Steady advances in research for the treatment of low back pain have occurred discussing the efficacy and effectiveness of physical therapy for low back pain.   As the reimbursement climate changes, physical therapists and medical doctors must continue to search for and provide the most cost effective care possible to the patient.   This document provides an update of current trends and research as published in the “Current Concepts of Orthopaedic Physical Therapy, 3^rd Edition,” by the American Physical Therapy Association in 2011.

Low back pain continues to be the most common cause of disability and lost time from work in the major industrialized countries.  It is important to identify patients who would benefit from physical therapy intervention.   The optimal time period for physical therapy intervention is generally with those patients suffering from symptoms three months or less (acute onset).  This supports the belief that most people with the onset of symptoms get better in a shorter period of time.   The majority of those with acute low back pain (80%) recover within 8 weeks, while those with greater than three months of pain require more complex treatments and are much less straight forward.   Both acute and chronic low back pain patients have the opportunity for full recovery based upon Costa, et al.

• What influences Recovery?  Those  with lower than average initial pain, shorter duration of symptoms and fewer episodes recovered more quickly than those with high intensity of pain and higher degrees of disability at onset (Hancock and colleagues).  Psychological and environmental factors are found to play a large role  in recovery of those with low back pain.  The use of “flags” or warning signs have become more common in clinical practice to aid in predicting outcome.   Yellow flags describe personal beliefs about pain and injury (pain catastrophizing). Blue flags are related to injured workers and perception of their work and work conditions. Black flags deal with factors such as social and financial (incentives to remain “disabled).   Self-efficacy has also been a strong predictor of successful outcome specifically when treatment is focused on self care strategies.
• Physical therapists must be able to identify patients at risk for serious conditions that may mimic low back pain such as cancer, infection, fracture and/or aortic aneurysm.  These conditions are recognized by one or more red flags which bring suspicion of a more serious condition.  Though serious diseases are rare they must be screened and a clinical decision made based upon a cluster of findings and clinical judgment.
• Diagnostic imaging, specifically MRI, may provide precise views of the spine and soft tissues.  Both MRI and CT are useful tools to identify serious compression of the cord, cauda equina, or spinal nerves.   Unfortunately, however, there is a lack of a clear relationship between positive MRI findings and the generation of pain and symptoms.  Numerous anatomic variations visible on lumbar MRI are not associated with symptoms; therefore, care must be taken not to “label” a patient who may have a normal anatomic variation.  It is documented that patients may interpret findings as negative and this impact may lead to worse outcomes than similar patients who do not receive MRI.  It is recommended that physical therapists educate patients utilizing anatomical models to educate and illustrate the effects of treatment because patients prefer to have clear explanations of their pain.   Some common myths patients have are as follows:  “all patients who have herniated disc need surgery, and surgeons always agree about this; radiographs and MRI can always detect the source of symptoms; when experiencing back pain, patients should be told to rest until the pain goes away; back pain is caused by injuries or heavy lifting; back pain is typically disabling; everyone with back pain should have a radiograph; and bed rest is the mainstay of treatment.”   It should be communicated that patients who have degenerative disc disease or bulging disks on MRI do not always have a serious condition.  Patients should not be advised they have a serious problem requiring ongoing clinical care without compelling evidence to support this.
• Research supports the use of manual therapy in combination with trunk coordination, strengthening, and endurance exercises to reduce pain and disability in patients with subacute and chronic low back pain.  The utilization of thrust manipulation to reduce pain and disability in patients  with mobility deficits and acute low back pain has strong research support. Centralization techniques through the use of repeated movements have shown to improve mobility and reduce symptoms in patients with acute, subacute, or chronic pain with mobility deficits.  Flexion exercises may be beneficial in reducing disability in older patients with chronic low back pain with accompanying radiculopathy.    Nerve mobilization procedures have fair evidence to support its ability to reduce pain and disability with patient s with subacute and chronic low back pain and radiculopathy.  Patient education should focus on promotion of the inherent strength of the human spine, the neuroscience that explains pain perception, the overall favorable prognosis of low back pain, the use of active pain coping strategies that decrease fear, early resumption of physical and work activities and the importance of in improving function, not just abolishment of pain.  Strong research evidence is present to support moderate to high-intensity exercises for patients with chronic low back pain and/or incorporation of progressive lower intensity fitness and endurance procedures for patients with chronic low back pain. 
• Physical therapy interventions based upon recent evidence consistently supports the use of the combination of spinal manipulative therapy, exercise and patient education.  A number of randomized clinical trials have investigated commonly used physical therapy treatments for low back pain.   Best evidence fails to support the use of lumbar traction, electrotherapy or spinal orthosis as contributing to the long term favorable outcome of patients with LBP.  Treatment based classifications exist to assist in inclusion criteria for intervention procedures for patients with low back pain.  These classifications demonstrate evidence of reliability and improved outcomes, but also require further study.    Nearly all guidelines agree that early return to activity, use of spinal manipulative therapy, and patient participation in active therapy demonstrate best long term improved outcomes.