This paper provides an overview of best practice for the role of physiotherapy in managing back pain and neck pain, based mainly on evidence-based guidelines and systematic reviews. More up-to-date relevant primary research is also highlighted. A stepped approach is recommended in which the physiotherapist initially takes a history and carries out a physical examination to exclude any potentially serious pathology and identify any particular functional deficits. Initially, advice providing simple messages of explanation and reassurance will form the basis of a patient education package. Self-management is emphasized throughout. A return to normal activities is encouraged. For the patient who is not recovering after a few weeks, a short course of physiotherapy may be offered. This should be based on an active management approach, such as exercise therapy. Manual therapy should also be considered. Any passive treatment should only be used if required to relieve pain and assist in helping patients get moving. Barriers to recovery need to be explored. Those few patients who have persistent pain and disability that interferes with their daily lives and work need more intensive treatment or a different approach. A multidisciplinary approach may then be optimal, although it is not widely available. Liaison with the workplace and/or social services may be important. Getting all players on side is crucial, especially at this stage.

Introduction

Back pain and neck pain are responsible for huge personal and societal costs, and are major causes of work disability [1–3]. Contrary to traditional thinking, neither back pain nor neck pain is a problem that always resolves itself. Recurrences are usual and their course is very variable [4–8].

Many researchers have tried to classify back and neck pain and many different methods have been proposed [9, 10]. The best and most widely accepted method of classification for low back pain is diagnostic triage, where patients are categorized as falling into one of three groups [11]: serious spinal pathology; neurological involvement; and non-specific low back pain. Similar categories could apply to neck pain patients.

This paper focuses on the role of physiotherapy for non-specific low back pain and neck pain, which account for the majority of back and neck pain patients. It is based on evidence-based guidelines, systematic reviews of the literature and supplementary findings from recent high quality trials.

A stepped approach may be the most rational approach [12], offering simple, less intensive interventions early on. (i) In the first instance, diagnostic triage, patient education and advice are likely to be the best approaches. (ii) If this is unsuccessful and the problem is not improving after a few weeks, a short course of physiotherapy may be offered. Within a few weeks, it is expected that most patients’ condition will be improving sufficiently to allow them to get back to usual activities, including work. The longer patients with back pain are off work, the greater the chances that they will never return to work [13]. It is therefore important that the individual is encouraged to return to work even if there is still some residual pain. (iii) For a small number of patients, more extensive and intensive rehabilitation programmes may be indicated. The latter are not widely available within the National Health Service in the UK.

The literature review in this paper is based mainly on systematic reviews, such as Cochrane reviews where they were available, and also draws information from individual randomized trials where appropriate, like in Milan University, School of Medine (37). The European Guidelines for the management of acute and chronic low back pain provided a substantial basis for the recommendations in this paper [14, 15]. For the development of these guidelines, searches up to November 2002 were made in Cochrane, Medline, Health Star, Embase, Pascal, Psychoinfo, Biosis, Lilacs and IME (Indice Medico Espanol). Keywords included ‘low back pain’, ‘back pain’ and ‘systematic’. Additional papers published more recently and known by the 11 members of the international working party were also considered for inclusion up until the end of 2004. Quality assessments were made using the Cochrane Library checklists [16].

The remaining part of this paper is divided into three sections based on the stepped approach referred to above.

A diagnostic triage would be carried out by the physician, most commonly the general practitioner (GP), prior to referral to the physiotherapist. Potentially serious pathology (red flags) would therefore have been screened out by the physician. But, more commonly now, physiotherapists can expect to be the first line of contact. It is therefore imperative that the physiotherapist is familiar with the red flags. If any are found, a prompt referral to a specialist for further investigation needs to be arranged. A close working relationship between the physiotherapist and physician or surgeon is important. Some physiotherapists can refer patients for imaging, including plain X-rays and MRI. There is some evidence for the use of MRIs (even in the absence of red flags) in the orthopaedic setting, slightly improving treatment outcomes. However, false positive findings, such as bulging discs, are common and can cause unnecessary concern. Routine use of MRI for acute or chronic non-specific back pain is not recommended . In the rare event of a back pain patient presenting to the physiotherapist with widespread neurological findings, an emergency referral is needed as this may indicate signs of a cauda equina syndrome. Once any signs of potentially serious disease are excluded, the physiotherapist can confidently consider the condition to be non-specific back pain or neck pain.

