FAQ Category: Lumbar Spine

The question has been raised: is there a link between metabolic syndrome and low back pain? Any condition that can reduce or restrict physical activity has the potential to contribute to weight gain, diabetes, and low back pain. In a recent study from Japan, researchers investigated the relationship and prevalence between metabolic syndrome and low back pain. They paid close attention to the differences between men and women’s health.

Metabolic syndrome is a combination of medical disorders that, when occurring together, increase the risk of developing cardiovascular disease and diabetes. Different groups (e.g., American Heart Association, International Diabetes Federation, National Cholesterol Education Program) have varied criteria to define metabolic syndrome. Most at least include these three: 1) raised blood pressure, 2) central obesity (increased waist circumference), and 3) abnormal cholesterol levels.

Statistical analysis showed that obese women with metabolic syndrome were more likely to develop low back pain compared with obese men with metabolic syndrome. This difference looked more like a tendency toward low back pain among women than a significant trend.

Why the difference between men and women? Scientists suspect female-specific hormones and menopausal status have something to do with it. Women who are postmenopausal are also older, have reduced estrogen levels, and elevated blood pressure. Lower estrogen levels also contribute to decreased bone density, which in turn, can lead to low back pain.

The transition from premenopause to postmenopause estrogen-deficient status is associated with the emergence of many features of the metabolic syndrome, such as central obesity (intraabdominal body fat), insulin resistance, and dyslipidemia, which are also known to be risk factors for heart disease. The prevalence of the metabolic syndrome increases with menopause and may partially explain the apparent acceleration of heart disease after menopause as well.

There are three basic decisions to be made regarding spinal fusions. The first is the surgical approach. Will it be from the front of the body (anterior), back of the body (posterior), side (lateral), on a diagonal angle (foraminal), or a combination?

The second is whether the fusion will be in a straight plane or unidirectional (e.g., just anterior or just posterior). Or if the fusion will be an interbody fusion — multiple directions (circumferential) around the spinal segment.

The third is how the procedure will be done. Will it be with an open incision, mini-open, laparoscopic, or minimally invasive? Each of these decisions will influence the others, so it is up to the surgeon to decide and plan what works best for you while operating to his or her strengths (what he or she has experience with and expertise in).

The posterior lumbar interbody fusion you are going to have can be done as an open procedure or as a minimally invasive procedure. Going in from the back eliminates the risk to the abdominal organs and major blood vessels (e.g., aorta or iliac vessels). At the same time, it allows for a circumferential fusion with just the one incision. The downside of this approach is that it requires retraction (pulling away) of the dura and nerve roots. Any pulling or tugging on the nerve tissue can result in nerve damage.

The anterior lumbar interbody fusion (ALIF) avoids damage to the dura and exiting nerve roots but puts the abdominal organs, blood vessels, and nerve plexus at increased risk of injury. An ALIF will require a second approach in order to provide a circumferential fusion or when posterior stabilization is needed.

A transforaminal lumbar interbody fusion (TLIF) is minimally invasive and spares risk to the posterior structures (muscles, spinal column). But the surgeon must remove the spinal (facet) joint and that could leave the spinal segment unstable. The nerve roots have to be retracted (pulled out of the way) so there is a risk of nerve injury.

Some of the newer techniques such as XLIF and AxiaLIF are less well understood. XLIF is actually a trade name that refers to a direct lateral lumbar interbody fusion. The axial lumbar interbody fusion (AxiaLIF) is used to fuse the last lumbar vertebra (L5) to the sacrum (S1). Both of these surgical methods of spinal fusion have a short operative time and are minimally invasive.

There are many factors and variables to consider when choosing the best surgical option for each individual patient. Even weighing all the pros and cons, there may be reasons why one method would not be as good as another for you. Other things to consider include operative time, minimizing blood loss, number of spinal segments being fused, reason for the surgery, and so on.

There are many different ways to fuse the spine depending on the spinal level of concern, surgeon experience and expertise, need for instrumentation (e.g., metal plates, cages, rods, screws), and patient size (obesity makes an anterior approach more difficult).

Studies have been done comparing different approaches (e.g., anterior, posterior, transforaminal, interbody). While each one has its advantages and disadvantages, the overall results seem to be similar across the board. Complications can occur in any surgery but spinal fusion is by and large quite successful.

