How to "flatten" low back pain



by Nathan Wei, MD, FACP, FACR

Nathan Wei is a nationally known board-certified rheumatologist and author of the Second Opinion Arthritis Treatment Kit. It's available exclusively at this website... not available in stores.

Click here: Second Opinion Arthritis Treatment Kit



Low Back Pain (LBP) deserves all the capital letters it gets because it’s one of the most common problems seen. In fact, it is the second most frequent reason (behind the common cold) for visiting a doctor’s office.

LBP is most common in the 40 to 70 year old age group. It's been claimed that up to 90 per cent of people will have an episode of low back pain at some point in their lives.

While most patients will recover from their attack, approximately ten per cent will go on to develop chronic low back problems.

The amount of money spent on low back pain, including the cost of treatment, legal, and economic (days lost from work, etc.) is enormous and estimates run to as high as 30-40 billion dollars annually... and this figure appears to be climbing.

While the cause of low back pain is usually benign, it is critical to rule out the more serious causes of low back pain such as tumor, infection, aortic aneurysm, or fracture.

The low back is comprised of a stack of vertebrae, each separated from the other in front by a disc containing a gel that acts as a cushion. In the rear, facet joints lined with cartilage also offer additional cushioning and support. The vertebrae and discs are held in place by a complex series of muscles, ligaments, and tendons. Finally, the spinal cord runs down through a central canal in the vertebral column. At each disc level, the spinal cord sends out a pair of nerve roots- one to each side. These nerve roots provide the innervation for the structures in the hips and legs.

Low back pain is caused by a number of different problems including trauma, inflammation, degenerative and mechanical processes, infection, and malignancies. Despite the myriad number of potential causes, 90 per cent of patients have a mechanical problem accounting for their low pack pain.

The history is key because it can provide clues to causes of low back pain that are not due to wear and tear. In most cases, though, a history of trauma, repetitive motion, or other activity is elicited. Sometimes the incident that sets things off is relatively trivial. A patient may state they were “just brushing my teeth”, or “just bending over to pick up the newspaper.”

It is this history that will point towards low back strain being the culprit. Strain refers to pain due to sudden and unexpected stretching of muscles and/or nerves. In addition, sudden injury and stretching of ligaments can contribute to muscle spasm. Multiple reasons are responsible for strain including repetitive motion, sudden movements, lifting, and twisting of the trunk. Physical examination will reveal limited range of motion, significant muscle spasm, and tenderness of the muscles that lie adjacent to the spine.

Factors predisposing to strain include occupations or hobbies that cause repetitive motion in the low back, excessive weight, poor conditioning, poor posture, and prolonged exposure to vibration. An example would be heavy equipment operators.

Another key point is that the low back shares an intimate relationship with the rest of the lower extremeties such as the hips, knees, ankles and feet. So... any problem occurring lower down will eventually lead to low back problems. An example would be a patient with a significant leg length discrepancy.

Structures in the spine that are often responsible for pain are the discs and the facet joints. The discs can herniate – i.e., the gel inside the disc explodes out and causes pressure on the nerve root. The discs can also degenerate and cause nerve root pressure. The facet joints can develop arthritis and cause nerve root irritation as well.

Significant degeneration in the spine, either in the facet joints or in the disc, can lead to narrowing of the spinal canal – a condition called spinal stenosis. Spinal stenosis pain is aggravated by standing, walking, or extension of the spine.

Sciatica is pain that radiates into the buttock and down the outside of the leg. This is due to pressure on a nerve root from either disc disease or arthritis in the fact joint... or both. Sciatica caused by disc herniation is aggravated by sitting or bending forward.

Sometimes low back pain will radiate down the front of the thigh. It is important, in this situation, to rule out hip disease, inguinal hernia, pressure on the femoral nerve, aortic aneurysm, and kidney disease.

Some other unusual symptoms that are a tip off to more serious problems include pain at night that interferes with sleep (malignancy), pain and stiffness in the morning (ankylosing spondylitis), pain accompanied by fever or weight loss (infection or tumor), back pain accompanied by numbness in a “saddle distribution” and loss of bladder/bowel control (cauda equina syndrome – pressure on all the nerve roots in the lower part of the spine- this is a surgical emergency!)

Physical examination should evaluate range of motion, the presence or absence of muscle spasm, the presence or absence of nerve root compression, deep tendon reflexes, and muscle strength.

A careful examination of organ systems is critical to exclude the less common causes of low back pain in patients where the history appears to be confusing or suspicious.

The laboratory is not particularly useful other than to help exclude systemic causes of low back pain.

Electrical testing can determine the presence of radiculopathy (pinched nerve).

X-rays are not that helpful. Most low back syndromes don’t have readily apparent x-ray findings, and the majority of older patients will have x-ray abnormalities that are not symptomatic.

CAT scanning and magnetic resonance imaging are more sensitive and specific.

Low back pain treatment is highly dependent on diagnosis. For the 90 per cent of patients who have mechanical low back pain, a number of modalities will help. For acute low back syndromes, bed rest for 24 to 48 hours may be curative. No longer... since prolonged bed rest is detrimental.

Aggressive physical therapy is often helpful. Spinal manipulation (chiropractic) may be beneficial as well. Some people have found traction to be useful.

Specific stretching and strengthening exercises accompanied by non impact aerobic exercise is one of the most helpful modalities.

Anti-inflammatory drugs and muscle relaxants are sometimes helpful in alleviating symptoms. Narcotics are not indicated.

For patients with more chronic problems, a number of modalities have been used with varying degrees of success. Soft tissue and epidural injections are often helpful. Transcutaneous electrical nerve stimulation (TENS) has also found advocates.

Recent studies have also shown botulinum toxin injections may be helpful for patients with mechanical back problems associated with muscle spasm. Also, for patients with chronic back pain due to muscle spasm and ligament stretching, prolotherapy with or without platelet-rich plasma (PRP) may be the ticket.

Surgery is indicated for patients who have intractable pain with a well-defined anatomic reason for the pain and who have a progressive neurological deficit.



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