PERSPECTIVE

Low back pain ranks with cardiovascular diseases and mental illnesses as the major causes of the escalation of healthcare costs.

The fact is there is no distinct boundary between the above disorders. The muscles, joints and nerves constitute the largest system affecting people’s health and productivity. As a dominant system, it also plays a role in the genesis and perpetuation of or prevention of and recovery from common diseases and disorders of other organs such as obesity, cardiovascular diseases such as high blood pressure and cholesterol, heart diseases, stroke, diabetes, psychiatric illnesses, osteoporosis and related complications, etc.

This prevalent problem is significant in light of the fact that individuals afflicted with LBP suffer and endure needlessly the pain, suffering and disability. Their families, friends and employers share their emotional anguish and financial strain.

FACTS

The profile of low back pain including leg pain, ache, sciatica, weakness, abnormal sensations such as tingling, numbness and pins and needles, muscle spasm and stiffness, joint swelling and stiffness (LBP) comprises:

  • LBP is a common affliction of people especially in the industrialized nations in America, Europe and Asia.
  • It is estimated that 80 – 95% of the population is afflicted by LBP in their lifetime. The fact is LBP and its chronic sequalae afflict all humans.
  • It is the most common cause of disability in America for individuals less than fifty years old.
  • The degeneration, spinal stenosis (narrowing of the canal, foramina or channels for the spinal cord and lumbosacral nerves), leg weakness and disability in seniors are the inevitable consequences of poor management of LBP.
  • Lack of proper and delayed diagnosis and ineffective and improper treatments cause pain, suffering, increased morbidity and mortality in people.
  • Since LBP is a multi-facet problem, disorder, disease, ailment, any program comprising only individual physician, doctor or therapist is ineffective to manage LBP.

LOW BACK PAIN IN THE NUTSHELL

The low back is the conduit for sensory, motor and autonomic nerves shuttling the life force between the spinal cord and the abdominal and pelvic organs, muscles and joints in the legs.

The vital structures of the low back comprise:

  • Ligaments
  • Low back muscles and tendons
  • Leg muscles and tendons
  • Trigger points and fibromyalgia
  • Facets
  • Joints
  • Fasciae
  • Spinal vertebral bones
  • Intervertebral discs
  • Spinal cord in the spinal canal
  • Nerve roots in the spinal canal
  • Nerve roots in the intervertebral foramina
  • Nerves
  • Dura mater covering the spinal cord and nerve roots
  • Neuronal circuitry with reference to:
    • Sciatic and referred pain in the legs
    • Abnormal sensations such as numbness, tingling, pins and needles
    • Myofascial pain syndrome
  • Arteries
  • Veins
  • Lymphatic channels

Essentially, the vital structures of the low back influence the well-being of an individual. They regulate the functions and affect the health of the abdominal and pelvic organs and muscles, joints and bones of the legs. The strength of the legs for walking and mobility is vital to all humans. They play a vital role in the genesis and perpetuation of or prevention of and recovery from common diseases and disorders of other organs such as obesity, high blood pressure and cholesterol, heart diseases, diabetes and related complications. In other words, the health and longevity of an individual can be secured by a healthy low back.

Unlike other body parts, the low back also cushions the weight of the upper body. It absorbs the impact when the feet or buttocks absorb the forces from the ground or surfaces. As a person bends, twists, walks, runs or performs the activities of daily living, fluctuating gravitational and muscular forces are imposed on the low back. Therefore, the back muscles, joints, nerves, tendons, ligaments, discs and bones – the tissues – are constantly subjected to varying strains and, in certain settings, they can be sprained and injured leading to inflammations and pain.

In a person’s life, the natural course of LBP is the hurt and then spontaneous recovery without intervention. For example, LBP in a well-known weekend sports enthusiast in balmy sunny weather and a home laborer – shoveling snow, raking leaves, picking grocery or a child, moving of furniture, dancing, etc. It was said that most LBP resolves within one week to several weeks and, in these circumstances, the tissues are able to spontaneously recuperate, repair and heal without the interventions.

