FAQ Category: Lumbar Spine

Piriformis syndrome: what is it? How do you get it? How do you know you have it? How do you get rid of it? What else do you need to know? That’s the substance of a recent review article written by two well-known and well-respected physical therapists on the subject of piriformis syndrome.

Let’s start with: what is the piriformis syndrome? The piriformis muscle is a flat, pyramid-shape structure. It starts along the anterior (front) part of the sacrum and inserts or attaches on the greater trochanter of the femur. That’s a bony bump at the top of the upper thigh bone. It is close enough to the sciatic nerve that it can either put pressure on the nerve. In about 10 per cent of all cases, the sciatic nerve actually runs through the piriformis muscle. Anytime the muscle contracts, the nerve gets squeezed.

Some experts think it’s this pressure that causes the symptoms that make up piriformis syndrome. Those symptoms include aching, burning, or sharp pain in the area controlled by the sciatic nerve. The pain starts in the mid-buttocks on one side and can shoot down the upper leg. Symptoms may go down as far as the knee but only occasionally go past the knee. How far down the leg the pain goes can help distinguish it from a herniated disc. Pain that does go past the knee down to the foot is more likely to be from a protruding disc putting pressure on the spinal nerve root.

Before going much further, it’s important to say there are some medical specialists who don’t believe the piriformis syndrome even exists. So, some effort has been put into identifying just what constitutes the idea of a piriformis syndrome. Here are six indicators of this condition:

There’s no doubt that smaller incisions during spine surgery (called minimally invasive spine surgery or MISS) has many advantages. Besides the tiny scar left behind, patients experience less tissue trauma. There is faster recovery of muscle strength when muscles don’t have to be cut away and reattached at the end of the operation.

Some studies show less blood loss with MISS, shorter hospital stays, and lower costs as a result. With fluoroscopy for viewing the spine, accuracy is improved when placing tiny screws in the vertebrae through these small incisions.

Why isn’t it done more often? There are several reasons. Not every hospital can afford to invest in the surgical tools necessary for this type of procedure. With each specialty area, new technology is available but very expensive. There are laser tools for cancer surgeries, computer-based CT and MRI scans, fluoroscopes (real-time X-rays) for orthopedic surgeries, and so on. From a business point-of-view, they purchase the equipment that will be used the most.

Surgeons must take the time to get trained in these newer techniques. Of course, each surgeon will have his or her own transition time learning how to do surgery with minimally invasive methods. Patient safety and good results are always on the surgeon’s mind.

It does take time and practice to learn any new skill or surgical technique. If there isn’t a large number of people in the area who will need the particular minimally invasive surgery needed, then the surgeon is less likely to seek out that training.

There’s been a lot of talk about stem cell research. Many scientists are convinced that the results of aging-related degeneration of the spine can be altered with stem cells. For example, the breakdown of disc material between the vertebral bones could be repaired by regenerating discs with stem cells.

But until that’s really available, other researchers continue to study alternative methods to replace the intervertebral discs. As you know, artificial disc replacement is now available. And just as you suspected, efforts are also underway to just replace the center portion of the disc called the nucleus pulposus.

Advanced technology now allows the surgeon to remove the damaged or degenerated nucleus pulposus and insert an implant in its place. The implant (prosthesis) is designed to bear the load through the spine at that level and prevent further collapse of the affected vertebral segments. The hope is that the remaining disc will be protected and remain strong over time.

Nucleus pulposus biotechnology has already gone through several generations of pulposus replacements. Replacement materials for the nucleus come in two basic types. There are mechanical metal or carbon devices that are inserted into the space left by removal of the pulposus. And there are injectable elastomers that fill up the nucleus pulposus cavity and harden after they have been squirted into place.

Studies so far have been encouraging. A large proportion of the small number of patients studied experienced pain reduction, decreased use of narcotic drugs for pain, and improved function. Complication rates have been low. And the discs have been shown to withstand 10 million cycles of fatigue when tested biomechanically using cadavers (vertebral segments preserved for study after death).

Most of the studies done so far have been completed by the companies that designed and developed the implants. Before these can be adopted for regular use, tests must advance from cadavers to animals to clinical trials with humans — first by the disc replacement industry and then by outside, independent agents. The race is on to find a way to slow or reverse disc degeneration eliminating the need for nucleus (partial) or disc (complete) replacement.