History taking and the physical examination

The physiotherapist carries out a subjective assessment (history) followed by the physical examination. Active listening to the patient’s concerns—not only about their pain and its localization but also about the consequences of pain and how it is dealt with—is essential to good diagnosis and management [1, 18]. A physical examination should be based on the history of the problem rather than strictly following a proforma. Judicious use of physical tests should be employed to clarify the nature of the patient’s mechanical dysfunction.

Explanation of the condition to the patient

Once the history has been taken and the physical examination has been carried out, the physiotherapist needs to provide a careful explanation to reassure the patient that no serious disease or injury has been found. This may be the most important and most challenging part of the treatment. Physiotherapists need to avoid reinforcing patients’ fears about the threatening processes that might be going on in their spine. These fears or concerns can act as a barrier to recovery [19] and need to be properly addressed. Patients often expect to be given a label to describe their problem [20], but this can be fraught with difficulties. Great care is needed to select appropriate, non-threatening words that will not be misinterpreted by the patient [21]. Providing patients with biomechanical information about the spine that is not evidence-based can add to their concerns [22]. Psychosocial factors are at least as important and need to be addressed in both back pain and neck pain patients [14, 15, 23, 24].

Encouraging an early return to usual activities

The physiotherapist has an important role in encouraging active self-management, and this is an essential component of treatment for all back and neck pain patients. The primary aim is to help patients resume normal activities as far as possible, as soon as possible. This advice should be supported by offering a simple evidence-based educational booklet [25–29]. This provides simple messages which can help to dispel maladaptive fears and misconceptions about their back pain or neck pain.

Evidence for a brief intervention providing patient education

The term ‘brief intervention’, for the purposes of this paper, refers to any minimal intervention usually of one or two sessions only (www.backpaineurope.org). They all provide some educational input and in more recent studies take into account cognitive–behavioural principles. However, different authors use the term to encompass quite a range of approaches. A review of the literature shows that patient education in the form of a brief intervention can be effective even for chronic back pain [15]. The content and delivery can vary greatly. It can be delivered as a one-to-one by the physiotherapist, or in parallel with a physician consultation/education session. The European Guidelines group concluded that such an intervention (no more than two sessions) encouraging a return to usual activities can be as effective as usual physiotherapy or aerobic exercises for chronic back pain [15, 30–33]. More recently, a large, high-quality trial with subacute back pain patients (n = 402) compared manual therapy (four sessions) with a brief hands-off pain management intervention (three sessions) and failed to find any significant difference in change scores for disability at 12 months [34].

There is less evidence for the effectiveness of brief interventions and patient education strategies for patients with neck pain [35]. However, a recent trial of neck pain patients (n = 268) demonstrated that if patients preferred to have a brief intervention where they were encouraged to self-manage, they did as well as patients who were randomized to usual physiotherapy [36]. Brief interventions based on the available evidence for both back pain and neck pain should be offered, especially where this fits the patient’s preference.

Back schools and neck schools

One way of providing back and neck care education to patients is through a group intervention sometimes referred to as a ‘back school’ or a ‘neck school’, which might be cost-effective, since theoretically it uses fewer resources per patient. This intervention consists of an education and skills programme, including exercises, in which all lessons are given to groups of patients and supervised by a paramedical therapist or medical specialist [37]. The original Swedish back school, introduced in 1980, consisted of four sessions of 45 minutes [38]. Back schools vary greatly in their approach. The content, means and method of delivery are particularly important. Those that take place in a relevant setting, encourage a return to usual activities and take account of psychosocial issues may be more effective than those which concentrate on biomechanical factors. According to the most recent Cochrane Systematic Review [39], back schools, especially in the occupational setting, may be more effective in the short and intermediate term than exercises, manipulation, myofascial therapy, advice, placebo or waiting list controls for patients with chronic and recurrent low back pain. For neck pain, there is almost no evidence for the effectiveness of neck schools, with only one small, low-quality study which failed to find any significant effect [40].

