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Low-Back Pain: Causes, Care, and Consequences

Low-back problems are one of the most common reasons for visits to doctors’ offices and the most common cause of disability among persons under the age of forty five. Most of the time, acute low-back pain is the result of simple strain and is a self-limiting condition that will resolve in four to six weeks, with or without treatment. But since back pain can be a forerunner of disability or a symptom reflecting serious pathology, every effort should be made to seek appropriate care that is based on a definitive diagnosis. Failure of physicians to ease the concerns of back-pain patients by explaining their problem and advising them in the care of back pain often results in dissatisfied patients who may be attracted by the approach of alternative medicine practitioners who tout a spurious quick-cure treatment based on a dubious diagnosis. Misinformation provided by such practitioners may contribute to disability by allowing progression of disease or by exaggerating the seriousness of the problem in the mind of the patient. Thus, while back pain is rarely serious, it should always be carefully evaluated to reach an accurate diagnosis and to determine if specialized care is needed. Care should be taken to inform the patient in a positive manner─to avoid unnecessary surgery as well as inappropriate or unnecessary treatment.

Something to Consider When You have Back Pain

Almost everyone will experience acute low back pain at least once during a lifetime. Much of what must be done to care for a bad back must be done by you. It would certainly help to be well informed about the causes of back pain when seeking appropriate treatment.

It goes without saying that when incapacitating back pain occurs as a result of a serious accident or injury, you should seek emergency medical care. When back pain grows progressively worse, persists unrelieved for longer than a week, or is worsened by rest, you may need the services of a specialist. Back pain that occurs for no apparent reason and does not affect movement may be a symptom referred from an internal organ. Once a diagnosis has ruled out a serious problem and it has been established that you have nonspecific or uncomplicated mechanical-type back pain, self-help measures designed to relieve your symptoms and to protect and strengthen your back may be the only treatment needed. If there is no active pathological process and your back pain lasts three months or longer, you may have a “chronic” back problem that can lead to recurring back pain, requiring ongoing vigilance and self help.

Time is the most important part of treatment for uncomplicated back pain caused by injury. It’simportant, however, to be aware of red flags indicating that back pain might be the result of something more serious that a simple strain. In the absence of red flags, imaging studies or special testing might not be indicated during the first four weeks of low back symptoms. When a red flag is present, you should not delay in reporting your symptoms to your family physician.

Back Pain Red Flags

Here are some red flags that should be considered when back pain is severe, persistent, or associated with other symptoms.

  • If you are on a treatment program requiring prolonged ingestion of a corticosteroid or a thyroid hormone, especially if you are past middle age, sudden appearance of back pain that restricts movement might be an indication that an osteoporotic vertebra has collapsed. The location of a vertebral crush fracture can often be determined by applying percussion over a prominent spinous process.
  • If you have a history of lung, breast, or prostate cancer and you develop a gradual onset of back pain, or if you have persistent back pain for no apparent reason, you should be tested for bone disease. Some forms of malignancy commonly metastasize to the ribs or the vertebrae, requiring a bone scan or some other special imaging procedure to detect the disease in an early stage.
  • Backache can be caused by a kidney infection that may go undetected until an elevation in temperature is discovered. Always take your temperature when you have a backache. If you have a fever, you should always see your family physician, regardless of what you think might be causing your backache. Any persistent backache that defies diagnosis should undergo testing and observation in a search for such elusive diseases as ankylosing spondylitis or rheumatoid arthritis.
  • Kidney stones can cause acute back pain. Unlike mechanical-type back pain that is relieved by rest and intensified by movement, the referred pain of a kidney stone produces pain that will not allow you to rest or sit still. If you have the misfortune of experiencing back pain that causes you to squirm about or roll around on the floor, you should go to a hospital emergency room as soon as possible.
  • Pain, numbness, and other symptoms radiating down one or both legs, or weakness in one leg or foot, especially when associated with back pain, would be a red flag indicating possible encroachment upon spinal nerves. Such symptoms could be caused by disk herniation, osteophyte formation, or some other pathological process.
  • Sudden appearance of constant and severe leg pain that is not associated with back pain, or cramping leg pain that occurs only when you walk and is relieved by rest (intermittent claudication), might be an indication of diseased arteries. Your family physician might want to refer you to a vascular specialist in order to differentiate vascular claudication from neurogenic claudication caused by spinal stenosis.
  • Loss of bladder or bowel control (especially urinary retention) that is associated with back pain or numbness in the perineal or saddle area of your pelvis is a medical emergency (cauda equina syndrome) requiring the immediate attention of a neurosurgeon. Such symptoms can be caused by a lumbar disk protrusion that has entered the spinal canal.

Diagnosing Back Pain

Although an x-ray exam is not often indicated (depending upon your medical history) when acute back pain occurs, your doctor might order an imaging study if symptoms persist longer than a month. A plain x-ray image can be helpful in finding a structural problem, such as spondylolisthesis, that might be causing back pain; it might also detect bone disease, an abdominal aneurysm, or some other problem that might be causing non-musculoskeletal back pain. When there is a red flag involving spinal nerves, an MRI study might be needed to look for nerve root impingement or disc herniation. CT-myelography might be ordered in the case of spinal stenosis or cauda equina syndrome, and so on. An appropriate specialist will order an appropriate testing procedure. In most cases, a good physical exam and a detailed case history by an astute clinician will provide a diagnosis that will often be confirmed by special studies.

Generally, non-musculoskeletal back pain referred from an internal organ is characterized by pain that is not affected by movement, percussion, and other mechanical testing procedures. Back pain complicated by neurological symptoms, such as loss of reflexes, localized muscle weakness, muscle atrophy, and other signs of progressive nerve damage, may be an indication of massive herniation of an intervertebral disk.

Barring the medical emergency of a cauda equina syndrome, any recommendation for surgical excision of a herniated disk would warrant taking time for a second and third opinion. Surgery can often be avoided when time is combined with periodic evaluation by a physician who can watch for progressive neurological signs that indicate an unquestionable need for surgery.

Basic Self-Help Measures

When the U.S. Department of Health and Human Services published Acute Low Back Problems in Adults in 1994, it advised that “The use of physical agents and modalities in the treatment of acute low back problems is of insufficiently proven benefit to justify their cost. As an option, patients may be taught self-application of heat or cold to the back at home.”