The area you mentioned (L5S1) can present a challenge because the pelvic bone (ilium) is so large and obstructs the area from the side. Some surgeons are now using what’s called a transaxial approach to fusing L5S1. A lateral incision is made and the surgeon goes through the psoas muscle (hip flexor along the front of the spine). The disc is removed from this vantage point and the spine fused using a minimally invasive system called axial lumbar interbody fusion or AxiaLIF.

There are some technical challenges and complications reported but it should be noted that not everyone experiences these. Injury is possible to the group of nerves or blood vessels to the pelvis and legs. Damage could occur to any of the muscles that are transected in order to get to the spine. Most problems are temporary and last less than a month. Occasionally, a patient will have a symptom that lasts as much as a year but this is unusual.

After reviewing many studies on lumbar fusion from 1950 to 2010, it is clear that more studies are needed to directly compare different fusion methods. There is not enough evidence at this point to say one approach is superior to the others. Tissue engineering and tissue regeneration may eventually replace surgical fusion. Such advanced biologic techniques could eliminate nerve or other soft tissue damage caused by currently used surgical methods.

Patients who have any type of spinal surgery can end up with persistent back and leg pain. This outcome is distressing to both the patient and the surgeon when just the opposite was expected (pain relief and improved function). Research to find out why these patients don’t get better is underway. If the surgeon can identify ahead of time factors that might predict failure, then the plan of care can be adjusted accordingly.

By finding preoperative predictive factors, researchers hope to help surgeons identify and preselect patients for surgery who will have a good result. Predictive factors can be almost anything: age, health, sex (male or female), menopausal status for women, tobacco and/or alcohol use, body mass index (BMI), and so on. In fact, depression is one of those factors that has come up as a risk for recovery.

Studies have revealed that psychologic problems such as anxiety or depression can have an affect on patient results after spinal surgery. But which came first: the depression followed by back pain or the back problem and then the depression? Is depression a predictor of results after a second (revision) surgery?

Researchers are evaluating each of these questions. Knowing the role of depression guides further research efforts. Recognizing that nonspinal health problems (including mental health issues) can affect the results of surgery is a big eye-opener. The next step may be to see if depression has the same influence on other types of treatment. Defining the role of other potential factors (e.g., diabetes, smoking, obesity, duration of symptoms before surgery) will also be important.

You are in good hands if your surgeon knows about the link between specific risk factors and results of surgery. If it turns out that you might not be such a good candidate for surgery, then the surgeon can suggest a more appropriate (and potentially more successful) approach.

Spinal stenosis is a narrowing of the spinal canal and/or openings for the spinal nerve roots to pass out of the spinal column and down the arms or legs. This narrowing can come about as a natural result of aging and degenerative processes. Bone spurs, thickening of the spinal ligaments, changes in the spinal joints are just a couple things that contribute to the development of spinal stenosis.

Surgery can be done to decompress the nerve tissue. The surgeon removes bone from around these sensitive tissues. Spinal fusion may be offered as a second approach for some patients. Fusion limits the amount of spinal motion, particularly at the segment where the fusion was done. It stabilizes the spine and protects the nerve tissue.

Your mother’s indecisiveness is understandable. After all, two spine surgeries is considerable. If she did not get the expected results (pain relief, improved function) then there may not be the motivatoin needed to face a third surgery.

There could be another reason and that’s depression. Your mother may not seem sad or experience bouts of crying but the inability to make important decisions like this one could be a symptom of depression. In fact, studies show that psychologic problems such as anxiety or depression can have an affect on patient results after spinal surgery. It’s possible that the poor results your mother has had may be directly linked with depression.

Before deciding on another surgery, it might be appropriate for your mother to be tested for depression. There are several reliable and accurate self-study surveys available for this kind of assessment. If she will let you, go with her to her next appointment and talk with her doctor about your concerns and her questions. The more you can sort through the whys and wherefores of her thinking, the better chances she has for a good treatment result.

Without knowing more of the details of your specific situation, it is difficult to predict what may happen. We do know from the many studies done in this area that on any given day in America, 10 per cent of the people are experiencing back pain. And that over the course of a lifetime, 80 per cent of all adults will have back pain at some time.

Does this mean that once you have back pain, you’ll always have back pain? No, most people (80 to 90 per cent) recover fully. But the chances of developing chronic pain increase with time. Studies show that people who have an episode of back pain who still have pain six months later are more likely to have recurrences and even become chronic pain patients. But again, this doesn’t mean that you will end up in the chronic category.

