LOW BACK PAIN
Practice Report
LOW BACK PAIN
Low back pain is most commonly related to acute or chronic strain of the joints and soft tissues that support the spinal column. Common causes of acute back pain include disc injuries and strain involving ligaments, tendons, or muscles supporting the spine.
Common causes of chronic back pain include muscle spasm, arthritis, stenosis, and other degenerative changes.
Lumbar Disc Disease
Discs act like shock absorbers between the movable bony segments of the spine. These discs can be strained to the point where they bulge, protrude, or rupture into spaces where the spinal cord or spinal nerves are affected. If the inner gel-like substance of a disc extrudes through a crack in its outside wall and into the surrounding soft tissue, the result is often severe pain and inflammation.
Acute vs. Repetitive Muscle Strain
Individual differences in spinal contour, pelvic size and symmetry, and connective tissue elasticity make some people more susceptible to repetitive strain than others. Every muscle has a tendon of origin and a tendon of insertion. The way these tendons attach to bone and joint structures determines the kind of movements produced by that muscle. In a repetitive strain situation, micro-injuries to strained tendons can evolve into persistent pockets of inflammation.
Small tendon fibers or ligaments attached to bones in the lower spinal column may tear resulting in bleeding, swelling and tenderness at the site of injury. This type of muscle-tendon-ligament strain can be the acute result of a specific incident of bending, twisting, or lifting, an injury incurred playing sports, or an accident of some kind. In such cases, patients often describe feeling like something gave way in their lower back, followed by radiating pain (often extending to the buttocks, the hip girdle muscles, and back of the thighs).
In both acute and repetitive forms of strain, tendon or ligament irritation causes the muscle to go into what’s called reactive spasm. If the problem continues, the muscle
Trigger point spasms are the most difficult type of spasm to treat. If a muscle remains in a state of reactive spasm long enough, the motor neuron that controls contraction and relaxation of its muscle bundles may get irritated and stuck in a “make the spasm even tighter” mode.
Chronic trigger point spasm leads to chronic myofascial changes in which muscle fibers waste away from poor circulation and are replaced by collagen. This can spread to other muscles in the area, creating a chronic regional myofascial pain syndrome. Trigger points feel like ropes or knots under the skin. When pressed they can be extremely tender. Trigger point pain is often described as “a claw” dug into a muscle.
When a chronic regional myofascial pain syndrome spreads to involve the right, left, upper, and lower regions of the body, the condition becomes associated with interrupted sleep and daily fatigue. If physical examination reveals widespread trigger points (knots) in addition to multiple tender points (without knots) in classic locations, the condition can be called fibromyalgia. Both fibromyalgia and chronic regional myofascial pain syndromes can be debilitating to the point of interfering with activities of daily living.
Risks for Chronic Low Back Strain
The lower back carries all the weight of the torso, and is the most frequently injured area of the spine. What puts individuals at risk for low back pain may include excess body weight, nutritional deficiencies, smoking, diabetes, poor muscle tone or low muscle mass, poor posture, hyper-stretchy ligaments, improper heavy lifting, poor sleeping position, and stress. The effects on quality of life range from mild to severe.
Pinpointing the source of back pain can be a challenge. If someone reports chronic low back pain in a setting where physical examination and imaging studies cannot account for the pain, the pain is often linked to psychological stress.
Persistent stress is known to amplify the perception of pain. In cases of benign persistent low back pain, psychosocial stress predicts a higher likelihood of low back pain-related disability.1
Chronic low back pain of uncertain cause that is resistant to conventional therapies may be more amenable to integrative therapies and a mind-body approach. In patients with low back pain for at least 6 weeks, those who received naturopathic care over a three-month period had better outcomes at less cost than those who received only patient education and usual care.2
Potentially Threatening Forms of Back Pain
If the pain is constant and unrelenting even with rest or when trying to sleep, or a
specific spinal bone seems unusually tender, imaging may be needed to rule out a serious problem such as a fracture, tumor, infection, abdominal aortic aneurysm, kidney
disease, pelvic inflammation or tumor, or metabolic bone disease such as Paget’s Disease or osteoporosis.
