Here at Elementary health, we are fully aware of the large number of people who suffer from lower back pain, including associated sciatica symptoms. Our work in the back pain Cambridge clinic, working with a vast range of physical capabilities, and our athlete performance work in London (sports injury clinic and rehabilitation), allows us to have very positive contact with such symptom sufferers.
In fact, lower back pain (lumbar spine pain) is currently one of the most common musculoskeletal illnesses for people to suffer from. Musculoskeletal illnesses are believed to generate some of the highest costs to society. Thus lower back pain is one of the largest costs to society!
The most commonly ‘diagnosed’ issues leading to an episode (acute), or multiple episodes (chronic), of lower back pain, with or without ‘sciatica’ (neural irritation), are:-
Spinal functional instability, end plate trauma, motor control imbalances, facet joint irritation / dysfunction / locking, discal strain / sprain, muscle strains, pulled muscle, muscle spasms, over use syndromes, degeneration, arthritis, ‘slipped discs’, ‘herniated disc‘, ‘bulging disc’, ‘slipped disc treatment‘, ‘sciatica’, ‘trapped nerve’, ligament sprain, ‘chronic pain’, lower back sprain, inflammation, ‘lumbago’, ‘lumbar spine pain’, ‘nerve root impingement’….. The list goes on!
The quality of some of these diagnosis concepts, and the actual correlation to your pain, are even more fascinating!
How This May Affect People
When this doesn’t go well, it often leads to a very dissatisfying outcome. This can manifest itself as: deconditioning, disability development, depression, loss of confidence in yourself and your body, which ultimately often leads to a dependency on pain altering medications, and poorer physical health.
So what are we to do? Are we to:- be immobile?, be mobile?, be active?, or minimally active?, train into pain (‘no pain no gain’)?, or train avoiding pain?, use medication management?, use massage?, use spinal manipulation?, Osteopathy or chiropractic or physiotherapy?, use prescriptive exercise?, regular treatments or minimal treatments?, have imaging or not to have imaging?, should we focus on structure or function?, or is it just age?!!!
Last summer I suffered from an acute episode of lower back pain. This pain resulted in me having to take time off work, which was not financially sustainable. I went to see several private specialists regarding my problem, to which I had very little success. After speaking to Michael I booked an appointment. Michael was aware that I had a fair knowledge of injuries and explained things to me with detail. He offered a very hands on approach and my pain greatly reduced after two sessions allowing me to return to work. I would definitely recommend Michael for any future injuries and I will definitely use him myself if required.
Our knowledge and understanding of the body, neural pain interpretations and mechanical anatomy of the low back, its associated structures and the muscles used for core control, spinal stability, movement and injury prevention, are still being updated and evolving. Allowing for constantly changing assessments, treatment and rehabilitation techniques.
Sometimes additional investigations are needed. However, for ‘non-specific lower back pain’, they are rarely needed as a primary input into your assessment and treatment.
Imaging was originally seen by most, as a tool to rule out pathology or disease states, and less to diagnose specific musculoskeletal causes. Often this was due to a poor correlation of images and symptoms.
New imaging approaches have developed, and our dependency on them increased!
However, recent studies show that by performing a thorough clinical case history and physical examination you can often, very effectively decide if MRI or additional imaging or other investigations are needed.
Studies show MRI use, looking at follow up assessments for patients who suffered sciatica, could not distinguish between favourable and unfavourable outcomes.
There are also recent studies that show that MR Imaging (MRI) of the lumbar spine, may actually increase the patient’s likelihood of continuing in pain or disability status, and elongate their symptom picture.
A study looking at a 10 year analysis of MRI findings and lower back pain, they concluded that ‘baseline MRI findings cannot predict future LBP’, ‘changes were not associated with LBP history’, and that ‘The progresses of findings were also not associated with the LBP history’.
Very importantly another study ‘found marked variability in the reported interpretive findings and a high prevalence of interpretive errors in radiologists’ reports of an MRI examination of the lumbar spine performed on the same patient at 10 different MRI centers over a short time period. As a result, the authors conclude that where a patient obtains his or her MRI examination and which radiologist interprets the examination may have a direct impact on radiological diagnosis, subsequent choice of treatment, and clinical outcome.’