Here are some basic self-help measures that anyone can use safely and effectively to relieve symptoms and to buy the time needed for recovery.

Cold and heat: As a general rule, it’s best to use cold applications during the first 24 to 48 hours after an injury─about 20 minutes at a time several times during the day. Cold constricts blood vessels and reduces swelling. When an injury is severe enough to cause swelling in deep tissues, early application of heat might increase pain and swelling by dilating blood vessels and drawing blood into the injured tissues. While it’s unlikely that significant capillary bleeding occurs in simple, uncomplicated back strains, many physicians routinely recommend cold applications during the first 24 hours as a safety measure and to relieve pain by numbing the tissues.

When back pain is not severe, it probably makes little difference whether you use heat or cold; you may try using brief applications of each and then use whichever feels best. Heat applied for 20 or 30 minutes will often provide soothing relief by relaxing spastic muscles. If heat seems to increase pain or cause a throbbing sensation, you should discontinue use of heat and use cold applications for at least two days before trying heat again.

A gel pack that can be cooled in a freezer or heated in a microwave oven can provide a convenient source of heat or cold. Such packs can be strapped to the back to permit movement around the house; they should always be wrapped in fabric to prevent tissue damage caused by excessive temperature.

Rest: When acute back pain occurs as a result of injury, you may have no choice other than to rest in bed the first day or two. But the sooner you begin moving around, the better. Unless you have sustained a spinal fracture or a herniated disk, it’s never a good idea to stay in bed longer than a couple of days. Prolonged bed rest─longer than four days─can lead to weakness and debilitation.

When you are resting in bed, placing a pillow under your knees will relieve strain on your lower back by taking tension off hip flexors (psoas muscles) that tug on the lumbar spine. You can relieve tension on hip flexors and get the added effect of traction by lying on the floor and draping your legs over the arm of a sofa. If you don’t have leg pain caused by nerve root impingement, don’t be afraid to move around the house, even if you have to grunt and groan to do so. Even though movement may be painful, the pain you feel will prevent excessive movement and will not worsen your injury. Use a walker or a pair of crutches if necessary. A simple wrap-around velcro back support might help when standing or walking. A behind-the-back cushion to maintain the normal lumbar curve while sitting might also be helpful.

Medication: When you have uncomplicated musculoskeletal back pain (without sciatic nerve root compression), you won’t often need prescription medication to relieve your pain. Over-the-counter medication such as Tylenol (acetaminophen) will usually provide adequate pain relief. But do not continue use of such medication for longer than about a week at a time. In most cases, the acute pain of a nonspecific back problem will subside after a few days. If pain persists unrelieved, see your doctor. Prolonged or excessive use of acetaminophen, aspirin, or any of the nonsteroidal anti-inflammatory medications (NSAIDs) can have serious side effects. Use medication only as needed if a cold pack or a hot pack does not relieve the pain enough to allow you to lie down and sleep at night.

Exercise: Avoiding bed rest that lasts for longer than a day or two will help reduce the weakness and stiffness caused by back injury. But after two to four weeks of restricting normal activities to relieve mechanical-type back pain, you should begin doing a little exercise to help regain lost strength and mobility─without placing compression or leverage on the lumbar spine and without contraction of hip flexor muscles that tug on lumbar vertebrae. Care must also be taken to avoid forced or excessive flexion or extension of the lumbar spine. Here are two starting exercises that can be done safely and comfortably by anyone.

  1. Get down on your hands and knees. Arch your back up and down several times with slow, deliberate movement. This alternate contraction of abdominal and back muscles with flexion and extension of your spine will loosen spinal joints and tone muscles supporting your spine.
  2. Lie on your back with your knees bent, your feet flat on the floor, and your arms at your sides. Lift your body from the floor so that your weight is supported by your feet and your shoulders to form a bridge. Work up to 12 to 15 repetitions. You can increase the resistance of the exercise in a progressive manner by placing a little weight over your lower abdomen and holding it in place with your hands.

 

Healing is a matter of time, but it is sometimes also a matter of opportunity.

— Hippocrates, 400 B.C.

 

Posted in: Chiropractic, General, Science and Medicine

Leave a Comment (64) ↓

64 thoughts on “Low-Back Pain: Causes, Care, and Consequences

  1. Looks like I stumbled onto about.com

  2. cervantes says:

    Our main problem, of course, is that we aren’t intelligently designed. We’re descended from creatures that walked on four legs, whose spines were horizontal. Now the lower back has to bear a compression load and it just doesn’t hold up very well over a lifetime of walking and running and jumping and carrying stuff. Maintaining good strength in the abdominal and back muscles by appropriate exercise definitely helps, however.

  3. Adam Rufa says:

    Sam,

    Nice job overall. The more I treat patients with low back pain, and the more literature I read, the more clear it becomes that we have a lot more to learn about low back pain.

    The only points I would argue with you about are 1) ice and heat–do whatever feels better because at best they provide short term pain relief. 2) “Most of the time, acute low-back pain is the result of simple strain” How do you know this? A more accurate statement would be, most of the time we have no idea why someone has acute low back pain. It is easy to say “it is a strain” but most of the time there is no clear way to determine this. So the diagnosis of a strain is simply a garbage diagnosis and no better than non-specific low back pain.

    Another important point to make is that the most predictive risk factors for developing chronic low back are psychosocial factors not pathology and anatomy.

  4. WilliamLawrenceUtridge says:

    @Adam

    Do I detect shades of Tension Myositis Syndrome in your response? I’d love to see a citation supporting your final statement.

  5. CarolM says:

    “ithout placing compression or leverage on the lumbar spine and without contraction of hip flexor muscles that tug on lumbar vertebrae”

    What does this mean? I’m just a layman going through a low back pain episode right now, though mine rarely last more than a week. I think it’s caused by a strain in my exercise routine…I keep think gentle stretching will help, but it doesn’t seem to. I stretch by bending over and slowly letting my hands drop to the floor. I’m usually pretty flexible.

  6. Sam Homola says:

    Adam,

    Thank you for your input. Your credentials as a Doctor of Physical Therapy and a professor of physical therapy certainly lend credence to your views.

    Carol,

    Toe touching can place compression on an injured intervertebral disc. Supporting weight in a standing position places axial compression on the spine and its disc cartilages. Leaning over to lift an object or to raise a window places leverage on the lower back. Exercises that require hip flexion, such as sit-ups and leg raises, cause contraction of muscles that attach between the lower lumbar spine and the thighs. All of these postures and movements could possibly aggravate acute low-back pain.

