There are many treatment options for low back pain: spinal manipulation, massage, exercise, acupuncture, medications, surgery, etc… But which therapies are most effective for treating low back pain? This post discusses the research on various treatments for lower back pain.
Low back pain is one of the most common musculoskeletal conditions in our society. The American College of Physicians recently released an updated guideline for the treatment of low back pain. This blog post will discuss the recommended treatment options for acute, subacute, and chronic low back pain.
Low back pain is one of the most common issues experienced in our society. In fact, it is estimated that one out of every four Americans report an episode of low back pain in the previous three months! Core strengthening exercises are often given for the treatment and prevention of low back pain. However, since there are so many different ways to strengthen the core, it is easy to get confused on where to start and which exercises are best.
We often think that injury and pain are synonymous. We experience pain when we sprain our ankle or accidentally hit our thumb with a hammer, which makes perfect sense. But does the presence of pain actually mean that there is always an injury to the tissue? This blog post will discuss the difference between pain and injury and why it is important.
Pain along the backside of the leg is a common condition which occurs in 2.2-19.5% of the population per year. While the cause of sciatica is frequently attributed to a herniated disc in the back, this is not always the cause. The piriformis muscle, a small muscle in the buttocks region, can also cause compression of the sciatic nerve leading to pain.This blog post will discuss the causes of sciatica and treatment options for the treatment of piriformis syndrome.
It is estimated that 100 million Americans suffer from chronic pain. Chronic pain is usually defined as persistent pain that lasts for over 3 months. There is a lot of confusion with what chronic pain is and how it is different from acute pain. This blog will go over what causes chronic pain and strategies to get rid of it.
A common experience for someone with an episode of low back pain is to go to the doctor’s office for imaging, with the thought that there is something structurally wrong with the spine that can be fixed. The imaging report often comes back with a diagnosis of a "damaged" spine such as degenerative disc disease, disc bulge, disc protrusion, disc herniation, and facet degeneration. Although 90 percent of individuals with low back pain have a disc herniation, it may not be the cause of your low back pain. This post will discuss how the "damaged" spine diagnosis does not correlate to low back pain and what other treatment strategies should be explored.
Let’s begin with some basic spinal anatomy. There are four basic aspects of the spine: vertebra, intervertebral discs, ligaments, and muscles.
The vertebral bones are specialized in the spine to protect the spinal cord and provide weight-bearing support. Each vertebra has several parts that have different functions. The big oval portion is called the vertebral body and provides support for the weight of your body. There are bony projections that go up and down, which are called facets. The facets allow you to move your spine in various directions. The final part is the spinous process, which sticks straight out and is used as an attachment for muscles (you can feel them on your own back).
The disc is made of three major components: the nucleus pulposus, annulus fibrosis, and the end plates. The nucleus pulposus is a jelly like substance found near the middle of the disc. The annulus fibrosis are rings of collagen oriented in alternating criss-crossing patterns. The nucleus and annulus together provide weight bearing support to the spine. The end plate separates the nucleus pulposus and the annulus fibrosis from the adjacent vertebra.
So what does it mean if you have a damaged spine and can it be reversed? Here is a short and simplistic definition of the “damaged” spine diagnoses from above.
Degenerative disc disease - the size of the disc between the vertebra has decreased.
Disc bulge - the annulus fibrosis is pushing out towards the spinal canal.
Disc protrusion - parts of the nucleus pulposus are leaking past the annulus fibrosis.
Disc herniation - same as disc protrusion.
Facet degeneration - the spacing between the two facet joints is decreased.
Some of these conditions are reversible while some are not. Degenerative disc disease and facet degeneration are not reversible while disc bulges and herniation can go away with time, but it can depend on the size of the herniation.
So if you have one of these conditions, will you always be in pain?
Fortunately, the structural model of low back pain is outdated. Many times these structural issues are incidental findings. Because the development of these degenerative disorders takes a long time, the brain does not interpret them as a threat, and therefore, they do not cause pain. With that being said, there are some circumstances where these disorders can cause pain, however, these situations are rare in occurrence.
A study in the American Journal of Neuroradiology reported on the findings of degeneration in asymptomatic individuals. Their 2014 study revealed:
- Disc degeneration was present in 37 percent of 20 year olds and increased to 96 percent of 80 year olds.
- Disc bulges were present in 30 percent of 20 year olds and increased to 84 percent of 80 year olds.
- Facet degeneration was present in 4 percent of 20 year olds and increased to 83 percent of 80 year olds.
The conclusion to their study was “these findings suggest that many imaging-based degenerative features may be part of the normal aging and unassociated with low back pain.”
There is a possibility that you could have any of the above conditions right now and not even know it. For example, in chiropractic college I had an X-ray of my spine and found out that I had a spondylolithesis (the vertebra has moved forward compared to the one below it) at my fifth lumbar vertebra. I had no idea it was there. So just because these conditions exist does not necessarily mean that you are doomed to a lifetime of pain.
The problem with the overemphasis on structural diagnoses for low back pain is that it implies that pain will not subside without medical intervention, which is not always true. In fact, patients who have X-rays taken have reported longer duration and increased pain severity. While it is important to identify when imaging is necessary, a majority of the time there is no structural pathology linked to low back pain.