Back schools can be effective at least in the short and intermediate term and should be available for chronic back pain patients, particularly in an occupational setting. Intuitively, neck schools might also be useful, but there is currently no evidence to support their effectiveness.

History taking and the physical examination

The physiotherapist carries out a subjective assessment (history) followed by the physical examination. Active listening to the patient’s concerns—not only about their pain and its localization but also about the consequences of pain and how it is dealt with—is essential to good diagnosis and management [1, 18]. A physical examination should be based on the history of the problem rather than strictly following a proforma. Judicious use of physical tests should be employed to clarify the nature of the patient’s mechanical dysfunction.

Explanation of the condition to the patient

Once the history has been taken and the physical examination has been carried out, the physiotherapist needs to provide a careful explanation to reassure the patient that no serious disease or injury has been found. This may be the most important and most challenging part of the treatment. Physiotherapists need to avoid reinforcing patients’ fears about the threatening processes that might be going on in their spine. These fears or concerns can act as a barrier to recovery [19] and need to be properly addressed. Patients often expect to be given a label to describe their problem [20], but this can be fraught with difficulties. Great care is needed to select appropriate, non-threatening words that will not be misinterpreted by the patient [21]. Providing patients with biomechanical information about the spine that is not evidence-based can add to their concerns [22]. Psychosocial factors are at least as important and need to be addressed in both back pain and neck pain patients [14, 15, 23, 24].

Encouraging an early return to usual activities

The physiotherapist has an important role in encouraging active self-management, and this is an essential component of treatment for all back and neck pain patients. The primary aim is to help patients resume normal activities as far as possible, as soon as possible. This advice should be supported by offering a simple evidence-based educational booklet [25–29]. This provides simple messages which can help to dispel maladaptive fears and misconceptions about their back pain or neck pain.

Evidence for a brief intervention providing patient education

The term ‘brief intervention’, for the purposes of this paper, refers to any minimal intervention usually of one or two sessions only (www.backpaineurope.org). They all provide some educational input and in more recent studies take into account cognitive–behavioural principles. However, different authors use the term to encompass quite a range of approaches. A review of the literature shows that patient education in the form of a brief intervention can be effective even for chronic back pain [15]. The content and delivery can vary greatly. It can be delivered as a one-to-one by the physiotherapist, or in parallel with a physician consultation/education session. The European Guidelines group concluded that such an intervention (no more than two sessions) encouraging a return to usual activities can be as effective as usual physiotherapy or aerobic exercises for chronic back pain [15, 30–33]. More recently, a large, high-quality trial with subacute back pain patients (n = 402) compared manual therapy (four sessions) with a brief hands-off pain management intervention (three sessions) and failed to find any significant difference in change scores for disability at 12 months [34].

There is less evidence for the effectiveness of brief interventions and patient education strategies for patients with neck pain [35]. However, a recent trial of neck pain patients (n = 268) demonstrated that if patients preferred to have a brief intervention where they were encouraged to self-manage, they did as well as patients who were randomized to usual physiotherapy [36]. Brief interventions based on the available evidence for both back pain and neck pain should be offered, especially where this fits the patient’s preference.