  7. rmgw says:

    “Such symptoms could be caused by disk herniation,”….now I’m confused – I thought disc herniation was “out” as a cause of this stuff?

    *Anecdote alert* : I had sciatica attacks in the past and went around doing all the “careful” stuff I was told for years, but thank goodness we’re now encouraged (by Sarno’s book, in my case) to be more proactive: Pilates and Ballet for me, the only thing that gives me back pain now is gardening. Also: go for that psoas muscle, chaps, makes the world of difference!

  8. CarolM says:

    Sam, thanks. It just so happens I do *all of those* postures and movements nearly every day.

  9. After years of sitting at a desk, my lower back pain became unbearable. I started doing yoga and it has essentially transformed my life. The reason why yoga has been so helpful is because you breathe into the poses and slowly stretch out your muscles, while strengthening the core AB muscles. I def. think it can help those with acute back pain. It’s helped me .

    So yes, I’m def. in line with what Sam is saying, postures like the ones he suggested are very much a part of a consistent yoga practice :)!

  10. Matt says:

    @William:

    From JAMA:

    “The most helpful components for predicting persistent disabling low back pain were maladaptive pain coping behaviors, nonorganic signs, functional impairment, general health status, and presence of psychiatric comorbidities”

    PMID: 20371789

    I will also mention that the use of imaging for chronic lower back pain (CLBP) has been called in to question due to the poor prognostic power of the results, as well as the presence of degenerative changes in asymptomatic individuals (PMID: 21952189 ). The biomechanical model of CLBP has also started to give way to a biopsychosocial model due to the modest effect sizes of treatments targeting specifically mechanical factors, as well as observed symptom improvements in patients regardless of objective improvements in, say, core strength or endurance.

    My main point is: acute pain is a much different disorder than chronic pain and should be dealt with differently.

  11. Adam Rufa says:

    “Thank you for your input. Your credentials as a Doctor of Physical Therapy and a professor of physical therapy certainly lend credence to your views.”
    I appreciate that but please don’t give me too much credibility because of my credentials. I would not want to be caught here making an argument from authority!

    William: Not a Sarno guy but the literature is trending towards psychosocial issues being an important part of low back pain. Where Sarno goes wrong is trying to come up with a peripheral explanation for the influence of psychosocial factors on pain. I think Melzack makes a much stronger argument with his neuromatrix theory of pain. http://www.ncbi.nlm.nih.gov/pubmed/17177754. Maybe my last sentence would have been more accurate if I said psychosocial factors are one of the most predictive factors of chronic low back pain.

    I will admit that the evidence could be stronger but the trend seems be towards the importance of psychosocial issues. http://www.ncbi.nlm.nih.gov/pubmed/15653082, http://www.ncbi.nlm.nih.gov/pubmed/16641782, http://www.ncbi.nlm.nih.gov/pubmed/8747248, http://www.ncbi.nlm.nih.gov/pubmed/15990670

    I did cherry pick some and there are articles which don’t support this correlation: http://www.ncbi.nlm.nih.gov/pubmed/17334295

    There is also pretty convincing evidence that the pain perception is highly influenced by a persons expectations, past experience and state of mind. I am away from my desk so I don’t have all my references in front of me but there are many.

  12. Geoff says:

    Interesting that there is no mention of “footwear,” “shoe” or “gait” in this post. One might get the impression that you’re missing the point.

  13. icewings27 says:

    What about acute pain that is caused by injury? In my case, a herniated L4-L5 due to a hockey check that causes serious sciatica all the way down my right leg. I’ve had six months of incredible pain, day and night, I’ve had the MRI to confirm the problem, I’ve done PT, drugs, and steroid injections. Nothing helps. Not even 1% of the pain has been relieved.

    I firmly believe I will get better with time, but I don’t have the patience to wait any longer. What else can the medical community do for me? I am considering surgery. But everyone I know says, “No! Don’t have back surgery!”

    btw, every time I google “sciatica” I get all kinds of SCAM sites. Low back pain is a real money-maker!

  14. EricG says:

    Geoff

    Interesting that there is no mention of “footwear,” “shoe” or “gait” in this post. One might get the impression that you’re missing the point.

    how tantalizing. do tell, what is the point implied to be missed?

  15. @EricG,

    I think the point Geoff was making was that this is an absolutely worthless article on SBM. It’s a simplistic explanation of generic back pain that has almost no relevance to actual clinical experience. I particularly loathed the part that if an orthopedic or neurosurgeon suggests back surgery that they should get a second or third opinion. I wouldn’t listen to a family doctor’s opinion on back surgery, much less that of some para/pseudo “doctor” such as a PT or chiropractor.

    P.S. The “psychosocial” aspect of developing chronic back pain in America is basically this: “Are you poor with a manual labor job? Ok you will likely develop chronic back pain.” Or, perhaps more frequently, “Oh, you fell down after spraining your ankle 17 years ago, and now you want to be on disability so that the rest of America can support you while you sit back and collect your measly check and do nothing? Also thank you for not having bathed in the last week, I’m sure my patients enjoyed sitting next to you in the waiting room.”

  16. Harriet Hall says:

    @Skeptical Health,

    “It’s a simplistic explanation of generic back pain that has almost no relevance to actual clinical experience.”

    It seems to me that it’s as good as any other explanation, and you don’t have the right to criticize unless you can offer what you consider to be a better, less simplistic explanation. And the whole thing comes out of the author’s lifetime of relevant clinical experience treating mostly back pain patients.

  17. Harriet Hall says:

    @Skeptical Health,

    “thank you for not having bathed in the last week”??

    Where did that come from? Anyone who has that kind of contempt for suffering patients shouldn’t be treating them.

  18. tmac57 says:

    CarolM- Having been a lower back pain sufferer for over 35 years, my anecdotal experience is that walking, for about 30 minutes or more per day, can loosen up the muscle spasms that are trying to contract your lower
    back. For me,when my back is ‘acting up’, the first 15 to 20 minutes of walking can be awkward and painful,but if I push through it, the spasms start to relax,and by 30 minutes,I am feeling much better.Don’t try to walk too fast,and wear footwear with adequate cushioning,and avoid standing in one place too long on a hard surface .
    I know everybody is different,but this works for me,and it doesn’t involve any expense , complicated technique, or medication,so it’s worth a try.Hope it helps.

