The Pro sports blog
The material provided here is general information and individual advice should be obtained with an evaluation or assessment by an appropriate physical therapist
Angelene Belle Dimaano, SPT
Low back pain is the most prevalent musculoskeletal disorder both globally and in the US. Unfortunately, over 70% of all adults will experience it in their lifetime. There are many elements that contribute to a person’s experience of low back pain; the major players we focus on clinically are nociceptive pain, neuropathic pain, and nonorganic pain. Nociceptive pain is pain that is alerted by tissue damage, neuropathic pain is pain associated with nerves, and nonorganic pain is pain that cannot be traced to any biological structure.
It should be noted that while low back pain can include all three elements, the neuropathic component is often underrecognized and undertreated. In fact, an analysis of a US claims database reveals a neuropathic component in 90% of chronic low back pain cases. While the neuropathic portion is underrecognized, in the two last decades, there has been an exponential growth in the body of evidence supporting its contribution. In neuropathic low back pain, there are a number of nerves, nervous tissue, as well as surrounding nerve structures that can contribute. Some structures include peripheral nerves such as the sciatic or femoral nerves and individual spinal nerve roots. Although it is not present in every patient, one must also consider contributions from the central nervous system in a patient’s experience of neuropathic low back pain.
Nerves and nervous tissue contribute to the perception of low back pain in one of two ways. One course is peripheral nerves, like muscles, can become injured from being over worked, being compressed, or mechanical trauma. In this case, pain is a normal and natural reaction that serves as an alert system to signify damage. The other course occurs when the central nervous system becomes heightened and therefore responds to non-painful stimuli or disproportionately to painful stimuli.
Physical therapy addresses neuropathic low back pain in three themes: (1) the body is resilient (2) movement does not equal pain and (3) nervous tissues have neuroplasticity: the ability to learn. Treatments that have been shown in the evidence to improve neuropathic low back pain include manual therapy for pain modulation, directional preference for centralization, neuromuscular re-education for proper muscle activation, cognitive behavioral principles of graded exposure to reintroduce activity, and neuromobilization of nerves and the surrounding structures to normalize pain response. The jury is still out on what the gold standard treatment for neuropathic low back pain is, but as the body of evidence supporting the neuropathic component of low back pain continues to grow, it is important to remember it can play a role and it can be treated.