Seronegative means blood tests came back negative for rheumatoid factor (RhF). RhF is positive when the joint problem is associated with some form of rheumatoid arthritis. Anyone who is seropositive likely has some type of underlying inflammatory cause of their pain.

When any part of the spine (including the sacrum and sacroiliac joints) is involved and there’s an inflammatory cause, the condition is referred to as a spondyloarthropathy. The most common seropositive spondyloarthropathies affecting the sacroiliac joint include ankylosing spondylitis, reactive arthritis (also categorized as Reiter’s syndrome), enteropathic arthritis associated with inflammatory bowel disease (IBD), and psoriatic arthritis.

If you are seronegative, it’s likely you don’t have any of these problems causing your symptoms. Another test that can be used to make sure the sacroiliac joint is even the cause of the problem is a steroid injection directly into the joint. Pain relief is an indication that the sacroiliac joint was, indeed, the source of the problem(s).

Steroid injection into the sacroiliac joint has been proven diagnostic in showing whether or not that’s the source of back, buttock, and/or leg pain. If the injection reduces pain by more than 50 per cent, the treatment is considered successful and confirms the source of the pain as being the sacroiliac joint.

But as with any test, it is possible to have a false positive or false negative response. In the case of a false positive test, the patient gets better but not because there was a true sacroiliac joint dysfunction that responded to the antiinflammatory/numbing agent. That’s why a second injection may have no effect.

In the case of a false negative, the first injection failed to change the patient’s pain, so it was thought that the problem wasn’t in the sacroiliac joint when it really was the culprit.

There are other factors to consider when evaluating the effectiveness of steroid injections into the sacroiliac joint for control of back, buttock, or leg pain. The results of a recent study of patients with sacroiliac joint dysfunction but without spondyloarthropathy (underlying inflammatory cause) may help.

Those who were treated with steroid injections found that having a lumbar or lumbosacral fusion could hamper the results. Those patients were less likely to get better or have a sustained (more than six weeks’ long) period of pain relief.

So, there may be an explanation for your situation. But it can be a very individual and variable reason for the outcome. Some say don’t bother having the second injection if the first didn’t work. Others want to test the theory that it was a false negative and that a second (or even third) injection is still reasonable. Your physician may have some additional insight to offer based on your history and clinical exam. Don’t hesitate to bring this up for discussion.

There have been many studies done looking at the effects of insoles for leg length differences. Both custom-made and off-the-shelf types have been examined. Different materials have also been compared.

Clinical experience of chiropractors, physical therapists, and orthopedic surgeons suggest that insoles or shoe lifts to correct a significant leg length difference can make a difference. But studies on this topic have been full of problems.

First, defining significant leg length discrepancy has been a problem. Is one-quarter of an inch difference enough to cause problems and/or require treatment? One-half an inch? A full inch or more? Does having a leg-length difference really contribute to back pain?

Second, there are many different designs of insoles (both custom and noncustom varieties). But studies comparing each type have not been done. Other variables such as age and gender might make a difference. There is some evidence that older adults tend to have worse results with insoles compared to younger patients.

The fact that so many people experience back pain every year has motivated scientists to take a closer look at ways this could be prevented and/or managed. So far, there is strong evidence that insoles don’t prevent back pain.

More trials are needed to come to any conclusions about the use of insoles to treat back pain. Whether or not there’s one single insole that’s the best or if certain insoles work better for some problems than others remains an unanswered question. For now, patients find they are on a trial-and-error basis in finding what works for them.

Back pain and the prevention of back pain is a major focus of research time, money, and energy right now. The fact that over 100 billion dollars is spent each year in direct and indirect costs associated with back pain tell us how big a problem this is.

There have been many efforts to see what kind of treatment works best for back pain. Likewise, there has been an equal focus on finding ways to prevent back pain from developing. One of those interventions has been the use of shoe insoles.

A systematic review of the literature regarding the use of insoles for the prevention and treatment of back pain was carried out and reported on. The authors used a well-known method of study review: the Cochrane Handbook. The Cochrane Collaboration is a group of over 15,000 volunteers in more than 90 countries. The group reviews the effects of health care interventions (treatment) tested in biomedical randomized controlled trials. The results of these systematic reviews are published as Cochrane Reviews in the Cochrane Library. Health care professionals rely on Cochrane Reviews as valid and accurate summaries on many topic of interest.