  19. @HH, how many Medicaid patients did you treat while working as a Family Physician in the military?

  20. Sam Homola says:

    SkepticalHealth,

    It goes without saying that a recommendation for surgical excision of a herniated disc would warrant a second opinion from an orthopedist or a neurosurgeon, not from a family physician!

    I cannot imagine anyone undergoing such surgery without getting a second opinion from an appropriate specialist. Disc surgery is sometimes done prematurely or unnecessarily.

    “Within the first 3 months of low back symptoms, only patients with evidence of serious spinal pathology or severe, debilitating symptoms of sciatica, and physiologic evidence of specific nerve root compromise corroborated on imaging studies can be expected to benefit from surgery. With or without surgery, 80 percent of patients with sciatica recover eventually. Nonphysical factors (such as psychological or socioeconomic problems) may be addressed in the context of discussing reasonable expectations for recovery.” (Acute Low Back Problems in Adults, AHCPR Publication No. 95-0642, 1994)

  21. @Sam Homola,

    1994 :) I’m sure any orthopedist or neurosurgeon who hasn’t read a book in the last 18 years appreciates you keeping them up to date.

  22. Harriet Hall says:

    @SKeptical Health,

    “HH, how many Medicaid patients did you treat while working as a Family Physician in the military?” Irrelevant.

    “any orthopedist or neurosurgeon who hasn’t read a book in the last 18 years appreciates you keeping them up to date.”

    Sarcasm does not contribute to a substantive discussion.

  23. tapertaper says:

    Read Stuart McGill for science on lower back pain.

  24. Sam Homola says:

    SkepticalHealth,

    My back-pain article was not designed to offer advice to orthopedists and neurosurgeons. It was clearly designed to offer simple and basic guidelines for lay persons who might need help in recognizing and avoiding misinformation that might result in inappropriate care for an acute back problem and other symptoms related to back pain, especially when it comes to “alternative medicine practitioners who tout a spurious quick-cure treatment based on a dubious diagnosis.”

  25. egstra says:

    I would also agree that gentle yoga (NOT power yoga or other such nonsense) can be useful, as can other forms of gentle stretching, and walking.

    My experience working in a rehabilitation hospital (as a psychologist) would suggest that there are two types of people with low back pain… those who find ways to set the pain aside somehow, and those who find it useful in some way. We used to ask the question; “How would your life be different without this pain?” Those who looked startled and said, “I wouldn’t hurt” were very different than those who said, “Oh, everything would be wonderful and I could run for president.”

    That is not to suggest, btw, that the pain was other than physical in origin.

  26. Steve says:

    Sam
    Please note this advice in your otherwise excellent discussion. Since this is what I do for a living I though it might help to mention.
    “cramping leg pain that occurs only when you walk and is relieved by rest (intermittent claudication), might be an indication of diseased arteries. Your family physician might want to refer you to a vascular specialist in order to differentiate vascular claudication from neurogenic claudication caused by spinal stenosis.”

    Neurogenic claudication has two simple rules that may help a person know what specialist they should see first.
    Again, in general and for lay persons. Vascular Claudication suffers describe a progressive leg cramp relieved by stopping and standing still, or worsening when climbing stairs. Spinal stenosis/nuerogenic claudication feels the same but is often relieved by leaning forward on something while walking, and unlike vascular worsens when standing still, but usually does not affect stair climbing. We often call it positive shopping cart sign.

    At the recent NASS meeting the number often quoted is 90% of patients recover in 9 months independent of any treatment.

    I would like also like to say the discussion about imaging in the above comments is for the most part irrelevant. Imaging is used to rule out horrible or bad things IE cancer/infection. Other than those general items it doesn’t guide treatment. MRI-CT-radiographs are descriptors of what can be done, not what should be done. Most people do not understand that spinal surgery is not restorative it is reconstructive. A person with a massive disc herniation and no symptoms should not have surgery anymore than a person with massive pain that has minor disc bulging.
    Bottom line, in my opinion, is that most people heal and we help manage the symptoms until they do. In the small percentage who fail to heal AND have a repairable mechanical problem that fits with the symptomatology we do surgery. This is in the framework of what is called uncomplicated acute mechanical back pain(or call it strain). Neurologic deficits change the ballgame, but not as much as some might think.

    Adam
    The psycho-social component is an interesting discussion but not very helpful many high profile spine groups require a psychiatric eval and treatment before considering surgery. Their statistical success is about the same. I would like to say that most people have some form of Psychosocial issues therefore it is kind of a broad and suspicious confirmation bias statement to say that it overrides anatomy and pathology. Chronic back pain rates in idopathic scoliosis and vetebral compression fractures have good data that supports anatomy and pathology over psychosocial. I will freely admit anecdotally that significant social or psychiatric issues are poor prognostic indicators. What is not anecdotal is that Workers Compensation injuries have recoveries that take 4 times longer. Very good research to back that up.

    Worker Recovery Expectations and Fear-Avoidance Predict Work Disability in a Population-Based Workers’ Compensation Back Pain Sample
    Spine:
    15 March 2006 – Volume 31 – Issue 6 – pp 682-689
    doi: 10.1097/01.brs.0000202762.88787.af

    Health Services Research
    Association Between Compensation Status and Outcome After Surgery
    JAMA.
    2005;293(13):1644-1652. doi: 10.1001/jama.293.13.1644

    @Skeptical Health
    I and my partners do frequently recommend 2nd opinions, although I will admit to steering them away from surgeons who have a very low threshold for surgery.

  27. Sam Homola says:

    Geof,

    I did not mention shoes, gait, etc, in my article since the article deals primarily with acute back pain of less than 3 months duration. Foot posture-problems can certainly play a role in chronic back pain.

    There is a difference between acute and chronic back pain. As noted by Matt, “Acute pain is a much different disorder than chronic pain and should be dealt with differently.”

    Some of the postures and movements that might aggravate acute mechanical-type back pain might be helpful in relieving the symptoms of chronic back pain, as noted by egstra in the case of yoga.

    Sorry that I did not clearly distinguish the difference between the care required for acute back pain as opposed to chronic back pain.

  28. Sam Homola says:

    Steve,

    Thank you for your interesting and helpful response to questions raised by my article. I hope that other professionals on this list will be as objective as you have been in providing helpful information for lay persons suffering from back pain and related symptoms. I greatly appreciated your considerate discourse.