If a nerve root is involved you may report a sharp, stabbing, shooting pain, the sensation of pins and needles in the leg, or even weakness of one or more muscles involve in walking. This raises the possibility of acute or chronic radiculopathy – fancy names for nerve root injury or irritation. Depending on severity, this type of back pain may warrant nerve studies and/or the higher resolution imaging provided by an MRI scan.
Spinal stenosis is an age-related degenerative change in the bones that make up the spine that results in pain involving both legs that gets worse with walking. The pain can be felt in the upper and/or lower legs. Sufferers often find that they can only take so many steps before having to sit and rest, which relieves the pain. Sometimes bending slightly forward will reduce pain or allow more walking distance before pain starts. An MRI scan is that standard test for diagnosing this condition.
Arthritis
Osteoarthritis is an age-related degenerative change in the soft tissue structures that support normal joint movement. Weakened support allows excessive play in the joint, resulting in micro-tears and pockets of inflammation too advanced or numerous for the immune and hormonal systems to control and repair.
The spinal column has over 200 points of articulation that could be affected by cumulative wear and tear accompanied by pockets of inflammation. Uncontrolled inflammatory osteoarthritis is a serious chronic pain condition that warrants an integrative approach to assessment and treatment.
Ankylosing spondylitis, arthritis of the spine gives rise to inflammation of the spine and lower back joints. One early symptom of this condition is morning back stiffness. We advise our patients not to get too hung up on diagnostic labels. Our goal is to understand how each person became plagued by lower back pain, and to develop an integrative care plan that is tailored to the uniqueness of that person’s health situation.
Imaging Studies for Low Back Pain
Evidence indicates that doctors should not be doing routine X-rays, CT scans, or MRI scans for acute low back pain, or for low back persisting for less than 6 weeks, unless they suspect a potentially serious underlying condition.3
Doing a series of X-rays, a CT scan, or an MRI scan as a reflexive routine for cases of acute or low back pain does not improve clinical outcomes compared to usual care unless there are grounds to suspect that a potentially serious condition is causing the problem. Unless there is reasonable concern about a potentially threatening cause, “routine” imaging studies for acute and sub-acute (onset less than 6 weeks earlier) cases of low back pain generate pointless exposure to radiation (in the case of x-rays and CT scans), and pointless expense (in all cases).
If significant low back pain persists without improvement beyond 6 weeks despite usual care, or if the pain gets progressively worse despite usual care, imaging studies should be considered.
The conventional medical approach:
• History investigates the nature of an injury or repetitive strain, and explores general health status. Physical exam involves focused examination of nerve and joint function, muscle spasm, and tender spots.
• Blood tests and imaging studies are sometimes run to look for signs of
inflammation or infection. Imaging and electrophysiological studies may include:
o X-rays provide detailed information about bone structures. They help assess the severity of degenerative changes in the lumbar spinal segments and the sacroiliac joints.
o Muscle ultrasound to assess soft tissues for evidence of trauma or chronic inflammatory changes.
o CT scans provide a higher resolution imaging of bones than X-rays.
o MRI scans provide high resolution images of bone and soft tissue, making them especially valuable when concerned about potentially serious disc or nerve problems.
o Nerve conduction studies and electromyography can help determine whether nerve injury exists, and if so, localize the injury to one or more specific spinal nerve roots.
• Treatment emphasizes prescription drugs for pain, and/or mood. Commonly prescribed drugs include:
o Pain relievers: non-steroidal anti-inflammatory drugs (NSAIDs) such as naproxen (e.g., Aleve) or ibuprofen (e.g., Advil) are often prescribed first. If these are not effective, a doctor may prescribe a short-acting narcotic analgesic such as tramadol (e.g., Ultram) or hydrocodone with
acetominophen (e.g., Vicodin). If back pain becomes chronic and short-acting narcotic analgesics are needed several times per day to control pain, a doctor may prescribe a long-acting narcotic analgesic such as Oxycontin.
o Muscle relaxants (such as cyclobenzaprine or carisoprolol) are also used for pain related to spasm – often with little thought given to underlying reasons or perpetuating factors for muscle spasm.