No one knows yet why some people recover from a bout with back pain and others don’t. There are so many variables to consider: age, sex (male or female), education level, satisfaction with work – home – life in general, income level, occupation, and so on. Research is ongoing to find predictive risk factors as well as look for ways to prevent back pain in the first place. Others are searching for ways to foster healing, recovery, and avoid recurrences.

If you have not explored treatment options, now might be a good time to check into some approaches to back pain. A medical doctor can advise you regarding medications to control pain and evaluate you to see if you might be a good candidate for other medical procedures to eliminate pain.

Other treatment known to provide benefits in recovery include: spinal manipulation, acupuncture, yoga, exercises, massage, or physical therapy. Sometimes it is necessary to find the right combination that will work for you. It can take time but it’s worth it when you are pain free once again.

Prognosis by definition is the forecast of what will probably happen and the outcome of an illness, injury, disease or other condition. Prognosis especially looks at the chances for recovery. Many times, recovery is based on pain relief, ability to perform daily activities, and return-to-work.

The natural history of back pain (what happens over time) varies from person to person. Scientists have not been able to accurately predict for everyone who will get well and who won’t. Right now, researchers exploring back pain are dividing patients into groups and subgroups. Then they look for common traits that might predict who will get well and who won’t. This type of classification scheme may also help us define what treatment type will work for each subgroup.

At the same time, efforts are being made to provide all health care professionals who treat back pain patients with a set of treatment guidelines called Clinical Practice Guidelines or CPGs. The CPGs are based on research evidence but also expert opinion and agreement. The idea is to create a response that is most likely to generate a positive outcome (prognosis) for as many people as possible.

There was a recent study where researchers from two large health care organizations tried to predict prognosis for patients with acute low back pain based on return to work. Over 600 people participated in the study. Each one had an episode of acute low back pain (with or without sciatica/leg pain) in the last 30 days. They were later contacted by phone (six months later and again two years later) to ask about their experience. As part of the survey, they reported their work status (full-time, part-time, unemployed and seeking work, not seeking work, retired).

Other data collected for review and study included how long the back pain lasted, level of pain intensity, and number of days in bed and/or off work. Each individual was also asked to rate their recovery as they viewed it on a scale from much worse to fully recovered.

Analysis of the data showed that prognosis when based on whether or not the person returned to work was much less favorable than when using other measures (e.g., pain, disability). Instead of the previously reported 10 per cent of patients who went from having acute low back pain to chronic pain, 13 per cent had chronic pain at six months and even more (19 per cent) had chronic low back pain at the end of two years.

Many of the remaining patients who did return to work did so with continued pain and physical limitations. Forty-one per cent (41%) reported having to change positions often just to get comfortable while 31 per cent tried to avoid bending or kneeling down. Other activities that posed problems for the group included turning over, walking quickly, getting up from a chair, or using stairs without a handrail.

In observing the results of the data, the authors make several other comments. First, there were quite a few people who were up and down with their back pain. Almost half of the group (47 per cent) had some additional recurrences of low back pain during the six months following their first episode. Second, patients with low back pain and sciatica (leg pain) were more likely to have a poor outcome. And third, results vary depending on the exact wording used to define acute and chronic low back pain.

The problems of going back to work while still in pain and continuing to work despite symptoms and disability need to be addressed. The fact that people often still have back pain six months after the first episode and that increases the risk of developing chronic back pain also needs attention. Efforts are needed to find ways to prevent back pain, recurrent back pain, and chronic back pain — in other words, improve the prognosis!

There are several different types and designs of disc replacement units or devices on the market now. Each one strives to preserve motion, mimic the body’s natural anatomy and function, and minimize or eliminate long-term side effects.

Artificial disc replacement is an acceptable (safe and effective) approach to the problem of degenerative disc disease many older people face. It is usually used at one level but has the potential to affect several levels on either side of it, possibly preventing breakdown at adjacent levels.

A successful result is defined by the Food and Drug Administration (FDA) as one that gives the patient at least a 15-point improvement in the Oswestry Disability Index (ODI). The ODI provides a measure of functional improvement that is so important for everyday activities. Other criteria set up by the FDA to look at success include: 1) no device failure, 2) no major complications, and 3) no neurologic changes.