    Sam

  29. @HH,

    I appreciate that you make a snide comment to me based on my experience with Medicaid patients when you, in fact, have never dealt with a single one. I fully expect you to be as catty as you were with Linda Rosa, so go ahead and save yourself the time.

    @Sam,

    I agree whole-heartedly and appreciate your manners when I show none. It just seemed like a somewhat out of place article for SBM.

  30. Chris says:

    When I have had lower back pain my evil doctor prescribed exercise! Well, along with some ibuprofen and cold/heat, plus lots of time. One exercise, which is what I do if my back starts to feel wonky, is to lie on my stomach sometimes with a heating pad across my back.

    Geoff, my evil doctor also told me to get good arch supports for my shoes. Which I now always use.

    Adam, the worst and longest time I had back pain started before Christmas. I attributed it to all of the extra duties I have thrust on me as a parent of young children (and getting a toddler in and out of a car seat did not help). That year I just supervised the tree decorating, It took six weeks for the pain to go away. So I did lots of reading, and watched a few movies using a laptop on the floor.

    My doctor is not really evil. Even though when I got hiker’s knee he prescribed even more exercises. I also realized that was the reason why I need to keep my legs straight when swimming with a flutter kick.

  31. Adam Rufa says:

    I am posting this without the links because it has been waiting moderation for some time:

    “Thank you for your input. Your credentials as a Doctor of Physical Therapy and a professor of physical therapy certainly lend credence to your views.”

    I appreciate that but please don’t give me too much credibility because of my credentials. I would not want to be caught here making an argument from authority!

    William: Not a Sarno guy but the literature is trending towards psychosocial issues being an important part of low back pain. Where Sarno goes wrong is trying to come up with a peripheral explanation for the influence of psychosocial factors on pain. I think Melzack makes a much stronger argument with his neuromatrix theory of pain. Maybe my last sentence would have been more accurate if I said psychosocial factors are one of the most predictive factors for developing chronic low back pain.

    The evidence could be stronger but the trend is clearly towards the importance of psychosocial issues. (Jarvik et al spine 2005, Carragee spine 2005, Grotel spine 2006, Gatchel spine 1995) Not to say that pathology and anatomy are never important but most of the time they are only part of the story.

    It seems we tend to forget that pain is not produced by tissue damage. Pain is a perception generated by the brain which can be triggered by nociception but is not always triggered by nociceptors. There are several studies which show that the perception of pain can be greatly influenced by other inputs to the brain (fear, expectation, catastrophizing, depression, visual etc..). I think it would be more surprising if psychosocial factors were not significant players in chronic low back pain.

    Steve: Maybe it is not very helpful in determining success of spine surgery but there is a good deal of evidence that it is predictive of overall disability (even more than pathology and anatomy in most of the studies have has read on the topic) .

  32. Alia says:

    From my personal experience – one of the causes for lower back pain may be sit-ups, if you are not careful with keeping the proper bodily posture. And especially if you are doing some exercise regimen like Weider 6. I go to a fitness club twice a week and our trainers always check whether we are doing the sit-ups properly.

    I had an episode of lower back pain once. It went away on its own, I just used some anti-inflammatory cream (probably would go away without it but I wanted to feel like I was doing something). And then I lost 50 pounds and haven’t had any back pain since then.

  33. William B'Livion says:

    “”"
    I cannot imagine anyone undergoing such surgery without getting a second opinion from an appropriate specialist. Disc surgery is sometimes done prematurely or unnecessarily.
    “”"

    What were my alternatives here:
    http://img571.imageshack.us/img571/6044/neckt.png

    Because i didn’t get a second opinion and had surgery 2 days after this MRI was taken.

    I had numbness in both hands, weakness in both triceps (which was not from what was shown here BTW, there were other things that a trained neurosurgeon could see that I can’t) and had some control “issues” with my hands.

    So yeah, I generally agree with you that second opinions are generally a good thing before surgery, sometimes the facts are SO clear that that’s just wasting time and money.

    @cervantes:
    “”" We’re descended from creatures that walked on four legs, whose spines were horizontal. Now the lower back has to bear a compression load and it just doesn’t hold up very well over a lifetime of walking and running and jumping and carrying stuff. Maintaining good strength in the abdominal and back muscles by appropriate exercise definitely helps, however.”"”

    It’s not the running and jumping and carrying stuff that f* us up. it’s the sitting staring at the screens on our desks, the sitting staring at the TV and the sitting around the dinner table stuffing our faces and then once month doing something vaguely physical. Running, jumping and picking heavy shit up routinely (e.g. doing the sort of stuff that is “Maintaining….”) will help prevent some of the chronic lower back pain caused by poor posture and “imbalanced muscles” (no, not some new-age hokey shit, but the notion that if you focus, for example, only on building your chest muscles (flys, pullovers, bench press) and not your back (low and high rows, face pulls etc.) you get musculature that is out of balance. It is double plus ungood when you do these things with bad form–which unbalanced musculature and tight joints can exacerbate.

    I had sciatica diagnosed a couple years before the above MRI was taken. A couple visits to the PT and daily exercises cleared it right up. I still do those exercises from time to time just to make sure.

    The problem is most folks do not want to exercise. They don’t want to move from a sitting desk to a standing desk or a “walking desk” (and most employers are loath to spend the money). They want a pill, or surgery, or some sort of magic (reiki, accupuncture, etc.) to fix it. This *might* be one area where careful chiropractic intervention could be useful, but unfortunately it teaches the patient the wrong lesson–that whatever’s wrong can just be fixed by a “re-alignment” when in fact what is needed is a little more muscle tone, a little less flab.

    There’s a lot of things that cause chronic pain, and it’s really unwise to generalise cases like this, but it *does* seem that move more hurt less is a good approach.

  34. William B'Livion says:

    @ Matt
    [quote]
    I will also mention that the use of imaging for chronic lower back pain (CLBP) has been called in to question due to the poor prognostic power of the results, as well as the presence of degenerative changes in asymptomatic individuals (PMID: 21952189 ). [/quote]

    When I went to see the orthopedist about my sciatica (see previous post once it clears moderation) we had a short discussion, and he looked at my x-rays. There was a discussion about the use of an MRI to get a better picture, but he (in a fairly leading way) discussed what would happen if we found something in the image, v.s. how we would approach it w/out an image. Since we were both of the mind that conservative interventions were more appropriate (meaning PT etc.) first, there was no reason to image unless the PT did not work.

    I think generally this is the right approach. Sometimes, however the evidence goes the other way.

  35. Chris says:

    Then there is this cause of lower back pain. Even more reason to keep exercising to keep back muscles stronger.

  36. Matt says:

    Steve,

    From Adam’s latest post

    “There are several studies which show that the perception of pain can be greatly influenced by other inputs to the brain (fear, expectation, catastrophizing, depression, visual etc..)”

    This is what I was referring to in my post regarding imaging, and I was referring specifically to chronic lower back pain. Given that medical scans seem to be of poor prognostic value and degenerative findings are not necessarily indicative of a patient’s experience of pain, it seems to me to be a waste of valuable time/money and can contribute to a patient’s fear of lifelong chronic pain and the expectation of little to no resolution of the disorder. This is not to say that imaging should not be performed in the case of acute pain when strongly indicated by red flags (@William). I do not think it is irrelevant that superfluous imaging is being recommended when there is not good evidence to support it. PMID: 21952189, 9388145

  37. DavidRLogan says:

    Sam,

    Great point about toe-touching! I see that recommended by PT’s and online gurus quite often, and I don’t think it’s a great idea, either.

    In any case, toe-touching doesn’t address the source of tight hamstrings. Those three are tight because we’re constantly in pelvic flexion (sitting, etc.). Stretching the illiopsoas and rectus femoris (and activating the glutes and abs, as many have already said) will go much farther toward fixing tight hammies, without the danger of toe touches (I think toe touches also risk the stability of the knee, at least in a non-athletic population). At the very least, that’s what I’ve seen help (keep in mind I have zero qualification w/r/t a serious back injury…I don’t want to endorse a universal and therefore risk the wrath of Skeptical Health…just pointing out a decent way to improve mobility rather than toe-touches)

    Good info on here. Thanks everyone.

    -David

  38. Vera Montanum says:

    Good blogpost and interesting discussion. But… not a single mention of supplemental vitamin D for recurring acute, or chronic, nonspecific back pain. There IS considerable research on this (some better than others). Among other things, subclinical osteomalacia is a common cause of nonspecific back pain, often with muscle spasms, which can be corrected by adequate vitamin D3 supplementation (2,000 to 5,000 IU/day, and usually takes 1-4 weeks). Pathologic conditions of the spine may be helped by D3, but other measures as variously noted above may also be appropriate and necessary. Again, there is reasonable quality evidence from years of research.

  39. Chris says:

    Vera Montanum:

    Again, there is reasonable quality evidence from years of research.

    Citation needed.

  40. Adam Rufa says:

    Sam,

    This is always what happens when you start talking about low back pain on the web. Just about everyone has had low back pain and everyone at least knows someone affected by low back pain. As a result there are a lot of opinions about what the best treatment is and what one should never do. But these anecdotes point out the fact that few can agree on what the correct treatment is and what one should avoid. For example the evidence does not support that shoe wear or hamstring flexibility has much to do with low back pain. PTs (such as myself) promote spinal stabilization exercises but there really is no evidence to show that these exercises are better than any other other exercise. The best general advice I can think of is keep moving, don’t worry to much about your pain and stay away from invasive procedures if you can.

    Until we figure out a way to accurately classify patients with low back pain (acute or chronic) we will continue to be confused by this group of disorders. A common analogy used is giving general advice to someone with abdominal pain without knowing the source of their problem. An appendectomy won’t help someone with a bowel obstruction yet we expect universal advice to work for everyone with low back pain.

  41. Vera Montanum says:

    #Chris to Vera Montanum: “Citation needed.”

    See research review papers on vitamin D for pain, with citations, [here] and research UPDATES discussion articles [here]. Hope this helps.

  42. Chris says:

    All by the same author, and none of them on PubMed. Could you just list the PubMed Identification numbers please. Be sure that they pertain just to lower back pain.

  43. Vera Montanum says:

    Chris… you will find many reference citations to primary research studies on back pain within those review papers to choose among, and then you can pursue the ones that are of most interest to you. Many of the research studies noted in the UPDATES articles have direct links to abstracts of the papers discussed, and from there you can obtain full documents.

  44. Steve says:

    @Adam Rufa
    Adam there is little debate that psycho-social factors impact directly pain of all types I would not debate that in any way. There is a little bit of a broad stroke to what is discussed here. My concern is related to what many people experience in chronic LBP. They feel, rightfully so, that some providers are dismissive of their symptoms because the have psycho-social issue. To be dismissive of any component either psychosocial or biomechanical is a poor practice. I think we agree, but the tone of some of your statements would give the lay reader the idea that we think LBP is all in their head. That impression is counter productive and makes them seek out magical solutions that do not work. I often tell my patients that you can get Diarrhea from stagefright, but I wouldn’t do a colonoscopy on you. I doesn’t mean that the diarrhea is not real. Rather you have to treat the cause. Currently psychological issues carry heavy stigma. I often take the more palatable tact that you have pain, stress makes it worse and it should be treated. Very few patients have the self insight to realize that it may be the primary cause. To tell them that their pain is psychogenic just makes them lose trust in your abilities and they find someone who will most likely take advantage of them. That said, Imaging is still necessary, sometimes the paranoid are being watched.
    Take this as anecdotal at best: I can role off ten patients with CLBP that I repeated imaging on revealing cancer. The imaging was repeated due to worsening of pain. Agreeably the large fraction of the imaging from that group showed no change. Not exactly cost effective, but as soon as the government extends the insulation from litigation that medical insurers enjoy I will stop ordering most of those test.

    @Matt
    See above

    I work in strange field if your doctor tells you you don’t have cancer people are thrilled, you didn’t have a heart attack… joy. Tell someone with Chronic Low Back Pain that their MRI is normal and see how that goes over.

    Please: to lay persons reading these comments understand chronic low back pain is not a disease it is a category of diseases with multiple causes and treatments. Acute back pain Keep it simple Sam offers good advice. Always get checked but realize in most cases those tests will not show much.

  45. Chris says:

    Ms. Montanum, I am sorry, but you made a claim. Therefore you need to provide the citations. Citations are the title, journal and dates of the PubMed indexed papers, not links to a blog.

    Making someone go to a website and wade through commentaries by someone who is not a scientific researcher (PhD in education) is not helpful. It just looks like you are trying to not provide evidence for your statements.