The results of this systematic review may have found a lack of evidence to support the use of insoles as a treatment for low back pain but that’s not the end of the discussion. That lack of evidence was related to poor research design in some of the studies already done. Without clear criteria for the selection of patients included in studies, proper analysis of data, and the collection of complete data, the evidence can be presented as favorable when, in fact, the evidence is really limited. That was the case in studies reviewed using insoles for the treatment (vs. prevention) of low back pain.

Where does that leave us on the issue of shoe insoles for the prevention or treatment of low back pain? That’s a good question. Right now, there are so many different kinds of insoles on the market, it’s difficult to know if perhaps a specific insole might be the answer. Some are customized, others are not.

Most of the large studies were done on military (male) soldiers. We don’t really have much information on women or older adults regarding this issue. And some of the studies reported a shift of pain from the back to the legs.

The authors concluded that there is strong evidence that insoles don’t prevent back pain. More trials are needed to come to any conclusions about the use of insoles to treat back pain. And, the book is wide open on whether or not there’s one single insole that’s the best or if certain insoles work better for some problems than others.

It can be difficult to tell when one episode of back pain resolves and a new episode begins. We don’t have clear definitions in terms of dates, times, pain location, and so on. Studying back pain recurrence has been a bit difficult.

For one thing, when is back pain a recurrence of the old problem and when is it a new and different problem? Is a second (or third) bout of back pain a recurrent episode if less than six weeks has gone by? Six months? Does the patient have to be pain free for any particular length of time (or at all) before the episode is considered a recurrence?

How do we draw the line? Maybe it should be based on the patient’s pain duration, location, and intensity. Maybe recurrence of back pain should only be counted as an episode if the person loses time off work or goes to see a healthcare or other back care specialist.

Right now, researchers are looking for indicators that might predict back pain recurrence. There is probably more than one indicator but at least four are known to exist: 1) return of pain, 2) time off from work, 3) seeking health care services, and 4) filing a worker’s compensation claim. Each of these four indicators can be either direct or indirect.

For example, recurrence of pain or other symptoms is a direct indicator. Pain intensity, duration, and frequency can be individually measured and reported. In some studies, patients filled out a pain questionnaire, while others completed a daily diary. There was not a consensus as to what constituted a pain-free period in between back pain episodes. Another direct indicator of back pain recurrence was the time away from work, also referred to as repeated absences.

The indirect indicators of back pain recurrence included recurrence of seeking (health) care (for back pain) and recurrence of compensation claims. Using the presence of any indicator always raises the question, Within what time frame? Some experts suggest recurrence be defined as seeking care for back pain within the first 45 days after the initial episode. Others use 45 to 90 days as a more appropriate time period to provide acceptable bounds for identifying a recurrence vs. a new episode.

Since there is not complete agreement on this subject across the board, you may have to rely on your physician to help you. If he or she agrees with you that this new episode is not a continuation of the original problem, a letter of justification sent to the insurance company may help move your case along.

In a recent study from Germany (where homeopathic treatment has been practiced and studied for over 200 years), patients with chronic low back pain treated with homeopathic remedies reported four beneficial effects. These included decreased pain, improved quality of life, reduced use of prescription or over-the-counter drugs, and reduced use of health care visits.

In the study, 129 adults with low back pain from any cause were treated by 48 homeopathic-trained physicians in many different centers across Germany. Before treatment, the patients wrote down all of their symptoms and rated their pain intensity from zero (no pain) to 10 (worst pain). They also filled out two other surveys of questions related to physical and mental function as well as quality of life.

Most patients received an average of six homeopathic remedies over a period of three to 12 months. Everyone had chronic (longstanding) low back pain. Some patients also had other symptoms such as headache, hay fever, trouble sleeping, fatigue, or skin problems. A wide range of different remedies was used but most of them boiled down to one of 10 basic categories.

Everyone was followed by phone consultation and/or personal follow-up visits for up to two years. At the end of the two years, one fourth of the group was fully cured (no back pain). About 20 per cent said they were at least 50 per cent better. The rest experienced some, but not as much, improvement. No one said they got worse.

But the authors were quick to point out that there are some important things to consider when reviewing these results. First of all, the patients in this study were seeking homeopathic care. It was not a randomized controlled trial where some patients are randomly placed in two or more groups.

