FAQ Category: Lumbar Spine

Despite many studies on low back pain (LBP), a single best treatment just hasn’t been found yet. Patient education with written materials can be helpful. Patients who understand what’s going on and how to prevent a recurrence of back pain remain active and seem to do better.

Physical therapists are actively comparing methods they use to find the best treatment approach for chronic LBP. Manual therapy including joint mobilization and manipulation and spinal stabilization exercises are two popular methods used.

Spinal stabilization exercises seem to get the best results in terms of decreased pain, increased function, and improved quality of life.

After reading the material you were given, apply the information and principles for two to four weeks. If after that time, you are no better or worse, make a follow-up appointment with your doctor. Ask about seeing a physical therapist for spinal stabilization exercises.

In the early 1990s, scientists studying muscle (motor) control made some new discoveries. They found out that the stabilizing muscles of the spine didn’t always contract or contract on time during certain motions in patients with chronic back pain.

A series of exercises were developed to rehab the motor control system. Retraining the abdominal muscles (transversus abdominis) and deep muscles of the spine (multifidus) came to be known as stabilization exercises or core training.

This program has been expanded by some to include retraining the diaphragm and pelvic floor muscles, too. The diaphragm is a dome-shaped muscle inside the body between the chest and abdomen. A program to teach back pain patients how to contract the core muscles in everyday postures and positions forms the basis of the spinal stabilization program.

It’s not clear yet just how these exercises really work at the physiologic level. We do know that contracting muscles on both sides of the spine at the same time helps hold the spine steady or stable. Perhaps traction of the spinal segments helps reduce pain, too.

About 80 percent of adults with an episode of back pain get better on their own within one to 10 days. Like you, a smaller number of people may still have pain one to two months later. This is called the subacute phase.

Studies do show that the longer a patient is off work, the greater the chances are of becoming a chronic pain patient. Long-term disability is the next step. To avoid this series of events, patients with nonspecific back pain are advised to keep active. Nonspecific back pain means it is not caused by tumor, infection, or a ruptured disc. Most often the exact cause remains unknown.

A few days of bed rest may be needed after the injury first happens. After that physical activity and exercise are the best treatment.

Some people attend a series of classes called back school. Physical therapists usually teach proper posture and exercises geared toward recovery. Patients are taught that pain relief isn’t always needed to go back to work. They are shown how to recognize when fear of reinjury is slowing down their progress. A short-term low-intensity back school gets workers back on the job faster than rest or a high-intensity program.

By definition, back school is an educational program for back pain patients. It’s usually presented to a group of patients rather than on a one-on-one basis. Exercises are a part of the program. Most back schools are taught by a physical therapist or paramedical health care professional.

There are many variations in the content and intensity of back schools. The Swedish Back School is a low-intensity program. Patients meet with a physical therapist for one to four sessions spread out over several weeks to a month. Exercises done twice/day are designed to increase strength and improve function.

High-intensity programs are geared toward work simulation. Patients enrolled in this type of back school meet more often. Exercises are progressed faster with an increase in the level of activity. Exercises are designed to help patients with the most difficult tasks at work.

A recent study comparing low-intensity back school to conservative care and high-intensity back school showed a faster return-to-work time with fewer sick days. Function improved faster too, although pain levels weren’t different from one group to the other.

When viewed from the side, there are three natural curves of the spine. The natural curve of the low back is called lumbar lordosis. “Swayback” is an exaggerated position of lordosis called hyperlordosis.

Hyperlordosis is caused by the position of both the vertebral bones in the lumbar spine and the pelvis. If the pelvis is tilted or tipped forward (anteriorly), the lordosis increases.

Abdominal strengthening exercises such as sit-ups can make a difference. The other curves in the neck and upper back also influence the lumbar position.

A full spinal X-ray may be needed to determine the cause of your hyperlordosis before the best treatment can be applied. There may be a structural cause that can’t be changed by doing sit-ups or other exercises.

Ask your doctor to help you. Getting a baseline X-ray now can help show you later if you are staying the same, getting better, or getting worse. This will also help when judging if the treatment is helping.

Artificial disc replacements (ADRs) have been in use for over 20 years now. In fact over 15,000 ADRs have been implanted worldwide. As with any new treatment, results have improved with time and experience.

Studies of patients needing a second operation (“reoperation”) after the initial ADR have helped direct and guide patient selection for ADRs. Improvements have been made to the implant itself that have also given better results.