This has to raise the question, are MRI reports reliable, and enough alone to justify a treatment approach?
There are ‘problems associated with excessive imaging for lower back pain’, which are well recognised. Evidence-based guidelines have been developed to help this issue.
However, currently, 42% of patients with lower back pain still ‘receive an X-ray, CT or MRI within 1 year of diagnosis, and of these, 80% receive imaging within 1 month of presentation’. This is not in keeping with current guidelines.
‘The uptake of imaging guidelines is likely to be similarly insufficient among the sports medicine community, where lumbar imaging is frequently used.’ ‘As well as recognising when imaging is appropriate, evidence-based reporting and interpretation of imaging findings is critical’.
Comparing the accuracy of ultrasound (US) imaging with manual palpation for locating the intervertebral level. ‘The difference in accuracy between manual palpation and US imaging was not statistically significant’. Therefore they concluded that ‘US imaging may not be superior to manual palpation for identifying intervertebral level’.
In very active sports people, ultrasonography can help assess the muscles of the back, such as lumbar multifidus (LM).
The lumbar multifidus function (contraction) was not associated with altered image findings, or lower back pain. Perhaps implying that muscle contraction and ‘tight muscles’ did not indicate the cause of lumbar spine pain.
These lumbar multifidus assessments using ultrasonography have found the lumbar multifidus, to be reduced in mass 4 weeks after an episode of lower back pain (LBP). Standing asymmetry of muscle mass was seen in people 3 months after an episode of back pain. Furthermore, those with continued with LBP showed specific deficits in LM morphology. Indicating that continued clinical care is needed, even after pain has dissipated.
Herniated Disc and Bulging Disc
MRI and other methods of imaging for disc herniation and disc bulges are of limited consistency. Leading to conclusion from research papers such as, ‘The diagnostic accuracy of CT, myelography and MRI of today is unknown, as we found no studies evaluating today’s more advanced imaging techniques. Concerning the older techniques we found moderate diagnostic accuracy for all CT, myelography and MRI, indicating a large proportion of false positives and negatives’.
When there is systematic review of imaging features of spinal degeneration in asymptomatic Populations (people who have no symptoms of back pain at all). This included assessment of disc health changes.
‘Thirty-three articles reporting imaging findings for 3110 asymptomatic individuals met our study inclusion criteria. The prevalence of disk degeneration in asymptomatic individuals increased from 37% of 20-year-old individuals to 96% of 80-year-old individuals. Disk bulge prevalence increased from 30% of those 20 years of age to 84% of those 80 years of age. Disk protrusion prevalence increased from 29% of those 20 years of age to 43% of those 80 years of age. The prevalence of annular fissure increased from 19% of those 20 years of age to 29% of those 80 years of age’.
They go on to say, ‘Imaging findings of spine degeneration are present in high proportions of asymptomatic individuals, increasing with age. Many imaging-based degenerative features are likely part of normal aging and un-associated with pain’.
A herniated nucleus pulposus (HNP) is a common condition that at times may induce back pain and radicular pain (such as sciatica). Pain can be relieved with conservative treatment or at times relieved spontaneously. Spontaneous regression of a HNP has been recognized with the advancement of radiological diagnostic tools and can explain the reason of spontaneous relief of symptoms.
End Plate Trauma
MRI visible cartilaginous endplate changes, seem to complement earlier reports suggesting a link between lower back pain and endplate degeneration. Signal enhancement (visible change in the MRI image) might be an indication of inflammatory changes in disc endplate regions. The authors went on to mention that this helps identify a subset of patients who could potentially benefit from novel therapies, which are directed towards treating the disc endplate regions.
Degeneration and Arthritis
Then there are studies showing that degeneration changes, are just a part of function and use. These however, have no correlation with pain, or perceptions of illness, or illness behaviour i.e. age and degenerative changes have no clear causal link with pain.
In fact studies on some of the most elite athletes, show lower back changes in images, with lumbar degeneration in up to 85 percent of people, and even spinal bony arch fractures or lesions, in 30 percent of people. All had no symptoms of lower back pain.