In a randomized controlled trial, some are treated one way (e.g., conventional means) and other patients are treated another (e.g., homeopathic treatment). The methods used in this current study didn’t control for the placebo effect. Placebo means the patient expects to get treatment that will be helpful, so even when they are getting a sugar pill, they get good results.

The fact that the patients in this study were self-selecting homeopathic care was examined more closely. It turns out that these patients were better educated and with higher incomes than traditionally treated patients. One other observation: the patients in this study had been treated conventionally and turned to homeopathy when the results were unsatisfactory. This set of patient characteristics called demographics may be important and bear further study.

It was also the case that only physicians with certification and experience in classic homeopathy were included in this study. And only about one per cent of the certified practitioners were included. So there’s lots of room for different results in the general population depending on who they are and who they see for care.

Giant cell myeloma (also called giant cell tumor of the bone) is a fairly uncommon tumor. It is called giant cell tumor because there are large bone-like cells with more than one nucleus (center).

These tumors are usually slow to develop and are benign. But because they can grow large and put pressure on nerves and blood vessels, they are often removed surgically. The recurrence rate is rather high — 50 per cent or more.

Some experts suggest this is because of bleeding into the surgical site when the tumor is removed. Any tumor cells that spill into the open area can be carried by the blood to other parts of the body. Metastases (spread) occurs most often to the lungs.

To avoid this problem, a group of surgeons has suggested limiting intraoperative bleeding. They do this using nylon tape wrapped around the large blood vessels supplying the area being operated on. The tape slowly compresses the blood vessel until it is closed completely.

Limiting bleeding makes it possible for the surgeon to see the outline of the tumor and remove it without contaminating (spreading) tumor cells in the area. Surgical sponges can be packed around the outside of the tumor to keep any cells from spilling into the area.

At least one report using this technique reduced the rate of recurrence in the first two years to 29 per cent. Complications from surgery are still as high as 50 per cent. Problems such as deep vein thrombosis (blood clots), wound infections, or wound dehiscence (delayed wound healing with surgical site re-opening often develop. Some complications are determined by the area operated on. For example, surgical removal of giant cell tumors of the vertebrae (rare) or sacrum (uncommon) can be accompanied by cerebrospinal fluid leakage.

Lumbar spinal stenosis (stenosis of the low back) is a common cause of back problems in adults over 55 years old. Spinal stenosis describes a clinical syndrome of back, buttock, and/or leg pain. It is a condition in which the nerves in the spinal canal are closed in or compressed.

The spinal canal is the hollow tube formed by the bones of the spinal column. Anything that causes this bony tube to shrink can squeeze the nerves inside. As a result of many years of wear and tear on the parts of the spine, the tissues nearest the spinal canal sometimes press against the nerves.

In the lumbar spine, the spinal canal usually has more than enough room for the spinal nerves. The canal is normally 17 to 18 millimeters around, slightly smaller than a penny. Spinal stenosis develops when the anteroposterior diameter (front-to-back measurement of the canal) shrinks to 12 millimeters or less. Stenosis can also occur when the transverse diameter (side-to-side opening) is less than 15 millimeters.

Irritation or a decreased supply of blood to the nerves is the main cause of the painful symptoms, numbness, and weakness. Postural changes (like flexion) can help reduce the compression of nerves and blood vessels in the spinal canal. As you bend forward, the spinal canal widens. As you straighten up or even extend backwards, the spinal canal gets narrower.

Even with spinal stenosis, it’s important to maintain an upright posture. Keeping the chest open gives the heart, lungs, liver, and other organs contained within the chest and upper abdomen room to function without being compressed. It also reduces the shearing force and abnormal load on the vertebral bodies that can lead to vertebral compression fractures.

Physical therapists can help with this problem. They can apply pain-reducing measures while helping you maintain your full height. Gentle soft tissue and spinal mobilization along with specific exercises are usually part of the program. The goal is to widen the spinal canal and take pressure off the spinal nerves.

It is important to improve the strength and coordination in the abdominal and low back muscles. Your therapist can also evaluate your workstation or the way you use your body when you do your activities and suggest changes to avoid further problems.

Lumbar spinal stenosis refers to a narrowing of the spinal canal, a long tube through which the spinal cord travels from the brain down to the tip of the spine. Many degenerative changes that come with aging reduce the space in this area. Bone spurs, thickening of the spinal ligaments, and decreased disc height are just a few of the factors that play a role in the development of lumbar spinal stenosis.

