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Low Back Pain


Norman Allan

Low Back Pain (LBP) is one of the most common human afflictions. 80% of the North American population see a doctor for treatment of low back pain at some point in their life and, indeed, at any particular time as many as 20% are suffering from low back pain.

There are many varieties of low back pain - many presentations and many causes - and the symptoms donít necessarily tell us too much about the cause.

Low back pain may strike when you lift something and feel a twinge which might get slowly better or slowly worse. Or you may attempt to lift something heavy and suddenly find yourself in acute and severe pain: you may be disabled. You might simply bend forward to reach for something and be unable to straighten. You can wake up stricken. Low back pain can have a sudden or a gradual on-set. The pain can be local or may radiated down the back of the legs in the distribution of the sciatic nerve in which case it is called "sciatica".

The external cause of low back pain can be lifting, overloading the spine, leading to a "failure": or a failure might be caused simply by an uncoordinated movement which compromises a joint and leads to muscle "splinting". The muscles go into spasm to "fix", to protect the joint, and then they typically take three days to relax.

Less frequent causes of low back pain include "referred pain". For instance, the kidneys might refer pain to the high loins, or again, inflammation in the abdomen can cause irritation in the muscles of the back and this in turn can cause back pain.

I believe the "lesion", the tissue damaged in low back pain, is most commonly either 1/ in the joint complex or 2/ the intervertebral disc (affecting the spinal nerve), and of these two common causes the former, the lesion to the joint, is much the most common. (In the literature other "lesion" are mentioned: ligaments, but these are, for the greatest part, part of the joint complex; and muscle and tendon tears, and yes indeed these may be part of the "lumbago" picture.)

Discs: letís speak first about discs. Though not the most common causes of low back pain, they can be troublesome and persistent. People in their twenties and thirties are most at risk. As you get older the risk decreases, perhaps because of the ageing of the disc itself.

The disc is made up of two parts. The central third is a jelly-like "ball-bearing" called the nucleus pulposus. It is surrounded by a cord-work of ligaments, the annulus fibrosus.

Failures, cracks, in the annulus fibrosus can lead to the protrusion of the nucleus pulposus from the disc. These are the "bulges" we hear so much about, and as the bulging proceeds we get "herniation" and "prolapse" of the disc. These failures in the annulus fibrosus are usually posterio-lateral and unfortunately this is precisely where a prolapse can impinge upon, and crush, a spinal nerves as it emerges from the spinal canal.
This is the so-called "pinched nerve", but let us stress again that these pinched nerves are relatively rare. (What is commonly called a "pinched nerve" by the public, by doctors and by chiropractors alike are in fact "pinched" or compromised joints!).

If you have a "slipped disc" there will be pain, there will be changes in the reflexes, and there will likely be radiation into the butt, the posterior thigh (and leg), and paraesthias (numbness and tingling). These signs will also very often be seen with the more common joint problems. They do not in themselves indicate a discal lesion. With a slipped disc there is almost always a reduction in "straight led raise" (SLR) - lying on your back you will be unable to raise the straight leg more than 20 to 40 degrees (instead of the normal 70 to 110 degrees). While reduced SLR may be seen with joint problems, the absence of reduced SLR strongly mitigates against a diagnosis of a discal lesion.

Disc problems may occur with intense pain, sciatic radiation, lost reflexes, paraesthesias, debility - you may be stricken and unable to move much or function - and yet this is not in itself a medical emergence! The "radiations", paraesthesias, lost reflexes are what we call "soft neurological signs" - donít panic.

"Hard neurological signs" are 1. loss of sensation (but not numbness and/or tingling), 2. loss of motor function (but not loss due to pain), and 3. muscle atrophy: and these hard signs warrent urgent medical attention.

What to do: doctors used to urge bed rest and this may be unavoidable, but it is no longer recommended. Rather, as chiropractors have always urged, it is best to undertake as much gentle exercise as you can manage without causing further aggravation.

JKW has a set of exercises for acute Low Back Pain that are proving to be very helpful.

In my practice I have also found that extremely gentle CranioSacral-like traction is helpful. However, I would not recommend strong traction.

Electrotherapy (including TNS: transcutaneous nerve stimulation, which you can use at home) can help with the pain.

If pain-killers are "whatever gets you through the night", you may need to use them, but on the other hand, muscle relaxants are of no proven value.

Acupuncture can be helpful.

I believe that the Gonstead Technique of chiropractic (were the vertebra is nudged forward) can help reposition the spine and take pressure off the disc, but rotary chiropractic adjustments are strongly counter-indicated.