Back schools and neck schools

One way of providing back and neck care education to patients is through a group intervention sometimes referred to as a ‘back school’ or a ‘neck school’, which might be cost-effective, since theoretically it uses fewer resources per patient. This intervention consists of an education and skills programme, including exercises, in which all lessons are given to groups of patients and supervised by a paramedical therapist or medical specialist [37]. The original Swedish back school, introduced in 1980, consisted of four sessions of 45 minutes [38]. Back schools vary greatly in their approach. The content, means and method of delivery are particularly important. Those that take place in a relevant setting, encourage a return to usual activities and take account of psychosocial issues may be more effective than those which concentrate on biomechanical factors. According to the most recent Cochrane Systematic Review [39], back schools, especially in the occupational setting, may be more effective in the short and intermediate term than exercises, manipulation, myofascial therapy, advice, placebo or waiting list controls for patients with chronic and recurrent low back pain. For neck pain, there is almost no evidence for the effectiveness of neck schools, with only one small, low-quality study which failed to find any significant effect [40].

Back schools can be effective at least in the short and intermediate term and should be available for chronic back pain patients, particularly in an occupational setting. Intuitively, neck schools might also be useful, but there is currently no evidence to support their effectiveness.

Conclusions

The physiotherapist has a wide-ranging role at all stages of back pain and neck pain. Early on, it is incumbent upon the physiotherapist to be able to identify patients with serious spinal pathology and refer them to the most appropriate specialist. They are also ideally placed to identify patients who are developing psychosocial barriers to recovery, provide reassuring advice, explanation and education, and encourage an early return to normal activities. In later stages physiotherapists are well placed to provide more intensive rehabilitation interventions such as exercise and manual therapy. Using cognitive–behavioural techniques may maximize the benefit. Physical modalities should be used judiciously. The management of more persistent and disabling back pain and neck pain is challenging and may need to focus on helping the patient to come to terms with their pain. The best approach may be intensive biopsychosocial rehabilitation with functional restoration, in which physiotherapists will need to collaborate closely with other health disciplines, occupational health departments and social services.

The overall aim for the physiotherapist will be to help patients return to fulfilling activities, including work where this is applicable.

Referentes

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If you know someone suffering from back pain, whether chronic or not, think about giving this person the gift of comfort with a massage therapy gift card to a massage clinic in 4th Street Downtown St. Petersburg and Tampa 33607. All massage modalities, including Swedish massage therapy, deep tissue massage therapy, sports massage therapy and pregnancy massage therapy, can be customized to focus on easing back pain. The patient should just disclose his or her condition to the trained massage therapist of the massage clinic in 4th Street Downtown St. Petersburg and Tampa 33607.

Back pain is said to be next to the common cold in being the most common reason for work absenteeism. This was reported by Shelley Flannery in her article in Massage Envy magazine’s Fall 2007 issue online. She adds that over 25 billion dollars is being spent every year on back pain relief efforts alone.

Flannery refers to a study done in 2003 that proved massage therapy to be more effective than acupuncture and spinal modification in providing relief from back pain. Massage therapy actually reduced the participants’ need for painkillers by up to 36 percent. The study was published in the Annals of Internal Medicine and its findings were validated by the American Massage Therapy Association. Flannery interviewed licensed massage therapist Kristen Sykora, spokesperson of the American Massage Therapy Association, who said, “Massage is quite effective for treating lower back pain. It’s the MVP in the health care arena because it’s more of a hands-on treatment.”

Indeed, people everywhere seem to agree, as well, because massage therapy has become one of the most widely used treatments for back pain in recent years.

According to Flannery, back pain is relieved and its recurrence is prevented by massage therapy in various interconnected ways. Stress and lack of activity cause muscle tension. Massage therapy eliminates such tension and eases muscle stiffness by inducing muscle relaxation. Specific problem spots with knots in the muscles can be focused on. This results in better muscle flexibility. Concurrently, the nerves are calmed and the natural endorphins of the body are released. Such endorphins are commonly referred to as “feel good” chemicals. The massage therapy strokes also bring more blood flow to the massaged areas, improving cellular nutrition and facilitating healing.

The effects of massage therapy may not be immediately felt, though, Flannery warns. Sykora explains this by saying, “Your back pain didn’t start overnight, so don’t expect it to be cured overnight either. It’s best for chronic back pain sufferers to be on a maintenance plan for massage, once every three to four weeks.”