The spinal cord is covered by a material called dura. The space between the dura and the spinal column is called the epidural space. It is thought that injecting steroid medication into this space fights inflammation around the nerves, the discs, and the facet joints. This can reduce swelling and give the nerves more room inside the spinal canal.

There is some evidence that the steroid portion of the injection inhibits pro-inflammatory cells. The net effect is to reduce inflammation and thereby reduce pain.

It’s also possible that the local anesthetic that’s part of a steroid injection puts a stop (or blocks) signals from the receptors for pain up the spinal cord to the brain. It is believed that pressure on the spinal nerve roots sets off nociceptors (pain receptors) that are self-sustaining. In other words, once they get turned on, the pain messages have a way of continuing without turning off.

Chronic low back pain continues to perplex and confound patients and health care providers alike. The field of health care is now calling for treatment based on scientific evidence of its effectiveness. Groups of experts are getting together to search the literature for enough evidence to support one treatment over another.

Recently, a large multidisciplinary panel of back pain experts was gathered together by the American Pain Society. Their task? Review all published randomized trials looking for evidence to help them draft some guidelines for the treatment of chronic low back pain. Efforts of this type are appreciated by those who work with chronic low back pain patients. Instead of everyone spending hours sorting through all the studies trying to make sense of them, experts in the field get together and perform the task, making summary recommendations for all to use.

This group focused on three areas: interventional diagnostic tests and therapies, surgery, and rehabilitation. Interventional refers to more invasive efforts to find out if specific musculoskeletal structures (e.g., joints, disc, muscles, ligaments) are causing the patient’s pain. The theory is that if areas can be targeted as the main cause of the problem, then more effective treatment can be directed at that area.

They came out of the review process with eight strong recommendations. The evidence reviewed showed a clear benefit of some treatment approaches that was greater than any potential harm or burden. But there were also some treatments that lacked evidence for or had enough evidence against them to recommend against their use.

Recommendation 4 may shed some light on your father’s situation. It says that nonradicular back pain responds as well to conservative (nonoperative) care as it does to surgery. Nonradicular low back pain refers to back pain caused by something other than pressure on (or irritation of) the spinal nerve roots. Surgery is considered a low-priority option for patients with this diagnosis.

Patients considering surgery should be told about the risks and possibility that the results will be less than satisfactory. Patients go into surgery thinking that they will wake up pain free and that just doesn’t happen. Risks for surgery with complications and cost make this option less than attractive for many people once they understand the big picture. Intensive interdisciplinary rehabilitation or other alternative treatment options are always recommended first before surgery.

There is a new trend to try and find out what patients want out of treatment — and more than just pain relief, though that would be good, too. Getting to the bottom of patients’ real priorities isn’t just a matter of asking them, What do you want?. There are pain limitations, functional limitations, social, and psychologic factors to consider.

Toward that end, some clinicians are using validated surveys to test patients in these various domains. And there are plenty of tests out there to assess people with chronic low back pain. Physicians, physical therapists, and other rehab counselors often use the Roland-Morris Disability Questionnaire, the Oswestry Disability Index (ODI), and the Quebec Back Pain Disability Questionnaire (QUEBEC) to look at disability and participation restrictions. They also use tools such as the Visual Analog Scale (VAS) and the Numerical Rating Scale (NRS) to measure pain intensity.

Another test called the McMaster-Toronto Arthritis Patient Preference Disability Questionnaire (MACTAR) looks at what the patient would like to do — what the patient cannot do because of pain. These are the issues that really matter to the patient. The MACTAR looks at mobility; community, social, and civic life; domestic life; work; interpersonal interactions and relationships; and self-care.

Each of those main sections has multiple subsections of activities and participation. For example, mobility looks at driving, walking, standing, running, climbing, and changing positions. Community/social/civic life includes sports, recreation, and leisure including crafts, hobbies, the arts, and culture. Domestic life ranges from shopping and doing housework to caring for plants or gardening, and preparing meals.

Other tests can measure coping skills, level of anxiety and depression, and any fear-avoidance behavior. Fear-avoidance refers to the concept that people in pain often stop moving in ways they think might cause it to hurt or cause another injury. The result of that behavior is more pain from the altered movement patterns or avoidance of movement.