The biopscyhosocial model is the current model for the treatment of low back pain. It takes into account many other factors that can contribute to low back pain besides structural causes. For example, the brain can become hypersensitive to the environment and different movements to protect you from further danger. Gradual exposure to these activities can allow the brain to realize you are not in danger. Pain has also been shown to alter how you move, which is good for avoiding further harm in the short term but can have long term consequences. A movement assessment such as a the Functional Movement Screen or Selective Functional Movement Assessment can identify these altered patterns and key in on ways to fix them.
In summary, degenerative disorders of the spine are most likely part of normal aging and do not correlate with low back back. Although degenerative disorders can cause low back pain, it is more of a rare occurrence than once thought. A less than attractive X-ray or MRI does not mean that you have to suffer from low back pain forever. A comprehensive approach to the treatment of low back pain can help put you on the right track to recovery.
W. Brinjikji, Systematic Literature Review of Imaging Features of Spinal Degeneration in Asymptomatic Populations. AJNR Am. J. Neuroradiol. 2014.
Let’s talk about some evidence.
One of the most common things I hear when someone mentions chiropractic is it is some sort of voodoo magic. There is a common misnomer that there is no evidence behind spinal manipulation and there are better treatment options for low back pain. In this post I’ll talk a little about the chiropractic profession and the evidence behind the treatment options for low back pain.
When most people on this planet mention chiropractic, they instantly associate it with spinal manipulation (adjustments, misalignments, moving bones, something was out of place, etc…). It is important to acknowledge that chiropractic is a profession, not a verb. Chiropractic as a profession treats the musculoskeletal and nervous system using a variety of methods such as manual therapy, exercise, and nutrition. Do chiropractors use manipulation? You bet we do. However, manipulation is not a panacea and has its time and place like other modalities.
Most of the time there is a muscular imbalance or a dysfunctional movement pattern that needs to be addressed as well (cue manual therapy and corrective exercises!). The way manual therapy and corrective exercises work is a topic for an another post. But for the time being, let’s keep it simple and say that manual therapy and corrective exercises strengthen weak muscles and decreases tension in tight muscles.
There are three categories of low back pain: serious pathology, mechanical spinal problems, and spinal pain with nerve involvement. A serious pathology is something like cancer or fracture which requires a referral. Majority of low back pain cases do not fall into this category, but it is very important to rule out anything in this category first. Benign spinal problems or spinal pain with nerve involvement are what the majority of people with back pain fit into, which can include disc herniations, sciatica, stenosis, scoliosis, and a whole list of other conditions.
The treatment of mechanical low back pain (benign spinal problems and spinal pain with nerve involvement) varies depending on the practitioner. A few of the most common treatments include: spinal manipulation, manual therapy, corrective exercise, NSAIDs, & ice/heat packs. So what does the evidence say about these treatments for low back pain?
Well, according to guidelines published in JOSPT, spinal manipulation, manual therapy, and corrective exercise were all recommended for acute, subacute, and chronic low back pain. The recommendation for these treatment modalities was based on strong evidence. The American College of Physicians and the American Pain Society also published guidelines that support the use of these treatments when self-care does not improve symptoms.
The research has also identified two factors that can predict a successful outcome when treated with spinal manipulation. The two factors were duration of symptoms less than 16 days and not having symptoms below the knee. When the two factors were met, the decrease in disability remained significant at the 6-month follow-up. This means that early treatment of low back pain may prevent long term low back pain. If these factors were not met, a longer recovery time may be expected.
Other common passive therapies such as ice, heat, traction, ultrasound, and interferential were not recommended by the European Guidelines for the treatment of low back pain. The Cochrane Reviews of ultrasound, heat, and ice also reported limited or no evidence for these therapies. Although some will experience short term relief, passive modalities typically do little to prevent the transition from acute to chronic pain and long-term disability.
The emphasis in the treatment of low back pain is to transition from passive care to active care quickly to prevent the development of chronic pain and long-term disability. The use of spinal manipulation, manual therapy, and corrective exercises aid in reducing low back pain while also preventing long-term disability. The evidence also supports this approach of spinal manipulation, manual therapy, and corrective exercises for the treatment of low back pain.
It is also important to realize that low back pain is multi-factorial, so some treatments will work for some while not for others. Therefore, it is important to have a thorough history and physical examination to determine the most appropriate course of action for any given low back pain case.
In conclusion, the evidence supports the use of conservative options such as spinal manipulation, manual therapy, and corrective exercise. A trial of conservative care should be considered before the use of more invasive options like surgery or injections, which may not be appropriate for the initial treatment of mechanical low back pain. Make sure to always consult a doctor to determine the most appropriate course of action for you.
Chou, Roger. "Diagnosis and Treatment of Low Back Pain: A Joint Clinical Practice Guideline from the American College of Physicians and the American Pain Society.” Annals of Internal Medicine 147.7 (2007): 478-91.
Delitto, Anthony. "Low Back Pain Clinical Practice Guidelines Linked to the International Classification of Functioning, Disability, and Health from the Orthopedic Section of the American Physical Therapy Association." Journal of Orthopedic & Sports Physical Therapy. 42.2. (2012).
Liddle, S. "Exercise And Chronic Low Back Pain: What Works?" Pain. 176-90. (2003).