Today there are different implant sizes. A new porous coating put on the ends of each ADR helps bone grow around the implant. This helps keep the ADR in place and prevents shifting or migration of the disc.

Overall failure rate for ADR is about nine percent. This is equal to the failure rate for spinal fusion, the alternate treatment option for patients with painful disc degeneration. With continued improvements in ADRs, you can expect to see more of these operations in the coming years.

All spinal surgeries have risks and possible problems. Damage to the blood vessels or nerves can cause disabling back pain. Back pain with leg pain is a sign of nerve compression. This can happen if the disc space is not prepared properly before the ADR is implanted.

Size and placement of the implant are also important. If the ADR is too small, it may not fill the disc space enough to avoid pressure on the nerve as it leaves the spinal canal. The disc cannot be placed too far forward or backward or it can shift. Migration can lead to implant failure.

What can be done now? There are several options. First, the implant can be removed and the site fused. Second, the implant can be replaced by another. Perhaps a different size implant is needed — or a different placement inside the disc space. Or third, the implant may be kept in place and “locked down.” Locked down means the ADR is held in place with screws.

Before any treatment is decided on, the cause of the pain must be found. If the nerve was damaged, fusing or changing the implant may not be helpful. Your surgeon is the best one to evaluate your care and advise you. Further tests and/or imaging studies may be needed to pinpoint the source of the pain.

Injecting cement into a fractured vertebra is called vertebroplasty. When conservative care for chronic back pain fails to bring pain relief, vertebroplasty is considered. Nonoperative care with medications, bracing, and exercise are usually tried first before discussing vertebroplasty.

Cement leakage is the most common complication of this procedure. The cement can move in any direction and can ooze out through the fracture or into the network of tiny veins in the bone.

The most serious problem occurs if the cement leaks into the space around the spinal cord called the epidural space. Pressure from the cement can cause painful neurologic symptoms. Immediate surgery may be needed in such cases.

Alternately, the cement may leak into the disc space. A recent study showed this might be more common than previously thought. They found this type of leakage occurred in 41 percent of their patients. Fortunately, the patients didn’t seem affected by disc space leakage. The vertebroplasty was still a success.

The McKenzie Method was named for a physical therapist who developed the idea by the name of Robin McKenzie. When used correctly the McKenzie Method is a way of classifying and diagnosing then treating low back pain patients.

It’s not intended to treat all back pain patients — only those who have certain patterns of symptoms based on movement. Each movement is repeated over and over to see its effect. For example some patient’s pain goes away completely when bending forward. This is called directional preference. The patient is told to avoid motions that increase the pain and move into positions that are comfortable.

If bending forward moves the back or leg pain to the middle of the low back or takes it away altogether, it’s called centralization. If movement in one direction causes the pain to travel down into the buttocks or down the leg, it’s called peripheralization.

If you don’t have a directional preference, then the McKenzie Method isn’t likely to help. Many patients who are helped by the McKenzie Method can avoid surgery. If McKenzie exercises didn’t help you, then you may not be a good candidate for this treatment. This may be a good time to go back to your doctor or therapist for a follow-up visit. There may be other forms of treatment that would work better for your problem.

Ah you’ve asked the question many scientists and researchers have spent years looking for an answer to. Chronic back pain is a common problem. A gold-standard treatment approach hasn’t been discovered.

Treatments tested and compared have included spinal manipulation, advice to “stay active,” and strengthening exercises. The McKenzie Method is another popular treatment approach to low back pain. It’s based on knowing and avoiding movements that make it hurt.

A recent review of the McKenzie method showed only a small difference between this and other methods already mentioned. Analysis of the data suggested the difference was not enough to declare the McKenzie method as the best approach.

Activity and exercise are still the number one top-ranked methods for managing chronic back pain. Until we have a way to diagnose low back pain accurately and match the treatment to the problem, many patients are going to have to go with the trial and error method. The key to managing painful back symptoms is to find what works and apply it consistently over time. That’s where activity and exercise seem to have the best overall results.

More and more studies are pointing to emotional stress and dissatisfaction with the work place as risk factors for chronic low back pain and disability.

According to a new study from Norway, fear-avoidance beliefs (FAB) may be a key factor as well. FAB describes people who are afraid to move normally for fear that their pain will increase. Or they’re afraid they will reinjure themselves. Scientists are looking for ways to test FAB at work and compare it to FAB during physical activity.