Studies to date show similar results for the ProDisc-L compared with results published for other artificial disc replacement implants. Not all studies are conducted alike. Any differences can put barriers in the way of making direct comparisons. Then it becomes more a matter of comparing apples to oranges — both are fruit (disc implant devices) but the rest of the study parameters differ too much to provide useful information.

In general, there is currently an 88 to 90.9 per cent satisfaction rate with ProDisc-L in the first few years. Patients do notice a decline in maintaining the good results as time goes by. In one study, by the end of five years, the 88 per cent success rate had declined to 71.4 per cent. Only 60 per cent of those patients said they would have the surgery again. There were no complications or adverse events in either group making it seem like the perceived success should be higher longer.

It’s possible that the decline in improvements seen over time is typical of lumbar disc replacement surgery no matter who does the surgery and/or no matter which device is used. Further study is still needed to assess the long-term (10 years or more) results.

Total Disc Replacement (TDR) in the lumbar spine (low back) for degenerative disc disease is becoming more popular as studies report good-to-excellent results. The device helps reduce pain while preserving motion and therefore offers a more functional treatment than spinal fusion.

There are several different types (brands) of disc replacement devices available now. More and more short- to mid-term studies are reporting their results. Most of the time, patient outcomes are measured in a variety of ways (not just one or two). Surgeons might use X-rays to confirm that the position of the device is holding.

The Visual Analog Scale (VAS) is often used to measure pain. The Oswestry Disability Index (ODI) helps measure function and sporting activity scale scores provide information on activity and recreation.

The Oswestry is one of the most popular tools used to measure before and after results of spine surgery including disc replacement. The researchers set a minimum number of points required for improvement on the Oswestry to be considered “improved” or “a success.” Alternately, in another approach, patients are asked questions such as: 1) how satisfied were you with the results of surgery? (e.g., satisfied, very satisfied, dissatisfied, or very dissatisfied and 2) if you had to do it over, would you have the surgery again?

So far researchers are finding similar results. Between 80 and 90 per cent of the patients have excellent results with no complications and no adverse effects of the surgery. That is for the first two years. But after that time, results seem to decline a little bit every year out. In one study, five years later, only 71 per cent of the group were able to hang on to their good results.

Only 60 per cent of the patients said, ‘Yes, if given the choice, I would have this surgery again.’ The authors expected that statement of satisfaction to be higher to match the increase in function in at least the 71.4 per cent group. There were no complications or adverse events in either group making it seem like the perceived success should be higher longer.

As they looked back over the study, the authors of that particular study observed several things that might account for the disconnect between functional improvement and patient satisfaction. First of all, the cut off for a threshold of improvement using the ODI (15 points better = success) might be too conservative. A 10-point difference might have given a higher satisfaction rate while still registering significant improvements in function.

It’s possible that the decline in improvements seen over time is typical of lumbar disc replacement surgery no matter who does the surgery and/or no matter which device is used. In this study, they only used one implant and therefore did not compare the mid-term results with other devices. At five years out, further study is still needed to assess the long-term (10 years or more) results. Future studies should also include a control group, which this one did not have.

Even simple surgeries are still surgery and that is an invasive procedure to the body. After surgery, the body does its best to repair and heal. An amazing number of processes take place as the body sets up an inflammatory response. Chemicals known as neurotoxins enter the area during this healing response and scar tissue forms. Any of these things can irritate the already compromised nerve tissue resulting in more (not less) pain.

Of the more than 700,000 people who have lumbar spine surgery every year in the U.S., one out of five (20 per cent) will experience persistent pain. In some cases, the pain is gone for a short time but comes back. The mechanism by which this happens is understood but why one person develops this response while another does not remains a mystery.

And the list of possible adverse effects is quite long. Though not everyone experiences all of these symptoms, besides back and leg pain, headaches, dizziness, stiffness, muscle or joint pain, and sensory changes have all been reported. Patient satisfaction is lowest when the expectation and hope is for pain relief but the reality is persistent pain (and sometimes even a worsening of symptoms).

No one likes to think about having another surgery after the first but when reoperation is necessary, it usually happens in the first three months. If you have not been back to see your surgeon, now is a good time to arrange for a follow-up visit. There may be a simple solution to the problem that doesn’t require further surgery. If a second surgery is indicated, it may be helpful to have it done sooner rather than later before any more scar tissue forms. Your surgeon will be able to advise you best on this.

Various studies have been done trying to identify the best way to approach back pain. Clearly, staying active and exercising seems to help. But the key question remains: what’s the best type of exercise for this problem?