Nerve Entrapment and Nerve Root Impingement
Interestingly again, ‘There is lack of sufficient high quality scientific evidence in support or against the use of MRI in diagnosing nerve root compression and radiculopathy. Therefore, clinicians should always correlate the findings of MRI with the patients’ medical history and clinical presentation in clinical decision making’.
Physical assessment by a clinician is vital in all cases of low back pain.
Pain affects and distorts the coordinated use of back muscles. This creates an ‘inefficient recruitment of the erector spinae (back muscles) as the load progressed’. This is clearly seen in rowers with a history of low back pain.
Herniated Disc and Bulging Disc
As with everything technique is always key. When lifting training was assessed they found that imbalanced techniques lead to earlier spinal injury. These increased shear strains were observed, and disc injury progressed from protrusion of the disc to full lumbar disc herniation. Specifically, they found that larger compressive loads applied to unsafe lifting technique led to frequent early failure of the endplate. However, smaller compressive loads with similar spinal patterns, applied under safe lifting led more loading cycles before tissue injury, and where the site of injury happened, was more likely to be the disc.
This ‘demonstrated that unsafe lifting techniques and loads, leads to greater risk of injury compared to safe lifting, and lumbar discal herniation (LDH) and disc protrusion were more common’.
A study assessing triggers of lower back pain and the flare ups of pain, found that patients continue to find mechanical / biomedical causes of Lower Back Pain and pain flare ups. The study findings contrast the psychosocial theories, and some of the current pain theories. What if there are also valid mechanical pain triggers, which patients continue to be aware of.
End Plate Trauma
These specific types of endplate defects are ‘associated with back pain history’. Endplate defects may be an independent risk factor for back pain.
Low back pain often hurts more with lifting weights and jumping. Back pain should be evaluated by people with good sports injury training and understanding. The clinician should determine what movements cause back pain for each individual sports person, and additionally determine what movements induce pain in the individual sports.
There may be some muscle strength changes from the distorted muscle control of lower back pain.
When there is testing of the reliability and agreement of isometric functional trunk and isolated lumbar strength assessment in healthy persons and persons with chronic nonspecific low back pain, they found that there is excellent reliability shown in a functional trunk and isolated lumbar muscle strength protocol.
All muscle strength outcomes showed comparable agreement, and that muscle strength changes of over 10% highlight a true different in neuro-motor control.
Nerve Entrapment and Nerve Root Impingement
Interestingly, a lumbar spine curve compared to thoracic curve, predicts lower back pain. ‘Participants with greater lordosis than kyphosis were more likely to suffer from low back pain than subjects without this offset’. Meaning that, ‘sagittal spinal alignment seems to be related with low back pain’.
Does This Apply To You?
Ah yes, but these are not average people!?!!
Well we also have imaging studies of the average person on the street, with no lower back pain. Interestingly, of this average adult population many will also have degenerative discs, or disc bulge present. Yet no pain! no ‘lower back problems’!
What Can Help
For lower back injury, ‘Prevention of injury remains an important goal for clinicians and researchers’. What does help lower back pain?
Acupuncture and Dry Needling
For cases of myofascial pain syndrome, dry needling seems to not be effective, and was less effective on decreasing pain comparing to the placebo group.
This may be why NICE guidelines, advised exercise and not acupuncture for people with low back pain. Recommending exercise, in all its forms as the first step in managing low back pain.
It turns out that multiple lumbar steroid injections for stenosis of the lumbar spine, seems to show no positive outcome in the long term.
Sometimes surgery is an important intervention for the continued care of a patient. These surgical selections need to be very accurate, and also take on board the whole collection of evidence.
For surgical fusion, one study stated “lumbar fusion for the diagnoses of disc degeneration, disc herniation, and/or radiculopathy in a workers’ compensation (WC) setting is associated with significant increase in disability, opiate use, prolonged work loss, and poor return to work (RTW) status”.
Interestingly, ‘surgery for radiculopathy with herniated lumbar disc and symptomatic spinal stenosis is associated with short-term benefits compared to nonsurgical therapy, though benefits diminish with long-term follow-up’
Additionally well worth noting that ‘for non-radicular back pain with common degenerative changes, fusion is no more effective than intensive rehabilitation’.
