the most about your pain?
This information can also guide your choice of treatment. What are the different physiotherapy treatment options and what do they involve? The many means used in rehabilitation (exercises, stretching, massage, etc.) often have different short-term and long-term effects. You can then understand, choose and get involved more easily in the treatment in question.
A crucial aspect is education for self-rehabilitation. If the time you spend with the physiotherapist is important, the time spent between each session should also be put to good use. The physiotherapist then teaches you what you can do on a daily basis. These are, for example, movements to do at home or at work.
Ease the pain
One of the common objectives between the physiotherapist and the patient is often to reduce pain. Either it's the initial request and the complaint itself, or it's a necessary step to achieve further movement.
Physical therapists can use a variety of manual techniques to relieve pain. It can be massages or mobilizations (the physiotherapist moves part of your body). Both can be combined. Some also use manipulations, which can cause joint noise (the famous crack!).
Otherwise, there are a number of purely analgesic (i.e. painkiller) techniques. These include, for example, the application of heat or cold, or the use of cutaneous electrostimulation (TENS).
Certain techniques, however, do not offer any interest beyond the placebo effect and their presence in modern treatment is more debatable. These are, for example, ultrasound or laser. No expensive machine has yet shown interesting efficiency.
The exclusive use of analgesic techniques is debated in our profession, because despite the satisfaction felt, the possibilities of long-term improvement are very slim.
If these tools can be part of care, active approaches must complement them. Indeed, these can also relieve pain, while providing a myriad of long-term benefits.
Getting back in motion through active approaches
Active approaches refer to anything you can do on your own, as opposed to passive approaches in which you passively receive the treatment (such as a massage). This term usually refers to all the exercises and movements that you can discover, explore and reproduce on your side.
In reality, the terms “movements” and “exercises” are very vague and can refer to many different things. For example, we use stretching, repetitive movements, muscle strengthening, aerobic training, positioning and muscle activation work, and more.
Several rehabilitation methods have emerged over the years. The best known to the general public, in France anyway, is certainly the McKenzie method.
However, there are others, such as Functional Cognitive Therapy, motor control or the Mulligan concept. Other approaches from the world of well-being can be included: mainly yoga and Pilates.
If the defenders of each approach are convinced of the merits of their own, it is important to remember that to date, none of them has proven its superiority. The most important thing might be to find an approach that works for you and work with a therapist who is familiar with it.
If we take a closer look, we notice that these approaches have important points in common that should be underlined. They seek to move you more, one way or another. They will often consist of choosing a movement or a way of moving that will improve your symptoms. Finally, they focus on self-care, that is to say on what you will do on your side to progress.
For many of you, not every day is the same. There are good days, when you feel ready to move, and bad days, when the exercises seem impossible. It is essential to feel able to adapt your exercises according to your condition.
To learn how to adapt your exercises, I have created a method comprising more than 180 movements organized into 5 levels of difficulty. To know more : Understanding Your Back Exercise Method
Assist in the management of daily activities
The physiotherapist also helps you to continue or resume your favorite activities, whether physical activities or other hobbies. Many of you have had to give up or severely restrict activities that you enjoyed. For a patient I saw recently, it was about being able to lift his grandchildren and being able to play with them.
So part of rehabilitation is finding strategies for managing activities. For some, it will mainly be a matter of varying the amount of effort, duration, speed, way of doing things... For others, it will be a matter of splitting up these activities.
When it comes to a return to physical activity after a long break, the physiotherapist builds a recovery program with you, adapted to your abilities. We are talking about the quantification of mechanical stress.
Sometimes the physiotherapist brings tools to manage a difficult daily situation. A typical example is morning unlocking, ie feeling more stiffness and pain upon waking. Some people need an hour or more to "unwind" in the morning. Sets of exercises can help you start your day faster.
You can also get the Morning Unlocking Program, specialized in morning lumbar stiffness, here: Morning Unlock Program.
Support in professional activity
According to the National Institute for Research and Safety, “chronic low back pain is the leading cause of medical incapacity among employees under 45”. In France, more than 11 million working days are lost each year due to low back pain. It is therefore difficult to deny the considerable impact of back pain on professional activity. Sedentary positions, such as handling positions, are largely affected.
