What is lower back pain?
Unfortunately this isn’t a question that really needs to be greatly expanded on, as most of us have experienced some lower back pain at one time or another. It is said to be the second most common complaint heard by physicians in the US. It is usually experienced in the lumbar region of the spine. The lumbar region consists of five vertebrae (L1 to L5) between the lower ribs and the sacrum. The complex anatomy of the lumbar spine is a remarkable combination of these strong vertebrae, multiple bony elements linked by joint capsules, and flexible ligaments/tendons, large muscles, and highly sensitive nerves.
What causes lower back pain?
There are a number of aggravating factors when it comes to lower back pain, including; physiological, environmental and personal factors.
Diagnosable conditions of the lower back include but aren’t limited to; degenerative disc disease, ruptured or herniated disc, spinal compression fractures, spinal stenosis, sciatica, spondylolithesis, scoliosis, arthritis or other non-musculoskeletal causes such as kidney stones, shingles, or infection.
However, it has been proven that of all lower back complaints, as few as 1% of them are diagnosable.
Meaning that more than 90% of all lower back complaints are ‘non-specific’, and inexplicable by medical imaging or testing. There is little doubt that muscular and myofascial pain is a major factor in non-specific lower back pain and orthopaedic testing by a physical therapist such as massage or myotherapist should be able to locate the muscle or ligament acting as the cause.
What causes non-specific lower back pain?
Initially lower back pain is likely to be triggered by a physiological factor, such as sprain or strain to ligament or muscles in the lower back. This could happen through improper or over use of the muscle or joint, irregular exercise, or poor posture. However, stress is such a big factor in exacerbating lower back pain that even the medical research is saying that the best treatments include mindfulness and movement, over medication.
What are those stressors?
Environmental stressors that can attribute to causing low back pain may include employment, relationships and the external demands of life such as;
- Noise – loud and constant low level noise
- Foreign organisms (bacteria, viruses, fungi)
- Poor work conditions (low satisfaction, poor ergonomics, too much noise, poor air circulation, lack of privacy, excess demands, etc).
- Relationships with others; bullying in the workplace, demanding family member, abusive relationship
- Living situation
- All the situations, challenges, difficulties, and expectations we are confronted with on a daily basis.
Internal stress comes from inside of us and determine our body’s ability to respond to, and deal with, the external stress-inducing factors or stressors:
- Nutritional status
- Attitudes & belief system
- Feelings of anger, fear and worry
- Overall health and fitness levels
- Presence of illness and infection
- Emotional well-being
- Amount of sleep and rest you get.
“Evidence suggests that fear avoidance beliefs are prognostic for poor outcome in subacute lower back pain.”  That is, those in fear of pain are likely to take longer to recover.
The fear of pain was assessed in 126 volunteers with a questionnaire before “inducing muscle injury to the shoulder.” The results found evidence that fear of pain before injury can predict recovery time. In other words: how well you respond to injury and recover is affected enough by fear that it can actually be predicted by measuring fear beforehand.
Pain itself often modifies the way the central nervous system works, so that a patient actually becomes more sensitive and gets more pain with less provocation. It’s called “central sensitization” because it involves changes in the central nervous system (CNS) in particular — the brain and the spinal cord. Sensitized patients are not only more sensitive to things that should hurt, but sometimes to ordinary touch and pressure as well. Their pain also “echoes,” fading more slowly than in other people.
Watch this great TED talk on ‘Why Things Hurt”
How is lower back pain diagnosed?
To diagnose the cause of low back pain, it is likely you will go through a series of diagnostic tests from your GP and then perhaps a series orthopaedic tests from your physical therapist. Imaging and blood tests will not show soft tissue injury, such as ligament sprain or muscle strain, so it is a good option to see a physical therapist if your tests come back negative.
Orthopaedic tests will include a range of simple postural back and leg tests to determine joints, ligaments and/or muscles that may be implicated in your pain. Communicate openly as best you can with your physical therapist about what you feel and when you feel it. If this is not completely obvious to you, then keep a pain diary, noting down when and where on your body you feel the pain, and what you have been doing in the time leading up to the pain. It’s also worth noting the external and environmental factors that might be surrounding the pain at the time. There’s even an ‘app for that’. The therapist is looking for the actions and muscles that recreate the pain you are experiencing.
How is the best way to treat it?
Well, I guess that is the million-dollar question…
“For people with chronic low back pain, opioid analgesics provide modest short term pain relief but the effect is not likely to be clinically important within guideline recommended doses. Evidence on long-term efficacy is lacking, the efficacy of opioid analgesics on acute low back pain is unknown.” Unfortunately, the overuse of imaging, opioids, and surgery remains a widespread problem. If pharmacological treatment is desired, clinicians and patients should select non-steroidal anti-inflammatory drugs or skeletal muscle relaxants.
Exercise, Physical Therapy & Mindfulness
The reality is that medical research is now saying, the best medicine is no medicine. The evidence indicates that medication is found to reduce pain by approximately 10%, while a systematic review and meta-analysis of yoga for low back pain found there is strong evidence for short-term effects on pain (as much as 48% reduction) and long-term effect on pain (a reduction of 33%).
The conclusion is that for patients with acute, sub-acute and chronic low back pain, clinicians and patients should initially select non-pharmacological treatment including exercise like yoga or tai chi, multidisciplinary rehabilitation including massage, spinal manipulation and acupuncture, and mindfulness based stress reduction such as cognitive behavioural therapy.