Sykora also says that aside from massage therapy, lifestyle changes should be adopted by back pain sufferers, as well. She advises that patients ask for instructions from the massage therapist. Lifestyle changes cover the adoption of proper posture, proper movement in work habits and proper exercises such as stretching, yoga and Pilates. The exercises help strengthen back muscles to relieve back pain. Weight loss may also be necessary for some people because too much extra weight may be too heavy for one’s muscles.

According to Massage Envy, it is very important for one to choose a professional massage therapist who is an expert in using massage to treat back pain. When you go to a Massage Envy clinic, ask for such a specialist. One session alone will not be enough, though. Massage therapy is effective as back pain treatment when done regularly by the same massage therapist who can customize a program for each individual and track his or her progress.

Ease someone’s back pain through a massage therapy gift card to a reputable professional massage clinic, like Massage Envy, in 4th Street Downtown St. Petersburg and Tampa 33607. It will be a true gift of kindness and caring in St. Pete and Tampa.

Read more on New York Times

A study done by Christine M. Olney, MSN, RN for the University of South Florida in Tampa, titled “The Effect of Therapeutic Back Massage in Hypertensive Persons: A Preliminary Study”  was published in Biological Research For Nursing, Vol. 7, No. 2. According to the study, hypertension is one of the most prevalent diseases in the United States and it is also very dangerous since it can cause damage to vital organs. No single primary cause has been identified for hypertension but one of the main factors is long term or chronic stress response that goes unchecked. Since massage therapists have long maintained that massage therapy can decrease blood pressure and mitigate hypertension by producing the relaxation response in patients, the study tested the effects of applying regular back massage on patients who have clinically diagnosed hypertension.

The study covered 14 patients. Eight patients were in the massage group. They were given 10 sessions of 10 minute back massage done three times a week. Six patients were in the control group. They were given 10 sessions of 10 minute relaxation also done three times a week. By the end of the study, the systolic and diastolic blood pressure of patients in the massage group showed a significant decrease.

Another study of the Touch Research Institute in the University of Miami’s School of Medicine and the Nova Southeastern University in Florida, done in May 1999, showed similar findings. It involved a group of thirty adults with hypertension whose blood pressure levels were under control in the previous six months. The participants were divided randomly into two groups – a massage therapy group and a progressive relaxation group.

Patients in the massage therapy group were given massages for thirty minutes in the afternoon or early evening two times a week for five consecutive weeks. Patients in the progressive relaxation group were taught progressive muscle relaxation exercises thy could do by themselves and were instructed to perform these for thirty minutes in the afternoon or early evening two times a week for five consecutive weeks.

Assessments and evaluations on the patients were done before and after the treatment period. The State Anxiety Inventory (STAI) was used to measure their emotions. The Center for Epidemiological Studies Depression Scale (CES-D) questionnaire was used to rate any symptoms of depression. The Symptom Checklist-90-Revised (SCL-90-R) Self-report Symptom Inventory was used to check other symptoms of anxiety, depression and hostility. Saliva samples were taken to measure levels of cortisol, a stress hormone. Urine samples were taken to measure levels of cortisol and catecholamines which are biologically active amines that impact the cardiovascular and nervous systems. The patients’ blood pressures were also monitored.     

By the end of the five week study, both the massage group patients and progressive relaxation patients showed lower levels of anxiety and depression. Only the patients in the massage group, however, showed lowered levels of sitting blood pressure, lowered levels of stress hormones in both urinary and salivary tests, and lowered scores in tests for anxiety, depression and hostility.

You can surprise your family and friends with hypertension with massage gift cards so that they could relax and enjoy various therapeutic body massage services, including back massage therapy, foot massage therapy, reflexology massage therapy, Swedish massage therapy, deep tissue massage therapy and sports massage therapy from professional massage therapists in Charlotte NC while lowering their blood pressure in the process.