However, there are common LBP in which the tissues cannot recover or the strain and sprain are too great to result in the spontaneous resolution of the inflammation and pain. Consequently, LBP can cause varying degrees of loss of activities of living, function and disability. LBP which does not spontaneously resolve necessitates the person to seek treatments. Treatments bring relief, recovery, restoration of function, and affect the course and outcomes of LBP.

Common symptoms and complaints

General constitution: fatigue, malaise, poor or disrupted sleeps and insomnia.

Quality of pains: sharp, piercing, lancinating, knife-like, sciatica, shooting, electricity, radiating, soreness, burning, hot-iron, dull, ache, cramps, gnawing, depressing, unbearable, sickening and nauseating.

Quality of sensations:– agony, numbness, sciatica, paresthesia, tingling, pins and needles, running water, ants crawling, decreased light touch, pin pricks and loss of sensations.

Leg, foot and toes: stiff, rigid, heaviness, swelling, “not my leg or foot”, weakness, knee buckling or locking, restless, unsteadiness, shuffling, slapping foot, walking difficulty, gait disturbances and fallings.

Gastrointestinal: loss of appetite, upset stomach, indigestion, gas, bloating, poor intestinal motility, irritable bowel syndrome, constipation and diarrhea.

Urinary: urinary retentions, poor control of urine and increased urinary frequency. Biomechanical disorders comprise stress, strain and sprain of the soft tissues such as the ligaments, muscles and bones of the low back. They are the most common cause of inflammation, pain, muscle stiffness and spasm and loss of mobility of the low back. These frequently occur in people in their ordinary activities of daily living.

Like the knee joint, the mobility such as bending, twisting and turning of the back is possible because of multiple small joints and facets, the short and long ligaments and muscles. These facets and joints are held together and supported by the ligaments, muscles and their tendons. Tremendous pressure and forces are constantly put on these structures.

A weakness or imbalance of these structures leads to the stress, strain or sprain of the ligaments, muscles, tendons, joints and facets. In most common LBP, usually, a group of related structures such as the ligaments, muscles and joints are stressed or strained at a time. Thus, people with LBP cannot exactly isolate or pinpoint the structure or structures involved in LBP.

In these individuals, the results are recurrent and disabling back pain involving arthritis, facet osteoarthritis, arthropathy, joint pain, weak and inflamed ligaments, muscles and tendons. The weakened structures further cause a constellation of widespread low back and leg pain, symptoms and disorders, visceral and pelvic organs disturbances and diseases. Myofascial pain syndrome or fibromyalgia afflicts all people and is as common and prevalent as back pain.

Sacroiliitis is the inflammation and pain of the sacroiliac joint – see the above figure. It is common and prevalent and closely associated with LBP.

The sacroiliac joints (SI joints) are easily seen in the back of a slender person as two dimples on the skin just above the buttocks. The SI joints are on both sides of the spine and are the links between the spine and the pelvis. These joints are supported by strong ligaments, muscles and tendons binding the spine to the pelvis. They bear all the weight of the body above them and sustain the load and pressure put upon them when a person is upright, stands, walks, runs or jumps.

Injury, inflammation and pain of the SI joints are common and prevalent. They are commonly associated with the inflammation and disorders of the above back structures.

They are also commonly stressed and strained in the activities of daily living such as walking, bending and lifting. They are more prone to injuries when the ligaments are lax, the muscles and tendons are weak, stiff or not resilient, muscular imbalances and misalignment of the body.

Other stress and strain of the SI joints can be caused by excessive force acting on them such as in heavy or prolonged lifting, bending of the trunk, torsional strain, movement from stoop to stand and falling on the buttocks. Certain activities in sports such as skiing, snowboarding, golfing, bowling, running and motor vehicle accident can also cause injury to the SI joints.

In the above conditions, walking, standing, trunk movements and even lying down cause pain, muscle stiffness and painful spasm in the back above the buttock of the involved side. Pain can radiate into the buttock and leg. Leg muscles can also become stiff and spastic. Movements and mobility become restricted.