There isn’t one test that can give a global picture of the patient’s needs, wants, or desires. It usually takes several to put together all of the information needed. Using a variety of tests helps give a valid measure of real-life participation limitations identified by the patient with chronic low back pain. That’s what it takes to get the kind of comprehensive information needed to make clinical decisions, establish treatment goals, and plan treatment.

During discography, contrast medium is injected into the disc and the patient’s response to the injection is observed. Computed tomography (CT) is usually performed after discography to look for anatomical changes in the disc and to show any tears or fissures in the disc itself.

In theory, pain that is similar to the patient’s current back pain suggests that the disc might be the source of the pain. But there are too many false positives to trust the test. And studies show that patients with a positive test who had surgery didn’t have better results than those who didn’t have surgery.

This has led surgeons to think that although discography may show signs of degenerative disc disease, that doesn’t mean the patient’s pain is coming from the disc. Therefore, provocative discography is no longer routinely recommended for the diagnosis of herniated disc-related low back pain.

Many people with chronic low back pain suffer loss of function and disability that is very limiting. The challenge of coping with a chronic problem can be overwhelming — even for the strongest individual. Recognizing the role of anxiety, depression, and inability to cope is a big step for many people.

The place to start may be with your primary care physician. He or she can help you find the right psychologist or behavioral counselor. You’ll probably spend some time being interviewed and filling out a few surveys with questions that will help identify problem areas for you.

Some people also experience fear-avoidance behavior. Fear-avoidance refers to the concept that people in pain often stop moving in ways they think might cause their back to hurt or cause another injury. The result of that behavior is more pain from the altered movement patterns or avoidance of movement. There is a specific questionnaire to help assess patients for this behavior, too. Addressing this area can help restore function even if pain is not any less.

Studies have shown over and over that there’s a strong role for behavioral and psychologic distress. Pain-related fears, poor coping skills, and fear-avoidance behaviors can be challenged and changed. The result can be improved function, fewer participation limitations, and greater quality of life.

Results from spinal fusion surgeries haven’t always been consistently positive. Surgeons and researchers are trying to narrow down the reasons for failures and less than satisfactory results. One approach has been to select patients carefully for success. This way of improving clinical outcomes is called patient selection criteria.

By studying groups of patients who have done well and comparing them to patients who have not had as good of a result, they are identifying risk factors that help predict who will be a good candidate for spinal fusion. Studies done so far have shown that osteoporosis (brittle bones), spinal stenosis (narrow spinal canal), and severe disc space narrowing are linked with worse outcomes.

Time off from work before surgery and psychologic status also have an effect on results of lumbar spine surgery. It has been shown that patients who are off work for more than 13 weeks before surgery recover more slowly and not as fully as those who work longer before having surgery.

There may be a behavioral or psychologic reason that is common among those individuals who are off work longer. Those same psychologic or behavioral factors might be the reason results aren’t better than they are after spine surgery. In general, psychologic screening has been effective in predicting worse results after lumbar spine surgery.

Your husband’s surgeon may screen patients routinely. It’s the same as doing blood testing to make sure everything is a go for surgery. But there’s nothing wrong with bringing up your concerns, questions, and comments. Understanding the preoperative process is always an important part of patient care.

It may not be a problem with strength. Researchers are finding that changes in motor control of the back muscles of people with low back pain may be why they get back pain again. Alteration in the timing of the short fibers on the side of the symptoms may be the key. Proper timing of deep muscle contraction in the spine is essential for normal spinal movement and spinal stability.

How did they discover this? Using electromyography (EMG) to record the electrical activity of the muscles, the researchers compared the activity of short versus long muscle fibers of back and shoulder muscles. Recordings of muscle activity were taken from both sides of the spine. Surface and needle electrodes were used to get accurate EMG readings.

Measurements were taken as the subjects moved their arms forward 45-degrees. Arm movement was used because past studies have shown that such movement causes activity in the back muscles. This testing procedure gives a reliable way to measure changes in motor control of deep muscles that control spinal motion.

EMG makes it possible to tell exactly when the muscle starts to respond and the pattern of muscle activity. They were specifically looking at the response of the lumbar multifidus muscle in the back in relation to the deltoid muscle of the shoulder. They expected to find different muscle activity patterns between the two groups of patients.

What they found was that when the control group moved their arms, short muscle fibers of the multifidus started firing earlier than long muscle fibers. But in the group with recurrent low back pain, there was no difference in when the short versus long fibers were activated on the involved side. The nonpainful side for the patients behaved normally (i.e., the same as in subjects in the control group).