If primary care advice doesn’t help, referrals may be made to a rheumatologist, physiatrist, neurologist, neurosurgeon, and/or orthopedic specialist.
The integrative medical approach:
• History investigates the nature of an injury or repetitive strain, and explores general health status from a systems biology perspective. Physical exam involves focused examination of nerve and joint function, muscle spasm, and tender spots, while taking into account physical signs of underlying metabolic imbalance. • Physical exam is focused on tender points, blood pressure, nutritional status,
muscle tone and reflexes, skin tone, sinuses, throat, lymph nodes, inflammation zones, and any other areas warranted based on the history. Hyper-stretchy connective tissue is also of interest because it predisposes to excess strain and premature osteoarthritic changes.
• Blood testing may look for signs of toxicity, inflammation, or infection, but may also look for markers of neurohormonal imbalance, nutritional deficiency, or other forms of metabolic imbalance, to assess a person’s capacity for a balanced interplay of damage control and restoration systems.
• Treatment may include prescription or over-the-counter medication, but it emphasizes lifestyle changes and natural therapies and is focused on restoring balance to the metabolic systems that, based on history or exam, appear to have lost their functional integrity. They include your systems for:
o Digestion and assimilation of nutrients (ability to break down and absorb good things while keeping bad things out of the system).
o Microcirculation of blood and lymph (ability to move oxygen and nutrition in, and trash water out, of tissue zones).
o Detoxification (toxin detection, handling, and elimination).
o Restoration (hormone and neurotransmitter balance).
o Inspiration (conscious and unconscious brain effects on behavior). • Physical therapy, chiropractic adjustment, massage therapy, proper stretching,
and exercises to improve the strength and resilience of the lower back and hip muscles produce the best results when attention is also being paid to issues involving assimilation, circulation, detoxification, and restoration systems, as well as the critically important desire to get well.
• Mind-body therapy are part of a panel of treatment options that include other mind-body techniques for managing stress:
o Addressing potentially maladaptive psychological defenses.
o Learning techniques for quieting the mind and body at will.
o Meditative practices including contemplative prayer, yoga, and Tai Chi.
At onebodymind.com, we view back pain the same way we view everything else: as a multidimensional metabolic rehabilitation project that applies specifically to you, and that is amenable to some degree to proper self-care. Our system of self-assessment and care is consistent with an emerging understanding of the origins of chronic illness that is based on systems biology research. We believe that wise self-care methods should be part of any plan to get key your bodily systems working better together as a team. In some cases, a well-placed injection or a carefully executed invasive procedure will fix the problem. In most cases, a metabolic rehabilitation model will help the back pain patient achieve more effective results.
An integrative approach to back pain looks at the unique big picture for each patient, and continually adjusts itself to achieve better results by restoring functional integrity to metabolic systems that have fallen out of balance.
References:
1. Discographic, MRI and psychosocial determinants of low back pain disability and remission: a prospective study in subjects with benign persistent back pain. Spine J. 2005 Jan-Feb;5(1):24-35.
www.ncbi.nlm.nih.gov/pubmed/15653082?ordinalpos=3&itool=EntrezSystem2.PEntrez .Pubmed.Pubmed_ResultsPanel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum 2. Cost-effectiveness of naturopathic care for chronic low back pain. Alternative Therapies in Health and Medicine. 2008;14(2):32–39.
http://nccam.nih.gov/research/results/spotlight/070708.htm
3. Imaging strategies for low-back pain: systematic review and meta-analysis. Lancet. 2009 Feb 7;373(9662):463-72.
www.ncbi.nlm.nih.gov/pubmed/19200918?ordinalpos=1&itool=EntrezSystem2.PEntrez .Pubmed.Pubmed_ResultsPanel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum
