This week we are going to start another series. I’m going to classify the next few posts as our clinical series. Our first post in this series, we are going to discuss Low Back Pain (LBP). As a chiropractor of over 20 years, this is a symptom (notice that I did not say condition) that I am extremely familiar with and have had the honor of treating and helping people work through numerous times. Some of the statistics on low back pain are staggering:
- Upwards of 80% of people at some point in their lifetime will experience low back pain
- LBP is the leading cause of work limitations globally
- LBP is one of the most expensive conditions to treat in aggregate — accounting for over $100 billion in care each year
- 69% or every 7 in 10 adults experience recurrent LBP within 12 months after recovery
- Conservative therapy (chiropractic, physical therapy) is perceived to be the most effective treatment for back pain — and it reduces the costs of back pain treatment by 72% within the first year of treatment.
These statistics demonstrate that collectively though we spend a tremendous amount of money on treating low back pain (LBP), we ultimately have done a poor job of treating and managing LBP. There are many things that can result in LBP. The most important factor in being able to successfully treat and manage LBP is understanding its cause. Therefore, a proper evaluation and assessment is vital in the ability to have an opportunity to provide the proper care and ultimately have positive outcomes for LBP. Far too often, we depend upon imaging (x-ray, MRI, etc.)
Currently within our medical model of healthcare, we feel the need to always classify a condition from a pathoanatomical standpoint. What does this mean? It means that in order for there to be a reason for someone to be suffering from lower back pain there must be some form of structural injury or deformity. Most commonly the intervertebral disc will be blamed for lower back pain. What we often hear referred to as a “slipped” disc, “bulging” disc, or “ruptured” disc. Though the disc certainly can be a causative factor for lower back pain, research shows that it may be responsible up to 60% of the time, there are many other factors that we need to consider and assess for causative factors of lower back pain. In addition, lower back pain is more often functional in nature than it is structural. Unfortunately, our current medical model places so much weight and emphasis on structure. Too often, we place the role of diagnosis on imaging such as an x-ray or MRI, instead of making a clinical diagnosis that is determined by a clinician. This is not to say that imaging does not have a place in our diagnosis and treatment plan in consideration of lower back pain. However, these tests should be reserved to help confirm a diagnosis when necessary or if there has been a direct causative factor of the LBP such as a traumatic injury or event. They are also necessary when there is a neurological component to lower back pain, such as muscle weakness. However, this is not very common with research stating an involvement of typically between 3-8%, meaning that 92-97% of the time there is not a true neurological involvement.
The fact that we spend $100 billion dollars annually on LBP along with the fact that 69% (7 out of every 10) adults will experience recurrent LBP within 12 months after recovery demonstrates the fact that we either do a poor job of treating this condition or that we do a poor job of independent care following recovery or a combination of both. I think that it is likely the combination of the two that leads to these staggering numbers. In order to successfully treat and manage LBP, we need to:
- Have a sound understanding of what is causing the LBP through a proper workup and assessment of the condition (again LBP is the symptom, not the diagnosis)
- Properly educate to help those who are experiencing LBP understand why they are having LBP and what they can do to reduce strain to their lower back
- Have treatment plans that approach long term solutions in place of short term relief
Certainly, there are times where low back pain is directly associated with an injury or trauma that has resulted in structural deformity such as a disc herniation, fracture, dislocation, etc.; however, this is more the exception rather than the rule. Every day I hear “I do not know why my back is hurting, I did not do anything or recall any type of injury”. The reality of this statement is that it’s not typically what occurred in the last day, week, or even month that has resulted in our lower back pain. It is more often incremental, cumulative stress over long periods of time that result in us eventually experiencing LBP. This is also why upwards of 80% of us at some point in our life will experience LBP. If LBP required us to have a direct injury or trauma to our lower back this percentage would be much lower, as many people go through life without ever experiencing a direct injury or trauma to their lower back. Given this fact, we need to have a greater understanding of what can contribute to increased demand or strain to our lower back over extended periods that can increase our risk of lower back pain. Commonly, the lower back tends to be more of a “victim” than a “criminal” when it comes to experiencing pain in this region. In other words, LBP often is a result of the low back having to compensate for a loss of function somewhere else in our kinetic chain. This increased strain from compensation then leads to overwork and overuse of the lower back, which over time leads to an increase in risk of pain and injury. As previously discussed in our joint-by-joint post, the primary role of our lower back is to provide stability over mobility. The two major contributors to lower back pain in our kinetic chain are the hips and the thoracic spine (mid back). The primary functional role of our hips and thoracic spine is to provide mobility. However, as a result of postural stress, previous injury, sedentary lifestyle, etc. there is a tendency for us to lose mobility in these regions. Loss of mobility in the hips and/or thoracic spine will result in an increased mobility demand on our lower back.
The two motions that are most commonly associated with low back pain and injuries are flexion (forward bending) and rotation (turning to the left or right). Ironically, enough the thoracic spine and hips are the two primary regions that allow our body to rotate. In addition, our hips are also the primary region that allows our body to flex or bend forward. When discussing these functional roles of the hips and thoracic spine, it becomes more obvious as to the role that limitations in these regions could be direct contributors to lower back pain and/or injury. A loss of mobility in the hips and/or thoracic spine that limits are ability to rotate, or flex will increase the need to create compensatory movement in these directions in our lumbar spine (low back) to help maintain our overall global range of motion in these directions. The increased compensatory motion from the lumbar spine with rotation and flexion results in increased shear stress to the anatomical structures including the intervertebral discs and joints, which increases the wear and tear to these structures increasing their risk of degenerative changes such as arthritis. Certainly, given longer periods of time on the planet (how I like to talk about getting older) we are not going to avoid some breakdown in the form of arthritis to our joints. However, we can help to reduce some of the increased demand to these areas that can accelerate these processes by maintaining good mobility in our hips and thoracic spine to reduce the stress on the lumbar spine. It is not by chance that the most common areas for disc injuries or arthritic change to be found are in the lower lumbar spine at L4-L5 and L5-S1 (there are 5 vertebrae in our lower back, L1-L5, S1 refers to the upper portion of our sacrum, which is the bone that connects our spine to our pelvis). This region is highly involved as it is the portion of our spine that is closest to our hips, when we lose mobility in our hips which limits our ability to forward bend (standing and bending to reach towards the floor), as a result we displace more stress to this area of our spine. In addition, when we couple that with a potential loss of rotatory (turning to left or right) motion in the hips and/or thoracic spine, we displace a significant amount of increased strain to our lumbar spine. Considering the lumbar spine rotates only 5 degrees in each direction, any loss of rotation in the regions above (thoracic spine) or below (hips) will significantly increase our risk of injury through increased shear stress to our lumbar spine. Again, the most common mechanisms for injury in our lower back are bending, lifting, and twisting. Do you think if we could reduce the strain associated with bending and twisting by maintaining mobility of our hips and thoracic spine this may result in decreasing our risk of lower back pain or a potential low back injury?
There are many factors that can increase the likelihood of decreasing the mobility of our hips and thoracic spine, some of these factors include:
- Sedentary Lifestyle
- Prolonged periods of sitting
- Poor Posture
- Previous injury
In addition, to the above noted factors, mobility in our thoracic spine and hips is closely related to “core” stability. The purpose of our “core” is to provide a solid foundation through good stability for our body, particularly our joints, to be able to effectively move around. As a result, poor hip and thoracic mobility can be directly related to poor stabilization. For example, poor flexibility of our hip flexors and hamstrings can be a direct correlation to poor “core” function resulting in poor stability. The tension occurring in our hip flexors and hamstrings can be a protective mechanism to create artificial stability by tightening up these muscles to compensate for the poor function of our proper stabilizers. The tension in the hamstrings and hip flexors that can be created to compensate for poor “core” function can result in a reduction of hip mobility and as a result we can displace more strain to our lower back, which is already compromised as a result of poor “core” function and stability. This series of events can significantly increase your risk of lower back pain and injury. Frequently, I will hear someone state that they do not understand how they can continue to be so tight as they stretch all the time. This typically is related to the fact that their issue of being tight is not a result of tight or stiff muscles, but an issue of an increase of tone in the tissue in an effort to compensate for the lack of stability. In other words, the tight muscle creates a form of artificial stabilization to compensate for the lack of true core stability. As a result, stretching or mobility-based therapies will not have a significant effect on reducing this form of muscle tension from increased tone as we need to address the stability issue to remove the increased tone to help decrease the stiffness and decrease of mobility.