  46. Adam Rufa says:

    Steve,

    I don’t disagree with you at all and I don’t mean to sound dismissive of any patient in pain. However, we do need to realize that a big component of the problem (with chronic pain of any sort) is often a malfunction of the pain system. These malfunctions (trigger of the pain experience in the absents of a real threat) seem to be influenced by education (and possibly graded activity) which reduces anxiety and therefore minimizes the threat perceived by the sub-conscious brain. Researches such as Lorimer Moseley (www.bodyinmind.org) and Steve George are doing a lot of interesting work in this area. I encourage any person in chronic pain to read the book “Explain Pain” http://www.noigroup.com.

    I also encourage interested parties to plug Lorimer Moseley’s name into youtube and watch some of his interesting lectures on pain.

  47. DavidRLogan says:

    As I mentioned on an earlier thread I’m not a fan of Vitamin D supplementation…metabolism has too many interactions with zinc and vitamin A. Doesn’t make sense to take a huge dose of just one…here’s an abstract which approximates that idea:

    http://www.ncbi.nlm.nih.gov/pubmed/17171460

    The mechanism in that study is still being vetted but, for instance, in Zinc deficiency, retinol binding protein won’t get synthesized and vitamin A won’t be used appropriately. There’re similar interactions, I’m sure, with Vitamin D (does anyone know?). And these “vitamins” are not just inert if used improperly (!!!) I remember in high school taking too much vitamin A and lying around for a week with a horrible rash from head to toe (no joke!) Vitamin D has been improperly labeled a “vitamin”…it has prohormone like effects and is a major player in gene regulation…

    …so from my perspective it’s irresponsible to recommend these vitamins out of context from hundreds of other factors. Not to mention the quality of nutritional supplements is abysmal (sunlight will always be superior to nutritional supplements…whoops I’m a vitalist!)

    I looked at the vitamin D “references” provided (to be fair, not all of them). Many mention that vitamin D is “linked” to this or that (spinal health). That’s not the least bit surprising. Vit D is a major nutritional factor involved in thousands of metabolic pathways. However I would urge resistance to the reductionist philosophy which says INGESTING vitamin D is a solution. There are hundreds of reasons the body would run low on vitamin D and very few of them are fixable with vitamin D pills.

    Have a nice evening everyone.

  48. Matt says:

    @Steve

    “They feel, rightfully so, that some providers are dismissive of their symptoms because the have psycho-social issue.”

    Few things get me quite as ticked off as the dismissal of symptoms on these grounds, and I deal with this almost on a daily basis. In my opinion more effort should be taken with these patients for the exact reason that they are at increased risk of chronic lower back pain. Explaining the role and balance of psychosocial vs. biomechanical (anatomy and physiology) is delicate in order to ensure that you don’t give the patient (or reader) the impression that the medical community thinks the pain is “all in your head.” I’ve used the webcasts at the bottom of the following website in the past:

    http://www.lifeisnow.ca

    and the book “Explain Pain” is a great resource for patients and practitioners regarding chronic pain.

    I’m definitely stealing your diarrhea example, it’s great.

    To lay persons: I agree, always get checked if you are concerned about your lower back pain.

  49. BillyJoe says:

    I am under the impression that osteporosis does not cause back pain untill you suffer a vertebral compression fracture. Does anyone know if this is correct. I tried googling for an answer unsuccessully.

  50. mattyp says:

    I remember my first time doing a red flag screen with a real patient. Someone that wasn’t a chiropractic student. I asked them “have you had any bowel or bladder problems or saddle anaesthesia?”

    The patient didn’t have to ask me “what the hell did you just ask me?”, because the look on their face said it all.

    They were also confused as to why I was taking their temperature. Having this as a printout would be useful. :-)

    As for osteoporosis being a cause of low back pain, I see no reason as to why osteoporosis would be a cause of low back pain in the absence of compression fracture.

  51. lilady says:

    For the *missing* citations about vitamin D requirements across the lifespan, the foods that are high in vitamin D, specific blood tests to test for Vitamin D deficiency and the use of vitamin D supplements, I would defer to the NIH:

    http://ods.od.nih.gov/factsheets/vitamind-HealthProfessional/

    Scrolling down the NIH Office of Dietary Supplements website, I see there are risks associated with taking vitamin D when you rely on advice garnered from the internet.

    Here is a case study of the risks of Vitamin D hypervitaminosis. In this instance, a mistake was made by the dispensing pharmacist:

    http://www.theannals.com/content/45/10/e52.full

  52. weing says:

    @BillyJoe,

    You are correct about osteoporosis. Vitamin D deficiency causes osteomalacia which does cause pain.

  53. Pman says:

    Enthesopathy can be an underappreciated cause of LBP as well, making MRI findings irrelevant.

  54. harris.skeptic says:

    http://www.cnn.com/2011/10/24/health/yoga-eases-back-pain/index.html
    Yoga, stretching may ease chronic back pain

    “Yoga was no more effective than stretching, however. This finding, which surprised the researchers, suggests that the back-pain benefits of yoga are mostly due to its physical (rather than mental or spiritual) aspects, the study notes.”

  55. BillyJoe says:

    weing: “You are correct about osteoporosis. Vitamin D deficiency causes osteomalacia which does cause pain.”

    Ah, via osteomalacia. Gotcha. Thanks.

  56. nwtk2007 says:

    There can really be no simple answer for lower back pain. The anatomy is simply too complex. As far as I know there are 7 ligaments associated with each segment so that alone gives you 35 to 40 sources of pain, assuming you are just talking about lumbar pain, 5 discs (not highly innervated), and in the lumbar also 10 facet joints, all highly innervated. All this, not to mention the surrounding paraspinal musculature.

    (By definition, a sprain involves ligaments and a strain involves muscles. To state that most incidences of LBP are strains is a bit naive. I’ve also found that most don’t distinguish between the two or some combination. Insurance collaborators/sympathizers tend to lean heavily towards the strain diagnosis.)

    Add to the picture joint mechanics, spinal variants such as stenosis, lumbarization or sacralizations of vertebral bodies, spondylolisthesis, stress fractured pars interaticularis’s (detectable or not detectable), past medical history of repetitive use or disuse, nutritional deficiencies, metabolic disorders, etc, etc and you have a pretty difficult picture to deal with. I haven’t even mentioned the neurological factors that might be involved.

