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low back information

Volumes of information can and have been written regarding spine pain (the neck and low back seem to get the most attention). The purpose of these pages are to help give you a better understanding of the pain and it's many causes. Although this is a good starting point, it is not meant to be, nor should it be used as a self diagnostic tool. If you are experiencing pain, please seek Professional Medical attention. These pages are only meant to help you better understand some of the terminology and concepts that may be presented to you by your physician or other healthcare provider when you see them. Some back (or neck) injuries have the potential to cause irreversible damage if not treated quickly. If for example you have urinary retention, it may be caused by compression of the spinal nerves. This is considered a medical emergency and requires prompt medical attention. Low back pain is often self limiting and often resolves on it's own within a few days. Still, with a reoccurrence rate that has been reported to be as high as 84% (Heiderscheit, B.and Sherry, M., 2007) and an average relapse rate of 58% (McKenzie, R., May, S., 2003) it is often still important to see a professional so that you can learn how to stop that from occurring.

Some statistics:

Anatomy the low back (lumbar spine)

In a very simplified manner we can consider the spine as a low back anatomy bunch of bones (Vertebrae) stacked up one on top of another. In between the bones are the Intervertebral discs. There are also ligaments that help hold everything in proper alignment and lastly (in this simplified description) there are Facet joints.

The discs help join the Vertebra from above and below together. More importantly they act as a shock absorber. They are like a Jelly doughnut and have a tough outer part (the Annular wall) and a more soft jell like inner part (the nucleus pulposus) . They act like shock absorbers and like a shock from a car they can be damaged. This may include: rupture (herniation), being over stretched, torn, losing height and flexibility, or they simply may be irritated and swollen from a trauma.

Nerve roots exit from in-between the Vertebras thru the Intervertebral foramen. The lumbar nerves blend together to form the Sciatic nerve that is responsible for the very well known "sciatica" (pain going from the back down the leg).

So what causes low back pain?

Well, this is not so easy to answer. There can be many reasons and the truth is, we still have a lot to learn about back pain. There are bulging discstill a lot of unknowns. In one study where they tested structures during surgery the top contenders for causing significant pain in the leg from the back were the Nerve root (90%) and the Annulus (45%). Of course there were other structures that did too but they were much less statistically significant. As for causing some pain, muscles were found to be responsible 41% of the time when stimulated. It is my feeling that muscles are rarely the sole culprit. Maybe that's because when that is the case, it resolves on it's own. They don't ever make it to my clinic so I just don't see it. Usually if a person I see is having a lot of muscle spasm it's because a structure below it is injured, or maybe just displaced putting stress on another tissue. The muscle is then doing it's best to immobilize that structure. Treat the structure below, and the muscle guarding and pain often go away without any direct attention or intervention.

The fact of the matter is that even an MRI which is a minimally invasive diagnostic tool can be misleading (and they are costly). In healthy people with no history of Low Back Pain it is not uncommon to find abnormal discs on an MRI. A good clinical exam is often the best and most cost effective way to figure out where the pain is coming from. A good clinical exam will take into account what produces or reduces your pain to help determine why you have it. Once we know that we know how to treat it. That being said, MRI's are still a valuable tool depending on the intervention being performed and practitioner you are seeing. They just may not be needed in a lot of cases of low back pain. In fact, in a summary of a published paper written by Flynn, TW et al. (2011) it was reported that overuse of MRI's in patients was related to an increased rate of surgical procedures. Furthermore, these surgical procedures have not been consistently shown to have good outcomes with regards to reducing pain and improving function (abstract of commentary is HERE).

Seek out a medical professional and they will help you alleviate your pain, or refer you to someone that can. The physical exam will shed light on what the treatment should be. This is the very essence of the MDT (Mechanical Diagnosis and Therapy) examination. MRI's are not usually warranted except under certain circumstances. If you already have an MRI I encourage you to not be so wrapped up in the findings. Rather be concerned about what you may be doing to slow your recovery and what can be done to alleviate the pain and stop it from happening again in the future. At integrative Physical Therapy and Spine Treatment Center Inc. we have a PT with Diploma level credentialing in the use of MDT. We use this approach during both our spinal and extremity exams. Our Diploma credentialed PT is the only clinician in private PT practice within the state of Alaska with this advanced MDT credentialing, and one of only two in the entire state. A study published in 2014 found that patients with low back pain who were treated by clinicians with training in the McKenzie approach (aka MDT) had had statistically better functional outcomes and required fewer visits (Deutscher, D. et al. (2014).