Some of the exercise methods currently being studied include lumbar stabilization (core training), McKenzie (direction-specific) exercises, muscle retraining, and Pilates exercise. You might find the results of a recent study using Pilates to treat low back pain of interest.

The research was conducted by physical therapists investigating the possibility of developing a clinical prediction rule (CPR) for Pilates-based exercise. CPRs are guidelines to help therapists identify and recognize factors that predict a response or nonresponse to treatment. Clinical prediction rules (CPRs) are helping physical therapists find ways to identify which patients would likely respond best to individual treatment approaches.

By studying patients who respond well to this approach, it might be possible to tell (in future patients) which ones would do best with Pilates training. The Pilates method includes breathing, balance, concentration, control, coordination, precision, and rhythm in movement.

Each exercise starts out gradually and builds up in terms of range, strength, and endurance required. This type of exercise progression is referred to as graded-movement. Motor control of both the large (mobilizer) and small (stabilizer) muscles is a part of the exercise program. Mobilizing muscles allow trunk movement while stabilizers provide stiffness and support to each spinal segment.

Everyone in the study (a total of 96 people) had low back pain but no previous back surgeries. Everyone filled out several surveys to assess pain, function, fear-avoidance behaviors, and general health. Range-of-motion measurements for the spine and trunk were recorded. Special tests for muscle endurance, ligamentous laxity, and spinal instability were also performed.

Everyone was treated twice a week for eight weeks with the Pilates method. Results were determined by retesting all the baseline measures. Slightly more than half the participants had at least a 50 per cent improvement in their test scores.

Then the authors examined a number of different factors or “variables” to see if any of them were consistently present in this successful group. They looked at things like age, body mass index, duration of symptoms, number of previous episodes of back pain, presence of leg pain or other symptoms, and hip rotation.

They found five predictors that suggested which patients with low back pain would respond to Pilates-based treatment. These included: trunk flexion (70 degrees or less); symptoms lasting less than six months; no pain, numbness, tingling, or other symptoms in either leg; being overweight (BMI greater than 24 kg/m2); and hip rotation greater than 25 degrees on either side (right or left leg). When three, four, or all five of these factors were present, there was a significant likelihood that Pilates-based exercise would help the patient.

These results are considered preliminary. Further study will be needed to confirm that the information fom this study can be used to set up a clinical prediction rule for Pilates-based exercise when treating low back pain. A randomized-controlled, clinical trial will be needed to validate this conclusion. If it all pans out as expected, therapists will be able to determine early on which patients will likely respond well to the Pilates method.

That’s a good question and one we may not have an exact answer for. But here’s some information that might guide you. There are two things we know for sure about low back pain: 1) there is no known cause for the majority of people who experience this problem and 2) there’s no magic treatment that works for everyone. Despite this knowledge, physical therapists have not been scared away from trying to find effective ways to help people manage this condition.

We know that exercise as a form of therapy helps many patients in terms of pain reduction and improved function. With that in mind, the next step is to find out which specific exercise program works best. Research toward this goal has led to the development of a concept called patient classification. Patient classification divides people into groups of people who have similar characteristics. This creates more of a homogeneous (similar) group, which is easier to study and provides more reliable data.

Patient classification has then resulted in clinical prediction rules (CPRs). CPRs are guidelines to help therapists identify and recognize factors that predict a response or nonresponse to treatment. Clinical prediction rules (CPRs) are helping physical therapists find ways to identify which patients would likely respond best to individual treatment approaches.

It sounds like you have found therapists who have some specific training in one of the many treatment methods out there. Perhaps you saw something about spinal manipulation or lumbar stabilization exercises. There’s also the McKenzie technique (direction-specific exercises), muscle retraining, and Pilates exercise.

Therapists are trained to evaluate all patients and consider whether there are reasons to use one approach over another. Even though they may advertise a specific type of method, if you don’t respond to that treatment (or the therapist can tell from the start that you need something else), then you will be treated accordingly or referred elsewhere.

The best approach may be a quick telephone interview with each clinic you have found. Let them know your situation and ask how their program might benefit you. You can also make a brief appointment to meet the therapist directly and ask a few questions that might help you find the right match for you. Like many people with back pain, it may take a period of trial and error to find the right treatment or combinations of approaches that works best for you. Don’t give up!