This particular study clearly showed a connection between abnormal motor control and recurrent back pain. It seems that just because back pain goes away doesn’t mean the muscles have returned to normal. For patients with recurrent back pain, in between episodes, their back muscles aren’t firing normally. This puts them at risk for reinjury or another acute episode of pain.

Strengthening may be what you need, but before launching into a program that might actually put you at risk for reinjury, see a physical therapist. The therapist can assess muscle strength and look at motor control strategies. As a movement expert, the therapist can help you regain normal motor function and help you regain the proper sequence of muscle contraction needed for spinal movement and stability.

Why do some people get back pain over and over while others recover without a single recurrence? That’s the question scientists from Australia posed in a recent study. They suspected that activity of the deep muscles in the back might be different in some people. This could be causing return bouts of back pain.

In fact, one-third of all adults with low back pain will develop pain again. And that’s even after returning to normal function with apparent good recovery from the first episode. Other studies have shown that there is a problem with muscle relaxation. Messages from the nervous system may get mixed up so that the muscles lose the ability to fine tune motion of the vertebrae.

It looks like changes in motor control of the back muscles of people with low back pain may be why they get back pain again. Alteration in the timing of the short fibers on the side of the symptoms may be the key. Proper timing of deep muscle contraction in the spine is essential for normal spinal movement and spinal stability.

Without the normal firing sequence of muscles, motor planning is altered. As a result, the nervous system sets up a pain pattern. Just because back pain goes away doesn’t mean the muscles have returned to normal.

For patients with recurrent back pain, in between episodes, their back muscles aren’t firing normally. This puts them at risk for reinjury or another acute episode of pain. But what causes this change in motor planning? Is there some kind of damage to the muscle itself? Or is it because the person alters the way he or she moves to avoid pain and protect the spine?

And it’s possible that our beliefs about pain and the desire to avoid pain may actually be able to influence motor control at the level of the muscles. If you haven’t already, think about seeing a physical therapist. They are experts in movement. They can help you correct any protective postures and movement strategies you may be using unconsciously in an attempt to prevent future episodes of back pain.

Experts in the area of social science tell us that people who lose their jobs can suffer severe problems. They start out in a state of fearful distress that quickly becomes a despairing attitude of giving up. The loss of income makes things even worse. Chronic pain and work loss can become so tangled up, it’s hard to separate them. One condition feeds into the other. As you have discovered, pain confounds work loss. And work loss intensifies the pain.

When chronic low back pain leads to disability and loss of work, doctors may prescribe strong (narcotic) pain relievers called opioids. This is done in an effort to help people get back to work. But critics of this approach say there’s no proof that opioid use improves outcomes. In fact, there’s some evidence that opioid therapy may actually be linked with increased risk of work loss.

To test the effect of opioid use on work loss, a study was done using data from Worker’s Compensation. Two groups of Worker’s Compensation claimants were compared. Everyone included in the study had filed a Worker’s Comp claim for low back pain. One group was provided with opioid therapy. Some were taking weak (Class III or IV) opioids. Others were given strong (Class II) opioids. The opioid group was further divided into two subgroups based on whether or not they took opioids for up to 90 days or for more than 90 days. The second group had filed a Worker’s Comp claim for low back pain but no one in the group was taking opioid-based medications.

Analysis of the data collected for the two main groups showed a significant link between opioid use and work loss. Workers taking any kind of opioid were 11 to 14 times more likely to suffer work loss compared to the reference (no opioid) group. Workers using strong (Class II) opioids were six times more likely to experience chronic work loss. The time frame used for this study was 90 days or more. And the overall costs for the opioid group was much higher than for the nonopioid group.

What’s the answer to this dilemma? Well, there may not be an easy answer for all patients. Each case must be decided and followed on an individual basis. Sometimes a team approach is really needed. For example, strong pain relievers such as opioids used in combination with a rehab program can help move the focus from pain to function. For nonspecific low back pain (i.e., it’s not caused by a tumor, fracture, infection or other serious medical problem), there is evidence that spinal manipulation by a chiropractor or physical therapist can be helpful.

Working closely with your physician will help ensure you get the full benefit of the opioid while minimizing or preventing any of its potentially harmful effects. Knowing that your goal is to get back to work will be helpful in keeping you on track in recovery.