Clinical studies suggest that seeing a chiropractor is slightly better than seeing an MD but not much better than seeing no one at all. You will probably need to see someone for a diagnosis and for reassurance, so find a chiro or a doctor with a good bed-side manner and a lot of integrity.

The "slipped disc" typically takes about six weeks before recovery is noticeable. Recurrence is not the rule, but can happen.

The Medical Emergency: "hard neurological signs" include 1/ loss of feeling/reduced sensation in the lower limb, 2/ loss of motor function not due to pain, and 3/ muscle wasting. If you observe these signs of frank nerve compression you need to see a neurologist or an orthopaedic surgeon as soon as possible!

Can surgery help? Yes, but rarely. Perhaps in 1% of cases. More often it is irrelevant and risky. The "bulging disc", as often as not, is asymptomatic (see for example: Deyoís "Low-Back Pain" article in the Scientific American). Operating simply because there are signs on X-ray or MRI is dangerous to say the least. Low Back surgery "fails" about a quarter of the time; helps about a quarter to the time - but it is sometimes essential. SoÖ find a doctor you can trust.

Facet and Sacroiliac Joints: joints are the most extremely sensitive of tissues. If you want to physically subdue someone you will probable do so by compromising one of their joints, for example, twisting their arm. This is because if a joint is not perfectly in place and functioning smoothly it will soon degenerate. Therefore, for their protection, they are extremely well innervated. (Before antibiotics we used to see a condition called "Charcottís joint": in syphilis "position sense" is lost and as a consequence the weight baring joints totally disintegrate.) Because the integrity of the joints is so important they are exquisitely sensitive. Have you ever put a finger "out of joint"? To me the very thought is painful.

In "medicalese" a dislocation is called a "luxation": in chiropractic when a joint is not fully dislocated but is out of place we call it a "subluxation". As indicated above, a joint out of place is trouble. It is trouble because it leads to degeneration and its trouble because it causes pain or discomfort. The pain in turn can cause further problems such as spasming in the muscles associated with the joint. And there may also be more complex complications. Irritation at any spinal level will tend to cause "an increased sympathetic tone" at that level. It is as though that spinal level is "adrenalated" and the organs at that level will be more "excited" and, at the same time, less well perfused with blood. (An example of this was a young lad who fell out of a tree subtly injured his back and ended up with severe asthma through a disharmonious excitation of the lungs: see Gonstead technique.) On another occasion leaning forward to lift something from the trunk of the car I seized up with immediate and severe back pain. I was a chiropractic student at the time. A classmate diagnosed a sacro-iliac joint "fixation" and an adjustment again brought instant relief.

Other dramatic instances of low back pain patently caused and cured by "joints" include a young man who slipped on the ice - his wife was in hospital delivering their second child, he was at home looking after the first, but he was now disabled. One adjustment had him fit again.

I recall a young lady who came to see me with chronic low back pain. We adjusted her "L5" in one session and her sacro-iliac in another. After this I didnít see her for half a year. I bumped into her six months later when she introduced me to her friend as the man who had changed her life. Not only was chronic back pain gone, but fifteen years of painful periods cleared up! (Here, through the mechanism alluded to above, a painful back was adding to the irritation of the womb.)

These rapid recoveries, though common, are not necessarily typical. Where there has been injury to the compromised joint it may take time for that injury to heal (and until the injured tissue heals the pain can cause spasms which can further compromise and irritate the joint: a vicious circle. There are treatments which can help with this healing: see sprains and strains coming soon to this site).

There are also more subtle treatments which may help with chronic conditions. M.V. had chronic back pain and chiropractic had not helped him much, but when we used CranioSacral Therapy in conjunction with the Gonstead Chiropractic Technique of chiropractic he recovered quickly and stayed pain free. (Feldenkrais, Alexander, and Rolfing are techniques that address similar issues and might also be useful.)

Not all back pain responds to these "conservative treatments". With chronic, intractable pain you may need to try more "heroic measures" such as nerve blocks or epidurals. It is difficult to predict where and when these procedures will help. They are measures of last resort. You need to find doctors, traditional and alternative, who you can trust.

The bottom line: if you have low back pain and it is not a medical emergency (as explained above this is loss of sensation, loss of power, muscle wasting) it is worth trying chiropractic or osteopathy. Where the problem is more extreme (bordering on the "medical emergency") you will need expert advise (probably a good chiropractor and an orthopaedic surgeon or neurologist), though you may still have to wait on your own slow healing.

And, take note: if you are well, or once you are well again, exercise and stretching are your best protection.

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