Herniated disk (nucleus pulposus) is involved in the inflammation and pain of the back soft tissues such as joints, ligaments, fasciae, tendons, muscles and nerves. Disc bulging or disc herniation is commonly associated with low back and leg pain.

Coccygodynia is the inflammation and pain in the tail bone. The pain can radiate up the lower sacrum or down into the genital area. It is usually caused by a fall in a sitting position or direct injury to the tail bone, poor sitting posture or poorly designed chair. The inflammations and pain are also caused by stress, strain or sprain of the sacrococcygeal ligament holding the tail bone to the sacrum or a fracture of the tail bone.

Trauma and injuries are not uncommon to the spine, spinal cord, linings of the spinal cord and nerve. Most of the trauma and injuries are minor and inflammations and pain eventually resolve. However, more serious injuries can occur such as hyperextension (bending backward) injury of the low back, overflexion (bending forward) of the low back or sprung back such as in motor vehicle, motorcycle, bicycle and ski accidents.

Non-mechanical causes of low back pain and inflammations are less common. However, LBP can herald in many diseases. Symptoms and manifestations include acute (happen suddenly), recurring, extraordinary amount of pain, stiffness and muscular spasm and dysfunction of the low back. Symptoms and disorders in other parts of the body include abnormal bowel sensations and movements and urination, cramps and ache in the leg(s) and foot/feet, weakness of the leg(s) and foot or feet, tingling, numbness and abnormal sensations of the leg(s) and foot or feet including toes.

Referred pain is caused by a disorder or pain of a part of the body. The pain is referred to and perceived in another distant part of the body that is not directly affected by the cause of the disorder or pain.

Most common sources of referred pain to the low back are the organs in the abdomen, pelvis and retroperitoneal space (an area in the back of the abdomen) such as stomach, intestines, uterus and ovaries, and kidneys. For example, pain of peptic ulcer, diverticulitis of the colon, pelvic inflammatory disease, acute prostatis, trochanteric bursitis (inflammation of the bursa of the hip area) and pain during menstruation can refer pain to the low back.

Infections are caused by bacterias, viruses, fungi and parasites. These organisms can reach and infect the spine, intervertebral bone and disk and the epidural (lining of the spine) space.

Abscess is caused by an infection by the above organisms of the spine, intervertebral bone and disk and the epidural space.

Cancers comprise local primary cancer affecting the vertebral bone of the spine, lining of the spinal cord and nerves such as prostatic cancer, plasmacytoma, chordoma, chondrosarcoma, fibrosarcoma, multiple myeloma, osteoma, neurofibroma and ependymoma.

Cancers comprise metastatic cancers spreading from other organs of the body such as breast, lung, prostate, kidney, thyroid, liver and large intestine.

Inflammation comprises ankylosing spondylitis, arachnoiditis (inflammation of the web-like lining of the spinal cord), herpes zoster from chicken-pox virus.

Metabolic and vascular diseases comprise osteoporosis, diseases of the bone such as Paget’s disease, hyperparathyroidism (over-active parathyroid glands), Fanconi’s syndrome, renal osteodystrophy and disorders of the aorta (see below).

Rheumatism comprises gout, spondylarthropathies and Familial Mediterranean Fever.

Cardiovascular diseases comprise aortic aneurysm, infarction (loss of blood supply to the nerves) and hematoma.

Neuropathy comprises diseases of the nerve caused by diseases such as diabetes, cancers and alcohol that affect the nerves of the low back.

THE MOST EFFECTIVE MANAGEMENT OF LBP

CAUTION: You must consult and see physicians skilled in the diagnosis and treatment of back pain and related disorders (LBP). The information herein and related work only serve to inform and nothing more.

  • Delayed seeing, diagnosis and proper treatment of LBP by competent physicians pose an increase risk and complication of an illness which can become a life-or-death matter.
  • LBP is extremely complex, insidious and can be serious.
  • Some causes of low back pain:
    • Degeneration, Rheumatologic Diseases, Trauma & Others
    • Metabolic Bone Diseases
    • Infections
    • Cancers
    • Blood Vessel Diseases
    • Psychogenic & Psychosomatic Disorders

The means for preventing and treating LBP and the means for realistically curbing the escalating healthcare costs can only be effectively applied in a team approach comprising:

  • Well-informed, educated and compliant patients.
  • Skilled physicians, massage therapists and exercise physiologists.