Pre-Surgery and Post-Surgery Rehabilitation
It has been concluded that ‘prehabilitation (pre-operative exercise) may reduce length of stay and possibly provide postoperative physical benefits’.
In chronic low back pain patients, the ‘patient group which has been operated on for disc prolapse often exhibits considerable functional deteriorations post‐operatively. Rehabilitation studies have shown that many of these patients also benefit from post‐operative rehabilitation including high dosage exercise programs’.
This is assuring of the ‘benefit of intensive dynamic exercises for low back pain’.
Osteopathy has research data that shows that lower back pain (lumbar spine pain) is the most common presenting issue, for people seeking osteopathic assistance (osteopath for back pain), showing very positive outcomes and satisfaction levels (lower back pain treatment).
Osteopathic manipulative treatment (OMT) for nonspecific low back pain (LBP), has been evaluated, for nonspecific LBP, LBP in pregnant women and OMT for LBP in postpartum women. OMT had a significant effect on pain relief and functional status in acute and chronic nonspecific LBP.
In chronic nonspecific LBP, evidence suggested a significant difference in favour of OMT regarding pain and functional status.
For nonspecific LBP in pregnancy evidence suggested a significant difference in favour of OMT for pain and functional status
Furthermore, evidence suggested a significant difference in favour of OMT for pain and functional status in nonspecific LBP postpartum.
The study concluded that ‘clinically relevant effects of OMT were found for reducing pain and improving functional status in patients with acute and chronic nonspecific LBP and for LBP in pregnant and postpartum women at 3 months posttreatment.
Osteopathy has been provided to a population of which 100% of the patients had chronic spinal pain and 98.8% had previously received other interventions for the same episode of pain. 83.2% of patients reported that osteopathy had ‘helped a lot’ or ‘helped’. 96.2% of patients were ‘very satisfied’ or ‘satisfied’ with care.
They found that, osteopathy is an effective method to help with secondary spinal care and with limited therapeutic complications. It helps reduce spinal surgery, and aids diagnosis and treatment of causes of back pain. Including lower back pain and sciatica pain.
The robust data supported the use of osteopaths to deliver a conservative spinal service, for the population of complex and chronic spinal pained patients.
‘Exercise is considered an effective treatment strategy for non-specific chronic low back pain (NSCLBP)’. When assessing what movement control and stabilization exercises to apply in people with ‘extension related non -specific low back pain’. The ‘effects of two exercise protocols (stabilization vs movement control) on pain and disability scores and the flexion relaxation ratio (FRR) of lumbar multifidus (LM) and iliocostalis lumbarum pars thoracic (ICLT) in people with extension related non-specific chronic low back pain’. They were both effective in decreasing pain, disability and normalizing muscle activation patterns in people with chronic low back pain (Pain and disability reduced). Additionally, flexion relaxation ratio (FRR) of ICLT was significantly increased after treatment in the movement control group.
In cases of chronic low back pain, a direct comparison of a physical, a cognitive-behavioural treatment and a combination of both. Looking at Active Physical Treatment (APT), Cognitive-Behavioural Treatment (CBT), in addition to Combined Treatment of APT and CBT (Cognitive behavioural therapy). Physical performance tasks improved in active physical treatments when combining active physical treatments (exercise therapy) and CBT, but not in the group who received just CBT.
Significant reductions of limitations were observed in functional limitations, patient’s main complaints and pain intensity. Indicating that pain catastrophizing behaviour can be reduced as effectively by mechanical approaches as it does by CBT. Making active rehabilitation for chronic low back pain a key piece. However, CBT can help with patient satisfaction. Showing sometimes the combination of the two may be indicated.
Herniated Disc and Bulging Disc
When we focus on the local structures, such as lumbar herniated disc and bulging disc, there is a growing body of evidence that the right care and back pain management, can lead to a repair process, in more adaptive spines. In fact these healing processes occur in a significant amount of people with lower back problems, leading to such changes as ‘spontaneous regression‘ aka ‘spontaneous resorption’ of the disc herniation from a lower back sprain. This lower back pain treatment such as slipped disc treatment, can then lead to spine pain relief.
