What is the best way to treat low back pain ?

Low back pain is one of the most common, and most complicated problems we see in clinical practice. Everyone from clinicians to patients has their own opinions on the best approach, and looking online reveals a bewildering range of options from Pilates, Yoga, manipulation, massage, Physiotherapy, acupuncture, osteopathy and chiropractic. The list is endless ! In my own time as a clinician i have trained in Spinal manipulation, myofascial release and trigger point acupuncture, Rolfing and literally dozens of exercise techniques to strengthen weak muscles or release others.

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How is one to decide the the best treatment ? Does one choose at random and work through the options (or therapists) until you find the right answer ?

Fortunately we don't have to choose at random. With careful assessment, back pain can be sub-divided into a series of classifications by applying various clinical tests, which have evidence base and are well validated in the scientific literature. For example, the vertebral end plate may sometimes sustain a small fracture, which shows up on MRI and is accompanied by bone bruising (known as modic changes), as shown on the image below:

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A patient presenting in clinic with such a problem, even without the benefit of an MRI to confirm diagnosis, can be diagnosed with the help of careful questioning as to the onset and behaviour of their problem (they frequently report a 'pop' in the back that occurred suddenly in response to lifting). validated clinical tests can confirm the hypothesis. Because this kind of back problem is aggravated by compression, the use of Pilates style spinal stability exercises (which increase compression forces) wouldn't help them, indeed it may make them feel worse ! Anti-inflammatory medication has been shown to delay fracture healing so that wouldn't be a good idea either. Appropriate treatment would go down the lines of suitable analgesia, muscle relaxants such as Diazepam to reduce muscle spasm, and gentle myofascial soft tissue techniques to reduce the compressive forces working on the effected segment. 

Compare this to a patient who also reports lifting reported low back pain, only this time their clinical tests indicate a shearing problem of one vertebral segment on another, usually caused by lax ligaments which have become overstretched. This patient may definitely benefit from Pilates exercises, and soft tissue techniques aimed as 'releasing' muscles are very likely to make them worse !

We could go on and on with these examples, talking about the different ways to diagnose and treat prolapsed discs, trapped nerves, facet joint pain, stenosis etc but i think I've made my point. The start of successful treatment plan begins with an precise diagnosis !