Physical therapists are indeed commonly involved in the treatment of patients with low back pain. Like all health care professionals, therapists must base treatment on evidence that the treatment is beneficial to the patient.

The evidence we have so far suggests that not all low back pain should be treated the same. Sometimes manipulation is the best approach whereas in other cases, exercises are advised. And even within those categories of treatment, there are subgroups to choose from. For example, exercise could include stretching for flexibility or strengthening to improve stability.

How does the therapist know what treatment to provide for each individual patient? The answer to that question can be found in the recently published document: Low Back Pain. Clinical Practice Guidelines (CPGs) Linked to the International Classification of Functioning, Disability, and Health (ICF) from the Orthopaedic Section of the American Physical Therapy Association (APTA).

Risk factors, clinical course, diagnosis, examination, and outcomes are all discussed in detail. Information provided and recommendations made are all based on current evidence available. The approach taken is toward returning patients to their previous level of function. This is a shift from the past when everything was viewed as disability and dysfunction rather than ability and function.

This publication is a must-read for all physical therapists who are working with patients who have low back pain. As the name implies, the 57-page document is a guide to assist therapists in knowing how to approach each patient with low back pain.

This clinical practice guideline for low back pain treated by the physical therapist was written by eight physical therapists best-known for their research, knowledge, and understanding of low back pain. An even larger group of names well-known to physical therapists are listed as reviewers. As more research is done and evidence becomes available, these guidelines will be updated.

You may want to ask your therapists if they are familiar with this document and/or using the guidelines to plan treatment for you. Patient education should be a feature of every physical therapy program provided to patients with low back pain. This would be an opportunity for your therapist to provide additional information as requested by you.

Medical doctors make diagnoses based on patient symptoms and clinical presentation (e.g., low back pain, lumbago with sciatica). When there is an underlying problem such as infection, tumor, or fracture, then the diagnosis reflects the pathologic process present.

Physical therapists confine their diagnoses to the musculoskeletal system in what they call human movement impairments. The way we move in everyday life during our daily activities may not be caused by a specific pathologic process. Instead, over time with sustained postures and repeated movements, we may eventually develop problems and pathologic abnormalities.

So both the viewpoint and the approach of these two health care professionals (physicians and physical therapists) is very different and thus requires different names of diagnoses. There are also diagnostic categories set up for billing purposes that may direct and guide the naming of a diagnosis. For example, there are ICD and ICF codes used to bill for services.

ICD stands for International Statistical Classification of Diseases and Health Related Problems. ICF refers to the World Health Organization’s International Classification of Functioning, Disability, and Health codes. There are both ICD and ICF codes used to name/describe low back pain.

There is a move now in health care for all organizations to use the ICF codes so that no matter where a patient is treated (anywhere in the world), the same codes will be used for everyone. This will also help facilitate consistency in research efforts.

Your physician is using the ICD code of lumbago with sciatica to best describe your problem with that system. Your physical therapist is giving a name to your condition that best describes it using the human movement system descriptors. Both are correct when coming from the two different perspectives, billing codes, and way the problem will be treated.

Your frustration is appreciated and understood. Many people find themselves in difficult circumstances like this without knowing how to work through the problem. You may need some help finding the optimal approach to your back pain.

Having other mobility problems (e.g., ankle pain, knee or hip arthritis) can certainly put a monkey wrench in the solution. Other health concerns faced by many people are called comorbidities. Comorbidities include such things as the heart condition you mentioned. Other people say the same thing about their diabetes, cancer, high blood pressure, and so on.

Bu, in fact, study after study show these are the very problems for which exercise is best suited. Some experts go so far as to say, “Exercise is the most important drug in America.” What they mean is that when medications are stacked up against exercise for heart disease, exercise yields the best results most often.

The challenge you are facing is in finding the right kind of exercise — something you can tolerate while getting some benefits. A pool-therapy program may be helpful. Some folks respond well to exercise on a recumbent bike. The best person to help you with this may be a physical therapist.

Therapists are trained to assess strength, motion, and function and then find optimal ways to help you manage your symptoms. This often includes exercise but may start with heat or cold modalities to help reduce the pain and make it possible to move more.

At first, it may seem a bit like eating an elephant. But as the old saying goes, you do it one bite at a time. With painful musculoskeletal problems, time and persistence are required to find what works best for each individual. Take the first step, be patient, and keep working to find what combination of care helps you the most to get on (and stay on) the road to recovery. Good luck!