‘Spontaneous regression of herniated disc tissue can occur, and can completely resolve after conservative treatment. Patients with disc extrusion and sequestration had a significantly higher possibility of having spontaneous regression than did those with bulging or protruding discs. Disc sequestration had a significantly higher rate of complete regression than did disc extrusion.’
Another study also eloquently highlights the need for inflammation, and the possible negative response of supressing and hindering this healing process by stating in its conclusion, ‘LDH spontaneous resorption is well documented clinically and in preclinical studies. Spine surgeons are becoming increasingly aware of this phenomenon and many recognize the usefulness of conservative treatment for LDH and advise patients accordingly. Different forms of nonsurgical treatments should be exhausted before considering surgery in acute stages of LDH, unless conservative treatment is contraindicated for reasons such as neurological deficit and intolerable pain despite administration of adequate pain medications’.
It went on to also say, ‘it is clear that the inflammatory response that occurs associated with LDH is crucial to its spontaneous resorption. Therefore, inflammation in this specific clinical context is a good prognostic indicator and should not be halted. Still, it is exactly an inflammatory response that causes a harmful effect on the adjacent nerve roots, causing pain. The control of the inflammatory reaction in this setting is an important challenge when treating patients with LDH. The combination of knowledge from the biological mechanisms behind LDH resorption and the detailed personalized diagnosis will be the determinant to tailor treatment to each individual patient’.
End Plate Trauma
We can assess your movement patterns and assist with ensuring your movements and lifting techniques are optimal.
Guidance for non-invasive treatments for Acute, Subacute, and Chronic Low Back Pain have been developed. Clinicians and patients should select non-pharmacologic treatment, this includes:
Patients with acute or subacute low back pain, having treatments such as massage, or spinal manipulation.
Patients with chronic low back pain, clinicians and patients should initially select non-pharmacologic treatment with exercise, multidisciplinary rehabilitation, motor control exercise, progressive relaxation, electromyography biofeedback, or spinal manipulation.
Lumbar muscle strain treatments have been investigated, and the rehabilitation effect of exercise with soft tissue manipulation in patients with lumbar muscle strain. Found the approach to be ‘more significant’ at reducing symptoms such as pain scales, than ‘conventional therapy’.
Nerve Entrapment and Nerve Root Impingement
Clinicians should only consider opioids as an option in patients who have failed all other treatments and only if the potential benefits outweigh the risks for individual patients and after a discussion of known risks.
Degeneration and Osteoarthritis
Some of the positive effects and patient’s experience of pain relief from manual therapy and exercise, may also be due to the increasing body of evidence, that pain is a brain interpretation of data, and the local structure itself, cannot consistently be linked with pain or general function.
The point here is there are many opinions and many solutions, to lower back pain. Perhaps some, in our opinion, are more rational than others and some statistically safer than others, and some more empowering than others. Perhaps think ‘who is a back pain specialist near me‘?
Comparing clinical effectiveness of nonsurgical treatment methods in patients with lumbar spine stenosis, showed that combination treatment of individualized exercise and hands on manual therapy, is a good option in short term management. Helping provide greater short-term improvement in symptoms and physical function and walking capacity than medical care or group exercises, and was associated with improvements in long-term walking capacity.
Whole Body Integration
Health literacy (HL) and the overall ability of patients to seek, understand, and apply health information play an important role in the management of chronic pain conditions.
Many people with recurrent low back pain (LBP) have deficits in postural control of the trunk muscles and this may contribute to the recurrence of pain episodes. The motor cortex contributes to control of postural adjustments, and there is evidence of reorganization of trunk muscle representation at the motor cortex in individuals with recurrent LBP, and this is suggestive that this reorganization is associated with deficits in postural control. Therefore reorganization of the motor cortex is associated with postural control deficits in recurrent low back pain.
When looking at the influence of active scars in the abdominal wall, on the abdominal and back muscles activity in chronic low back pain.
An ‘active scar has been defined as one which is tender and around which the tissues show various abnormalities’. These active scars in the abdomen may ‘cause the underlying muscles to be less active’. In addition, an active scar on the abdomen may increase resistance to stretch, thus restricting flexibility of the back. Such scars may, therefore, be a cause of back pain.