Some experts suggest that FAB is a kind of back pain-related anxiety. Emotional distress may include more than fear of back pain — it could include general anxiety, depression, and stress-induced body pain.

It’s this emotional distress that may hold people back. Those who recover and return to work in less than a month have a rapid decrease of FAB and emotional distress. Patients with high stress/distress that lasts more than four weeks are more likely to become chronic pain patients. They have with pain and symptoms that last a year or more after the injury.

As a manager in the workplace, it may be a good idea to consult with a behavioral psychologist. He or she can help you and your employees manage recovery after workplace injuries.

Scientists are a long way from fully understanding back pain. What causes pain, what leads to chronic pain, and how to predict who will become disabled are still unknowns.

There may be a fine line between physical and emotional response to pain. More and more studies are finding a behavioral component to low back pain. Attitudes and actions in response to pain can lead to what’s called fear-avoidance behavior or FAB.

This means if a person has back pain that hurts with certain movements, they will avoid that motion and even avoid other movements as well. Pretty soon they avoid activity because “it might hurt.” It can be a downward spiral from there with increased inactivity causing stiffness and more pain. More pain leads to less movement and so on.

Some people certainly do exaggerate or magnify the symptoms. There are some tests that can help sort out behavior from physical symptoms. For example the Oswestry low back pain disability questionnaire is a measure of physical disability that can help put patients into groups. The groups include patients with no disability, mild disability, moderate or severe disability, and bed-ridden or exaggerating the symptoms.

There are also separate tests for symptom magnification. Tests of this type are performed by a medical doctor or other trained/certified health care professional. Without a formal test of this type there isn’t a simple way to prove an employee is exaggerating.

We don’t have a yes/no answer for you on this one. Many studies have been done on preventing back pain, what works and what doesn’t. There may be some factors linked with back pain that you don’t have control over.

For example, people over 65 may have an increased risk of back pain. According to one study, women are more likely to have disabling back pain five years after their first episode of back pain.

Activity level is part of the prevention equation. It’s just not clear what kind or how much is needed to stay healthy. A low level of physical activity does predict persistent disabling back pain one year after the first painful episode and again five years later.

It’s possible that more physically fit adults recover faster from back pain, too. Men who are physically active during leisure time seem to have less back pain and fewer symptoms than women.

Physicians often rely on clinical experience to judge situations like these. Patient history and clinical presentation help them sort out the symptoms and the possible cause. However, without further imaging studies there’s no way to know for sure. Sometimes it’s hard to differentiate between pain from the disc versus scar tissue even with X-rays, MRIs, and other diagnostic tests.

Two advanced diagnostic tests may help. The first is the discography or pain provocation test. In this test a needle is guided by a special X-ray device into the disc. A small amount of dye is injected into the disc. If the disc is the source of pain, the pressure from the extra fluid will reproduce the patient’s symptoms.

The second test is a gadolinium (Gd) contrast magnetic resonance imaging. Gd is a useful contrast agent when doing MRIs. It provides greater contrast between normal and abnormal tissue compared to other dyes injected during the MRI procedure. Gd in abnormal cells causes the cells to become very bright and easier to see.

There are a few disadvantages to the Gd-MRI. Gd doesn’t show why the cells are abnormal (e.g., scar tissue versus tumor cells). The patient may have a small reaction to the use of the dye. Headaches, nausea, and skin burning at the site of the injection have been reported.

Studies have confirmed that activity restriction isn’t needed after a disc is removed. The operation is called a discectomy. It’s usually done for painful disc herniation.

Using your back during ordinary activities of daily life will not do any harm to the back if you follow some basic guidelines. First, you must have your surgeon’s approval to resume all normal activities. Patients shouldn’t be too cautious and afraid to move but they should also wait until healing has occurred and the surgeon gives the “go ahead”.

Once you are medically cleared, you can start doing everyday activities such as vacuuming, sports activities, and lifting. Try each activity slowly and gradually build up to full speed. Research shows that it’s best to bend your back when lifting light objects and to bend your knees when lifting heavy items.

Specific exercises may be prescribed to help strengthen your core trunk and abdominal muscles. Other exercises to improve endurance and coordination may help you get over any fear avoidance behaviors you may have. For example, it’s common for patients with chronic back pain to avoid activities and movement because they are afraid it will cause their back pain to start or get worse. Over time avoiding movement actually increases pain and stiffness.