The first step is to make sure a serious problem or cause for her painful symptoms has been ruled out. Before proceeding any further, it must be clear that there isn’t a fracture, infection, or tumor at the bottom of her symptoms.

If she is indeed having what we call nonspecific low back pain, then the current recommendations for management are: stay active, exercise (prescribed by a physical therapist for each patient), manual therapy (including spinal manipulation by a physical therapist or chiropractor), and acupuncture. Pain control through medications has a role but it should not be the only treatment applied.

Studies show that older patients are more likely to have been to the doctor for low back pain before and given exercise recommendations. With subsequent visits, they are less willing to accept exercise as the answer and more likely to tell their doctor “exercise won’t work for me.”

Older adults are also more likely to complain of pain elsewhere (e.g., hip, knee). This may be a factor in why they are given pain relievers and other medications instead of following the current accepted guidelines for the management of low back pain.

When cognitive behavioral therapy (CBT) is suggested, there has been even more resistance than to exercise and less positive attitudes. CBT is a form of counseling aimed at changing attitudes and fears about movement and staying physically active.

Some people with chronic low back pain are so afraid of causing pain that they start to avoid movements and activities that might cause pain. This attitude is called fear avoidance behavior (FAB). And FAB has been shown in many studies to be reduced with cognitive behavioral therapy with the net result of decreased pain and improved function.

These attitudes about exercise and behavioral therapy among older adults represent a new challenge in the treatment of low back pain that may not have been recognized previously. Experts in this area recommend a thorough pain assessment and referral to appropriate specialists (physical therapist, acupuncturist, chiropractor, counselor) for patients who are willing to go. Education of the patient is often the key to compliance and response to treatment.

The mystery of low back pain and how to treat it continues. Until scientists can pinpoint the exact cause of nonspecific low back pain, treatment is usually symptomatic: decrease pain as quickly as possible and restore normal movement. To that end, researchers have managed to find evidence-based clinical practice guidelines (CPGs) to direct conservative (nonoperative) care.

“Usual” care consists of spinal manipulation, soft tissue treatments, exercise, and education or advice. Care as outlined by evidence-based clinical practice guidelines follows what your physician has provided.
First and foremost, patients should receive advice and education.

Self-care is emphasized and information provided about the causes, course, expected course, and treatment of low back pain. Patients with acute (early onset) low back pain are encouraged to stay active and return to work as soon as possible.

The use of exercise therapy, massage, heat and cold, traction, corsets or supports, and electrotherapy is not supported. There isn’t strong, consistent, or reliable evidence that these types of treatments are effective.

In a recent study from the School of Chiropractic and Sports Science in Perth, Australia chiropractors attempted to give meaningful numbers to results of treatment for acute low back pain. They compared two groups of patients who have experienced nonspecific low back pain of less than six weeks’ duration. The two main measures of clinical outcome included disability scores and pain.

The results showed no difference in final outcomes at the end of four weeks. What was particularly striking was the fact that patients in the experimental group (following clinical practice guidelines) were significantly better after two weeks compared with the control group who received usual conservative care.

So for faster results which could mean getting back on-the-job or back to daily activities sooner than later, the evidence-based guidelines remain the first choice for treatment of acute episodes of low back pain.

The authors note that this ‘less-is-more’ approach recommended by your physician has been confirmed effective by other studies as well. X-rays are not recommended on the first visit unless the physician has reasons to think there might be a fracture or tumor. The reliance on drugs such as antiinflammatories and muscle relaxants is diminishing now, too based on research.

The key here may be the type of back pain and the response rate for recovery. Studies do indeed show that patients with nonspecific, acute low back pain respond well to spinal manipulation. Acute low back pain usually refers to an episode of back pain of less than six weeks’ duration. Nonspecific back pain means there is no fracture, tumor, or infection. Instead, some aspect of soft tissue, joint, and/or biomechanics (the way things move) is likely the cause of the problem.

Experts in the area of low back pain agree that “less is more” when it comes to treating acute low back pain. In fact, two sessions of spinal manipulation have been shown to reduce pain and disability by 50 per cent and should continue to be the first treatment choice for this type of problem.

The use of exercise therapy, massage, heat and cold, traction, corsets or supports, and electrotherapy is no longer recommended for acute, nonspecific low back pain. There is not strong, consistent, or reliable evidence that these types of treatments are effective. These kinds of treatments may offer symptomatic relief for the management of chronic low back pain but they simply don’t provide a “cure.”