Your job, whatever it is, involves a set of physical (prolonged postures, efforts, repeated movements, etc.) and mental (stress, concentration, organization, etc.) constraints. When these constraints exceed your body's ability to adapt, Musculoskeletal Disorders can result.
The physiotherapist participates in the fight against back pain at work, by acting on several of these factors. He can, for example, teach you how to stretch and alternate between several postures. He participates in adapting your workstation, in collaboration with an occupational therapist and an ergonomist. Ideally, collaboration also takes place with occupational medicine.
Over the years, working methods have changed. The coronavirus pandemic and the democratization of teleworking are an important example of this. Telework has changed the lives of many workers, with a decrease in daily physical activity and often unsuitable workstations. Is this your case?
Many things can be put in place to help you, including warming up at the start of the day. A guide to anti-back pain in the office and when working remotely is also offered on Understanding Your Back.
Specifically work on certain aspects of chronic pain
In the latest recommendations from the Haute Autorité de Santé on common low back pain, physiotherapy is a first-line treatment for low back pain at risk of becoming chronic. At the same time, a growing number of physiotherapists are taking a close interest in chronic pain and are specifically trained in it.
We mentioned above certain risk factors for the chronicization of pain: anxiety, fear, lack of control, etc. We work on each of these aspects, respecting our field of expertise.
One of the most important aspects of the work of the physiotherapist is the recovery of confidence in the movements. As soon as possible, it is a question of finding a movement as unconscious and spontaneous as possible. It also goes through the feeling of having a solid back (as opposed to a fragile and vulnerable back, which we are afraid to solicit).
When the pains have been there for months or years, you have become accustomed to moving and standing in a certain way. Sometimes these habits help keep the pain going. The physiotherapist then helps you explore new ways of using your body.
To facilitate this learning, a whole set of techniques can be used: feeling the movement yourself with your hands or through contact with the therapist, seeing yourself in a mirror, being guided orally, etc.
3 myths about physiotherapy for back pain
Several myths about the action of physiotherapists persist despite all our communication efforts. These received ideas are often conveyed by ignorance of our skills. Here are three.
The first received idea is that our action is only local. We would remain focused on the place that hurts, without caring about the rest. This has been false for many years: the physiotherapist's assessment is global and complete.
The second misconception is that we treat the symptoms, instead of treating the causes. Once again, this is false because the physiotherapy diagnostic assessment precisely seeks to explain the causes of back pain.
The third received idea is that our treatments are essentially passive. Many patients have only experienced the famous massage – heat – electrotherapy combo. However, this is not representative of what a physiotherapist can offer you. I advise everyone to find a professional who will actually guide you and teach you how to manage your back pain yourself.
Collaborate with other health actors
Physiotherapy is part of a global and multidisciplinary management of back pain. In cases of chronic back pain, isolated action by a single healthcare professional is unlikely to lead to major change. It is essential to establish communication between the various stakeholders.
The physio works with the prescribing doctor first, then with specialist doctors. He communicates the results of his assessment as well as the treatment that has been chosen. If necessary, he can give him a feedback on the evolution of the care.
Thanks to the time spent with his patients, the physiotherapist sometimes realizes the need for additional care, with another health professional. Redirecting a person to another therapist can be crucial for optimal effectiveness.
The psychologist can have an important role in chronic back pain. The consequences of pain weigh heavily on mental health, and can fuel pain. The collaboration between psychologist and physiotherapist can then lead to much better results.
Finally, the physiotherapist may be called upon to collaborate with other professionals such as:
- occupational therapists (in the adaptation of the workstation, the management of activities, the maintenance of autonomy)
- psychomotor therapists (in the work on emotions and the representation of the body)
- ergonomists (in reflection on professional activity)
- teachers in adapted physical activities.
- other manual therapists (osteopaths, chiropractors, etc.)
The role of the physiotherapist is multiple and concerns many facets of back pain. This seems consistent with a modern view that places pain as a biopsychosocial phenomenon. The physiotherapist has gone from a role of “repairer” who “corrects” the defect responsible for the pain, to that of a specialized guide who assesses and accompanies the person as a whole.