    Additionally, with literally millions of permutations of the different possible combinations in which these elements might be responsible for pain and you can see the true difficulty and possibly begin to understand the ubiquitous nature of lower back pain.

    To me, functionality is the ultimate key to treatment and relief. I find that the most sedentary individuals have the greatest difficulty dealing with LBP and that although they might experience pain, the active individual is much better equipped to deal with it. Add in exercise and stretching with proper warm up prior to both and one can help people developed a regime which diminishes their LBP and allows them to be better at dealing with it if chronically afflicted.

    I really liked the comment regarding the notion that we are not intellegently designed. In fact, I would argue that if we are designed, we are designed to ultimately fail/breakdown. Who knows.

    As to treatment I have found that the simplest treatments and combinations of treatments seem to work the best but each patient is a bit different. From a doctors standpoint, I find that the do it yourself approaches to treatment and prevention are the least effective; for example getting a patient to lose a bit of the extra 50lbs they are carrying in addition to getting them to exercise/stretch/etc is much more difficult than getting them to change religions. But if I hover over them and really get them to doing something in addition to a bit of therapy then they stand a chance of improvement. But as was alluded to above, many might then find that they are no longer disabled and would thus be able to work. Heaven forbid!

  57. Sam Homola says:

    It has been my observation that run-of-the-mill acute low-back pain is most often the result of a simple joint or muscle strain, which is sometimes complicated by structural abnormality.

    A low-back ligamentous sprain may involve tearing or stretching of ligaments and is a painful, incapacitating injury that may require emergency medical care or hospitalization.

    While a patient may recover from a simple muscle or joint strain in 4 to 6 weeks (90 percent recover within one month), a torn muscle or a joint sprain may require a very long time for recovery, often resulting in some degree of disability.

    Although the exact structures involved in the production of acute uncomplicated mechanical-type low-back pain may not be known, a diagnosis of “strain” may be used to imply that a sprain or some other serious injury has not occurred.

    Just my opinion; no references.

  58. elmer says:

    How come I don’t get lower back pain? I get pain all over my frigging body, but I think I’ve experienced maybe a month of lower back pain in my entire life. What am I, some kind of freak?

  59. elmer says:

    btw, I don’t do yoga (I looked into it once, but it struck me as overly and arbitrarily complicated); however, as I understand it, it’s a pretty difficult discipline, and one shouldn’t be expected to master it in 3 months…

    Anyway, I definitely am down with the yoga concept of “oneness,” which seems like something I go for in my own pain control. I’m sure someday somebody will come up with some sort of objective evidence for the phenomenon, using one of those brain-scanning toys that are so popular nowadays.

  60. nwtk2007 says:

    Don’t worry elmer, you’re not a freak if you have never had LBP, just lucky. I can say the same thing about neck pain out side something that just pops up for a few minutes here and there. Two motorcycle accidents, water skiing spills at 60ish mph, football, etc, etc and nary a neck pain. But the lower back has at times been outrageous.

    Mr Homola, I would agree that is the everyday world of pop up LBP, most of the time the problem is minor strain but one cannot discount pre-existing conditions or previous injuries and their occasional and subsequent aggravation, which, in legal terms, constitutes a new injury. So, in most cases, I would have to be a bit hesitant to diagnose non-complicated lower back strain, but I essentially agree with what you have said.

    I would disagree with you that in cases of true sprain injury that disability results. As a side note, disability is determined by a judge, but the true loss of ability is impairment, meaning that one might be limited in performing a function yet is still able to perform others and can, in theory, continue to work, even in some heavy and demanding occupations. Disability is also a free check for money with inducement not to try to work.

    I have also found it interesting that the doctors insurance carriers prefer to do peer reviews or “impairment ratings” will, inevitably, diagnose a strain, even in the face of a highly symptomatic disc in which a neurologist has recommended specific care for.

  61. I’m late to the commenting party! For those still following along, here’s a couple contributions.

    For fun, get a load of this appallingly bad Dr. Oz segment about chiropractic and back pain. It’s a 5-minute parade of myths and nonsense. At its maximum badness, Oz knocks over a stack of cardboard boxes and declares, “This is what happens to the spine” — possibly the most hyperbolic perpetuation of the myth of spine fragility I’ve ever seen. Even cutting it some slack as a cute bit of theatrical hyperbole, it’s just awful, and exactly the opposite of what people need to know about back pain. Even subtracting the chiropractic stuff, this is just barmy back pain information.

    Low back pain correlates rather poorly with frank trauma and any identifiable “structural” problems. Lots of people have nasty pain without any “oh sh*t” moment of injury. It’s not that there’s no such thing as a back “strain” or disk herniations, but I do feel that such mechanisms have been exaggerated. Meanwhile, the “psycho-social” perspective gets exaggerated and distorted as an alternative (and it particularly gets confused with a more strictly psychosomatic, Sarno-ian all-in-the-head view). So I wrote an e-book about back pain — plug plug plug! — that mostly champions a compromise perspective: it’s not structural, it’s not psychosomatic, but a kind of hybrid. No cure for sale: just low back pain education from one evidence-based perspective. Many, many, many references. :-)

  62. elmer says:

    The “hybrid” would be “bio-psycho-social” (which I thought was pretty standard), no?

  63. Sam Homola says:

    Thanks for sharing the news about your back-pain book, Paul.

    Readers of SBM can rest assured that Paul’s work is objective and evidence based—in keeping with the standards of science-based medicine.

  64. Thanks, Sam!

    Elmer, I’m certainly not claiming that a “hybrid” view (bio-psycho-social) is original or exotic. :-) Among the back pain intelligentsia, blending perspectives is more or less an inevitability. However, that doesn’t mean there isn’t plenty more to say about it. It’s complex — that’s the point — and its implications certainly need to be explored and discussed. At length. Book length!

    My answer also depends on what you mean by “standard.” It’s easy enough for any clinician to agree that back pain is indeed ever-so multifactorial. However, you sure wouldn’t know they have embraced it from the things that they tell their patients! In practice, in so-called “common sense,” and in “conventional wisdom” the structural perspective is still dominant to an almost absurd degree. Dr. Oz’s video was a beautiful example of that. And so are countless other more legitimate sources of information. For instance, those scary spine models are still seen in offices across the land, even though they greatly exaggerate the clinical importance of herniation!

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