How do we know if low back pain is related to a mobility issue in the hips or thoracic spine and/or a stability issue in the core? The key is to assess these areas in addition to the lower back when evaluating someone who presents with lower back pain. Too often, the medical model focuses on the area of pain and does not look any further. Often, individuals with LBP are assessed briefly and then sent for an x-ray and/or MRI for further testing that then shows some form of structural deficiency typically in the form of arthritic change of a joint or disc, or both. Once this is determined, it becomes the focus as the cause of pain and then the treatment focuses solely on pain management. The first line of treatment typically is with either OTC (over the counter) or prescription anti-inflammatories (ibuprofen, naproxen, prednisone) and muscle relaxers. Since these medications do not often treat the causative factor(s) of low back pain, they often provide short term relief at best. As a result, many times individuals will be referred for pain management that involves a steroid injection, or epidural to attempt a more local anti-inflammatory. Again, this treatment is focused on reducing pain and inflammation and does not address the underlying probable mechanical issues that are causing the pain and inflammation. Sometimes, these procedures will provide some benefit as to pain relief, however often in time the pain will return (recall the 69% recurrency rate) in a short to moderate period of time, as the low back continues to be overworked as a result of continued compensatory stress without the issues leading to compensatory stress (hips, mid back, core) being addressed. Ultimately, if these procedures fail patients are often found in surgical rooms receiving surgical intervention to “fix” their problem. There is a high failure rate to low back surgeries for a reason, as mechanical low back pain is often a result of other factors overworking and overstressing the lower back that have still not been addressed.
My point in discussing this typical progression of medical care for lower back pain is not to say that there are not times where these procedures are necessary and appropriate and ultimately the best decision for low back pain. However, I do believe that just as research shows conservative management in the form of chiropractic and physical therapy is frequently the most effective form of treatment for lower back pain (while reducing health care cost by 72% within the first year). There will always be a need for invasive care including epidurals and surgery and I have referred out for these procedures’ multiple times. These procedures are best reserved for acute cases of lower back pain that are related to trauma or injury, including fracture, dislocation, and herniated discs with a neurological component, where the disc is impinging or compressing a nerve and is unable to be managed through conservative approaches. Especially when there are hard neurological findings from the pinched nerve including weakness or loss of muscle tone from muscles that are supplied by the nerve that is being impinged. Without trauma or injury and when there is no neurological involvement, treatment should be focused on conservative management that assesses and addresses all the potential underlying contributing factors to low back pain. In these cases, low back pain and inflammation are typically a result of the compensatory stresses that we have discussed and as such we need to discover if this is the case through a proper mechanical assessment. Treating pain and inflammation without determining what is causing the pain and inflammation is the equivalent of cutting the cord to the fire alarm on a house that is burning down. Pain and inflammation, just like the fire alarm, are present to tell us when something is not right. As a result, though reducing pain and inflammation should be a portion of the treatment plan obviously, we also need to determine factors that could be causing or exacerbating the inflammation and address these factors as a portion of the treatment plan as well.
The first step in determining what the best treatment approach will be is to discover what is causing or contributing to pain. This is done through a thorough evaluation that not only assesses the area where pain is presenting, in this case the lower back, but also areas that could contribute to lower back pain. Since lower back pain, has many factors that could be causing more stress to the lower back, some of which we have discussed, we need to assess the whole body from the ankles to the neck to discover the underlying issues that are displacing more stress to the lower back. Once determined we are ready to devise a treatment plan with a focus on long-term change by correcting the underlying deficiencies to reduce strain to the lower back and allow the lower back to function as intended. It may be bias, but the combination of chiropractic manipulation and therapeutic exercise do a wonderful job of helping to correct these underlying issues.
To learn more about improving hip and thoracic mobility, as well as core stability review our previous posts on these topics by clicking on the topic below:
We hope that this post has provided some insight into why back pain is so prevalent in our society today and helped to shed some light into why we need to consider other factors when determining why there is such a high prevalence of lower back pain. There is certainly a need for all of the treatment options that we have today from the most conservative to the most invasive, however determining what the best option is for the individual by way of understanding what the causative factors of their lower back pain are and not just treating them from a symptomatic standpoint is the key to having better and more positive outcomes. Along with reducing the potential for future recurrencies.
…Till Next Time