Well-informed, educated and compliant patient plays a crucial role in the management of his or her LBP. Patient can give accurate and reliable history including the cause, assist in the physical examination and, of course, complying with the care, treatments and management LBP. Ultimately, patient decides the outcomes of a good program of care and management of LBP.

The clinicians are endowed with different skills and varying and diverse abilities and expertises to treat and care for low back pain and related disorders. The cornerstone of the effective management of LBP comprises:

  • The effective ongoing program of maintaining the health and optimal condition of the lumbosacral spine.
    • Education, constant reinforcements and compliance being performed and concerted efforts of patients themselves.
    • The biomechanics of the lumbosacral spine.
  • The expeditious and effective diagnosis, treatments, whenever necessary and indicated, and support by skilled and knowledgeable physicians and therapists.

In tens of thousands of patient cases particularly those in seniors, the spine and legs served as the crucible for the data supporting the current medical approach.

Diagnostician is king, expert is emperor

The effective management of LBP is complex and requires skilled physicians with expertise in many disciplines. Expert, not unlike an Emperor ruling a far-flung empire, has the experience and skill to recognize the simplicity and complexity of LBP and can choose and tailor the treatments and management suitable for LBP of an individual. A physician’s accurate diagnosis leading to the effective care, treatments and management result in the good outcomes. A skilled physician with excellent knowledge of human anatomy expertly performs the treatments resulting in fast and early recovery.

Exercise physiology

In most circumstances and settings, weak and lax ligaments, muscles and tendons contribute to the causes of LBP.

A skilled exercise physiologist as a team member with the physicians and therapists can significantly contribute and affect the good outcomes of LBP.

The exercise regimens include proper cardiovascular conditioning, muscular toning, conditioning, strengthening, toning, stretching and ergonomics of the back.

Always consult your physicians including your heart physicians before participation.

Nutrition

Obesity or excess body weight imposes stress and strain on the spine and its vital structure and contribute to the cause of LBP. In most circumstances and settings, in conjunction with the above, a balance caloric expense and intake and good nutrition ensure the health and optimal conditions of muscles, tendons, joints, nerves, and bones.

BACK PRODUCTS

Furniture such as a chair or a seat affects the posture an individual using it. Most people spend more than one third of their lives on furniture at home or work. So, the ergonomic and supporting furniture is important.

Bed affects the posture of the low back and legs of a person lying on it. A firm and supporting bed is important. Most people spend about a third of their lives on bed or the like. In general, a good bed should give a person a good night of sleep. The person – with or without LBP – should awake refreshed and have no complaint or exacerbation of LBP upon arising from the bed.

Back braces and corsets comprise various types of soft and hard braces and corsets that can be used to aid the muscles, ligaments and tendons in the support of the low back. These devices are helpful and effective during the time of LBP. There are off-the-shelf types that can be readily bought. However, custom-made braces and corsets are crafted by skilled technicians who make prosthetics and orthotics that optimally fit the contour of an individual.

A physician who treats LBP can advise the patient on the use, application and indications and the sources for acquiring the braces and corsets.

Gel supports, cushions, insoles and footwear can significantly reduce the forces being transmitted from the ground to the back as each foot of an individual strikes the ground during standing, walking, jogging or running on hard ground or concrete surfaces. Thus, these devices affect the posture of and reduce the load on the muscles, tendons, ligaments, joints, nerves, bones and disc of the back.

Generally, most brands of running sneakers are well designed for absorbing the impact from the ground. On the contrary, well-designed dressed shoes for absorbing the impact from the ground are uncommon.

Traditional mechanical back stretcher and the like require that a stretching force of more than 50% of the body weight of the person is applied to stretch the soft tissues of the low back in order for it to be effective. In brief, at this level of force, the stretching is uncomfortable if not painful and is usually not tolerable by most patients. Therefore, essentially, this type of back stretcher is ineffective.