The abdominal muscle activity asymmetry decreased after treatment of an active scar of the abdomen.
‘The diaphragm plays an important role in spinal control. Increased respiratory demand compromises spinal control, especially in individuals with low back pain (LBP).’
Individuals with low back pain show a greater susceptibility to diaphragm fatigue (exhibit propensity for diaphragm fatigue), which was not observed in controls. An association with reduced spinal control, could mean that diaphragm fatigue may be a potential factor in the etiology of low back pain, and that greater diaphragm fatigability is present in individuals with recurrent low back pain.
‘Abdominal muscles are important spinal stabilizers and its poor coordination, as seen in diastasis of rectus abdominis (DRA), may contribute to chronic low back pain (LBP)’.
Diastasis and lower back pain seem to correlate. Diastasis of rectus abdominis muscles in low back pain patients may be interrelated, especially among men.
This all makes it rather clear that core control has a lot of relevant with low back pain.
When assessment and comparison of the effects of hollowing and bracing exercises on abdominal muscles. The study concluded that, ‘performing bracing exercises rather than hollowing exercises is more effective for activating the abdominal muscles’. Challenging past models of abdominal hollowing.
Then we can start to look at a more global pattern, and treatment plan. People with lumbar dysfunction, have less balance, and alterations in core control, compared to healthy individuals. Diminished core stability measurements correlate with the extent of low back dysfunction. This indicates that, balance and core stability training, may be a successful rehabilitation protocol for spinal dysfunction.
Training the control of motion and stability, in the presence of change, plus training core stability, may help spinal mechanics and normal low back function, in relationship with the body’s trunk.
A session of respiratory muscle training in athletes with chronic low back pain performing overhead squats. Reduced the activities of some ankle joint muscles, including tibialis anterior and peroneus longus, with resultant changes to the angle to reach peak activity in tibialis anterior and peroneus longus, in different phases of movement. The study concluded that ‘respiratory muscle training prevented excessive ankle joint muscle activity through stimulating local muscles’, ‘indicated an improved postural control and multi-sectional proprioception to maintain postural stability and stimulated the local muscles of the core area’.
Also this is suggestive that when a person suffers lower back pain, their core control, breathing mechanics, and lower leg controls are all compromised, and that these can also be re-educated.
Many lower back pain presentations can be treated with osteopathy and dynamic exercise therapy effectively. It does not matter whether the issue is of a primary or secondary origin, both will have significant improvement.
Perhaps this shows why whole body assessment and treatment, is reported anecdotally in clinic to be so effective. These positive effects from manual therapy and exercise, may be linked to the increasing body of evidence, that pain is a brain interpretation of data, and that the local structure itself, cannot consistently be linked with pain or general function.
Additionally, manual therapy by an osteopath including the use mobilization and manipulation, and prescription exercise therapy, are all safer than long, or even short term medication treatments, such as non-steroidal anti-inflammatory drugs (NSAIDs).
There are many opinions and many solutions, to low back pain (lower back pain / lumbar spine pain). Perhaps some, in our opinion, are more rational than others and some statistically safer than others, and some more empowering than others.
The new updated NICE guideline for lower back pain, includes the guidance to remain as active as normal, seek support and advice at a specialist clinic, for education, management advice, manual therapy including spinal manipulation, mobilisation and soft tissue treatment by an osteopath, hydrotherapy application, increase in muscle strength (strength training) and specialist exercise therapy for rehabilitation.
At Elementary Health we provide a seamlessly layered combination approach, of diagnosis, education and therapeutic application. This includes education of anatomy and pain theories, manual therapy, osteopathy, posture advice and training, lifestyle advice, hydrotherapy guidance, dietary overviews, and dynamic exercise therapy with motor control training rehabilitation. All of these work together to provide a uniquely structured approach, towards the aim of restoring your brain’s interpretation, or ‘mapping’ of your healthy functioning body, giving you back the control!
If there are any other questions, or, you wish to book a consultation with Michael Parr the consulting osteopath in Cambridge, based at Elementary Health. Please don’t hesitate to call or email.