The majority of patients responding to basic extension and flexion principles of treatment have been educated in the means of achieving pain relief and restoring function. They have carried out the self-treatment procedures and have to a large extent become independent of therapists. Following successful treatment it requires little emphasis to convince patients that if they were able to reduce and abolish pain already present, it should also be possible to prevent the onset of any significant future low back pain.
Of all the factors predisposing to low back pain only postural stresses can be easily influenced and fully controlled. We must develop this potential ingredient of prophylaxis to the full. The patient must understand that the risks of incurring low back pain are particularly great when the lumbar spine is held in sustained flexed positions; and that when the lordosis is reduced or eliminated for prolonged periods, he must at regular intervals and before the onset of pain make a conscious effort to interrupt flexion, restore the lordosis and accentuate it momentarily to the maximum. It is essential that the patient knows the reasons for doing this, and therefore we must explain to him in lay terms that on restoring the lordosis the intradiscal pressure decreases, the nuclear fluid moves anteriorly and the posterior stresses in and around the disc are reduced.
Briefly summarised, the following prophylactic measures should always be taken:
- Prolonged sitting requires (a) maintenance of the lordosis by muscular control of the posture or, preferably, by insertion of a lumbar roll, (b) hourly interruption of sitting by standing up, walking around for a few minutes and accentuating the lordosis by a few repetitions of extension in standing (Proc. 6).
- Activities involving prolonged stooping require (a) interruption of stooping at regular intervals by standing upright, (b) regularly reversing the curvature of the lumbar spine, restoring and accentuating the lordosis by a few repetitions of extension in standing (Proc. 6).
- Lifting requires (a) the use of the correct lifting technique. Generally, if the object to be lifted exceeds fifteen kilograms, the strain must be taken with the lumbar spine in lordosis and the lift must be performed using the legs. If the object to be lifted weighs under fifteen kilograms less care is necessary, unless one has been in a bent or sitting position for some time prior to the lift. In the latter case the same rules apply as for lifting weights exceeding fifteen kilograms, (b) accentuation of the lordosis before and after lifting by a few repetitions of extension in standing (Proc. 6).
- If inadvertently pain has developed during sitting, stooping or lifting, the patient should immediately commence extension in lying (Proc. 3).
- Extension in standing (Proc. 6), very effective in preventing the onset of pain, is less effective when used to reduce present pain. Extension in lying (Proc. 3) is the technique of first aid for back pain.
- Recurrence: At the first sign of recurrence the patient should immediately commence the procedures which previously led to recovery. Although an episode of low back pain can commence suddenly and without warning, many patients are aware of a minor degree of discomfort before the onset of severe pain. If this type of warning is given, the patient has an excellent chance to prevent the development of symptoms, provided the appropriate procedure is applied immediately.
It is not possible for patients to remember all verbal instructions and advice given during the first treatment. To avoid tedious repetition and to ensure the necessary information is conveyed to the patient, a list of instructions is supplied on the first visit. This list firstly deals with information for patients in the acute stage of low back pain, and secondly provides information required once recovery has taken place. These instructions form an important part of self-treatment, because when followed properly they will help in reduction of present symptoms and prevention of their recurrence.