Patient information and education seem to be the keys to fast, effective relief from early onset of back pain. Research studies repeatedly report these focus areas as the best way to reduce symptoms (especially pain), reduce health care costs, and prevent acute problems from becoming chronic.

Based on current evidence, it sounds like your physician is actually following the recommended clinical practice guidelines (CPGs) for the treatment of acute low back pain. Prescribing medications without evidence of their benefit is poor medicine at best and just giving in to patient complaints of pain, misery, and suffering.

All the studies confirm that if you follow the advice as given to you by this physician, you will actually do better in the short- and long-term. Rest and inactivity may be okay for the first 24 hours but after that, the proof we currently have strongly supports patients with low back pain stay active. That doesn’t mean go out and run a marathon (or some other extreme level of activity) but rather, keep moving as much as possible in the pain free range.

It’s best to avoid adopting what’s commonly referred to as the sick role (e.g., staying in bed) as this will delay recovery. One recommendation the research supports that may have been mentioned by your physician was the use of manipulation for acute (early onset) low back pain.

Early onset means seeing a chiropractor or physical therapist for manipulation of the spine within the first three weeks after symptoms began. During a spinal manipulation, the practitioner applies a high-velocity force to shift position of the vertebra.

Realigning the spinal bones also helps restore more normal soft tissue structures around the spinal joints. The results are decreased pain and more normal movement — or perhaps the other way around: more normal movement and subsequently less pain. Paying attention to posture and alignment and including a program of exercises for flexibility and strength is also a good idea and supported by the medical literature.

According to a new study from New York University School of Medicine you may not be far off. There has been speculation by many experts about the process used by medical doctors in deciding how to treat acute (early onset or first episodes) of low back pain. This question has been raised again and again because there are now actually clinical practice guidelines (CPGs) to advise physicians on the best known (evidence-based) approach to low back pain.

In the study, the researchers surveyed 284 physicians from five different clinical sites (both primary care physicians and emergency department physicians). They asked questions about physicians’ decisions related to patients with low back pain.

Physicians were given a case scenario of a patient with recent onset of low back pain. After giving a written summary of the patient’s characteristics, physicians were asked about the diagnostic approach and treatment they might choose for this patient. Analysis of the data took into account the type of treatment recommended based on three factors (sex: male or female, socioeconomic status, and clinical presentation).

Each of these three variables was analyzed based on diagnostic tests physicians would order and the type of treatment recommended. Some of the diagnostic options included blood tests, urinalysis, X-ray, CT scan, MRI, or discography. Of course, no diagnostics was an option, too.

On the treatment side, physicians could recommend no treatment or referral to another physician (specialist), physical therapist, chiropractor, osteopath, or psychologist. Choices of specialists included orthopedic surgeon, physiatrist (physician who specializes in rehabilitation services), neurologist, gynecologist (for women), and anesthesiologist.

For half the physicians, no diagnostics and referral were recommended. Patients were given instructions to stay as active as possible, use heat or cold, and take pain relievers as needed (e.g., ibuprofen or other antiinflammatory). The natural course of the back pain would be explained and an educational pamphlet provided. Almost all physicians recommended a follow-up visit. When referral was recommended, it was most often to a physical therapist.

Of particular interest in the results was the apparent independent link between sex (male versus female) and socioeconomic status (SES) with activity recommendations. It seems physicians were more likely to encourage patients to remain active if they were white-collar workers (higher SES status), especially men. Blue-collar workers (e.g., manual laborers) and women were more likely to be told to take it easy, rest, and restrict heavy lifting or other manual work at home and at work.

The other nonclinical factor that seemed to influence physicians’ treatment decisions was the clinical presentation. Patients who expressed distress about their back pain were more likely to be given a prescription for medications. Though not stated, the authors presumed this behavior on the part of physicians was to reduce the patient’s suffering.

However, there is no scientific evidence that such treatment is beneficial or yields any better results than doing nothing. And there is plenty of evidence that staying active will improve outcomes.

The authors summarized their findings by saying that this study provided more evidence that for the most part, primary care and emergency department physicians are not treating patients with acute low back pain according to current clinical practice guidelines. Instead, they are being influenced by patient characteristics such as gender (male versus female), socioeconomic status, and complaints of pain, distress, and suffering.