So what's the treatment for low back pain?

Tough to answer, and it will likely depend on what type of practitioner you go to, and the training they've had. If it is a conservative treatment like PT, the goal will usually be to restore balance in the spine and body. That can occur in many ways such as with mobilizations, Lumbar Decompression (VAX D), Myofascial Release, strengthening exercises, and postural changes. A good clinician will look for the reasons why you developed pain in the first place. If you are like many people there may not have been one specific event that started it all. Your activities, postures, muscle imbalances, tightness, or weakness may all gradually contribute to developing pain in the back (or neck). If there is a lot of pain and spasm they may use modalities to help the muscles relax and speed the healing. It is important to get reduction of inflammation in the tissues below. Things like Ultrasound, moist heat, and ice can help with that. Still, the underlying mechanical problem must be addressed. Sometimes these passive treatments only relieve the symptoms for brief periods because the underlying mechanical problem is never addressed. These leads to the inflammation and pain coming right back. Currently we rarely see the need for, or use these passive modalities any more. Using MDT and showing the patient how to treat themselves usually results in such a dramatic reduction in pain the passive treatment is unnecessary. You want to treat the cause, not just the symptoms.

There is no one generic treatment. It will vary because we are all individuals with our own set of specific issues. However, there are a lot of commonalities amongst patients with low back pain. A prior history of a herniated disc, having had low back pain before, or poor posture can all contribute. Often times weak core muscles are blamed. What is often found, is that many patients have similar contributing factors. Because of that it is not uncommon for people to have very similar treatments that they respond well too. However, that can only be determined once an evaluation is completed. Embarking on, or being provided a generic treatment can often result in slow progress, or a failure to improve. A good clinical exam will pave the way to not only a more rapid recovery, but it will also lower the likelihood of having low back pain again.

What about neck pain?

The neck and back have a lot of similarities, but also a lot of differences. Many of the same tools can be used such as modalities, mobilizations to get proper alignment, and traction to open up the disc spaces (like the VAX D) taking pressure off the nerves and helping reduce bulging discs. Muscular weakness and alignment issues also occur in the neck. It is not uncommon to have an underlying shoulder problem that is the cause of your neck pain. Of course there is Whiplash too which can leave a person with a lot of muscle and soft tissue pain. Once again it is difficult to pin point a treatment without having an actual patient and their specific circumstances to address. A clinician using the MDT approach will be able to help identify the causing factors and help you to make the needed corrections to return to a painfree situation.

As mentioned above, a study published in 2014 found that patients with low back pain who were treated by clinicians with training in the McKenzie approach (aka MDT) had had statistically better functional outcomes and required fewer visits (Deutscher, D. et al. (2014). This is likely true for the cervical spine too, but future research will be required to validate that. To learn more about MDT please go HERE.

Reference list:

  • Croft, P, Packager A, McNally R, (1997). Low Back Pain - Health Care Needs Assessment Radcliff Medical Press, Oxford
  • Deutscher, D., et al. (2014). Physical Therapist' Level of McKenzie Education, Functional Outcomes, and Utilization in Patients With Low Back Pain. JOSPT, 44 (12) pp 925-936.
  • Frank, JW, Kerr MS, Brooker AS et al. (1996). Disability resulting from occupational low back pain. Part 1: What do we know about primary prevention? A review of the scientific evidence on prevention before disability begins. Spine 21.2908-2917.
  • Heiderscheit, B. and Sherry, M., (2007). Evidence-Based Sports Medicine (2nd edition): What effect do core strength and stability have on injury prevention and recovery?, page 63. (Domhnall, M., Ed., Thomas, B., Ed.). BMJ Books.
  • McKenzie, R., May, S. (2003) The lumbar spine mechanical diagnosis and therapy, volume 1. Waikanae, New Zealand: Spinal Publications New Zealand LTD.
  • Netter, Frank H., M.D., Sharon Colacino, Ph.D, Consulting Editor. (1998). Atlas of Human Anatomy. Pharmaceuticals Division, CIBA-GEIGY Corporation. 
  • Waddell, G (1994). Epidemiology Review.  Annex to CSAG Report on Back Pain. HSMO,
    London.

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