There are several ways to actually test driving ability. A standard driver’s test at the licensing bureau is one way to find out how “road worthy” a person may be. There are also special tests given to older adults who have had a stroke or other disabling injury. These are usually administered by an occupational therapist in a rehab center. Your mother could make arrangements to take either one of these tests.

There are some studies on pain and driving ability. A recent study reported that pain, pain meds, or the two combined together can increase the number of traffic accidents. People affected most often were middle-aged between 35 and 65 years old.

More accidents occur in older adults (over 65) who have other medical problems. Dementia, diabetes, arthritis, and heart disease are just a few examples. Women seem to be affected more often than men though it’s not clear why this is true.

It may be best to assess driving ability in city traffic and on the highway. You can start by asking your mother to drive you somewhere and see if you think there’s a problem. If talking to her is not helpful then contact her doctor and make the suggestion. She may be more willing to consider a test if her physician recommends it.

Cognitive behavioral therapy (CBT) is one of several different kinds of treatment models for patients with chronic pain of any kind. It has been shown effective for patients with pain and disability associated with the low back.

The basic principle behind CBT is that people with chronic pain start to change the way they act and move. These changes occur over time and limit what they can do and how they function. Beliefs and avoidance behaviors get started that keep the patient from ever getting better.

During CBT you will be taught how to increase your activity level. The goal isn’t to reduce pain, though that may happen as a by-product. The plan is to increase what you can do each day.

So for example, each day you may be asked to do more repetitions of a particular exercise no matter what happens with your pain. The pain may get worse but you still perform all the activities and exercises. The hope is that your attitude toward pain will change and your activity level will become more normal.

Daily life goals are set and reviewed periodically. Pain levels are not recorded or compared from day to day. Physical and occupational therapists, social workers, psychologists, and vocational rehab counselors are usually all a part of a CBT program for low back pain.

Moderate to severe and even disabling low back pain often responds favorably to exercise. Studies show that patients can cope with an intensive physical training program. Not only is it safe, but it works!

Other studies have shown that prescribed exercise doesn’t cause re-injury or make the symptoms worse in patients who already have back pain. The key idea here is “prescribed” exercise. This means a physical therapist has evaluated your situation and designed a specific program for you.

Such a training program takes into consideration your age, body mass index (BMI), and your general health. Any special risk factors will be further evaluated. Training to restore muscle strength, flexibility, and endurance is started and gradually increased over time.

Recent research also suggests that active physical training might not work for everyone. In a subset of patients, a behavioral or psychological approach works better. With behavioral treatment, patients are taught how to change beliefs and behaviors that are holding the patient back.

For example, many patients start to avoid certain movements and activities for fear that it will cause pain or reinjury. This is called fear-avoidance behavior. Cognitive behavioral therapy helps the patient recognize when this is happening and start to change.

Ask your doctor to recommend a physical therapist who is trained in the treatment of chronic back pain and back care programs. http://www.backcarebootcamp.com/bcbc_online/ may be of interest to you and your health care provider.

Adjacent-segment degeneration after lumbar fusion is one of the more serious long-term results being reported. Usually the segment above or below is affected. Studies report anywhere from four to 17 percent of the patients experience this problem.

Some doctors argue that this new degeneration is part of the ongoing aging process and would have happened anyway. Others claim that aging can only be blamed when a segment goes bad that isn’t right next to the fusion. Still others say that aging may be part of the formula but that a change in the mechanical stresses on the low back after fusion is a major factor.

Other risk factors include fusion at more than one level, uneven spinal alignment after fusion, and injury to the nearby facet joint. The facet joint gives the spine its motion. Any deformity or changes in the joint can lead to degeneration and spinal instability.

PLIF or posterior lumbar interbody fusion is considered one of the best ways to fuse the spine. The disc is removed along with the facet joint giving the nerves plenty of room. Bone from that is removed is used for the graft. Fusion rate is fairly high for this method.

Hardware failure such as screws breaking or slipping doesn’t doom the patient to a failed fusion. Often the patient wouldn’t know there was a problem if they didn’t see it on X-rays. There is no pain or change in function or activity.

The surgeon will probably follow you a little more closely with X-rays and possibly CT scans. If there are any signs of nerve compression, then a second (revision) surgery may be needed.