Lower Back Pain

Of all the problems associated with chiropractic therapy, lower back pain would be the most easily recognized.

Prevalence in the Australian community is high. The rate has been calculated by Walker et al as being as high as 80%(1) over the course of a lifetime with around 67% suffering lower back pain in a 12 month period.

Low back pain is therefore a common condition in the Australian adult population. Most people have experienced back pain at some stage in their life. Almost half the population reported low back pain in the Walker study six months preceding the survey. In addition 10% of the survey group indicated a period of disability due to back pain in the six months prior to the survey.

Whilst a period of disability following low back pain is common, the outlook in the longer-term is generally favourable. For the large number of people who have a lower back pain episode the great majority will get over it.

The problem with Lower Back Pain

Lower back pain is poorly understood by many people, even those who work in the health industry. This is one of the reasons that so many misunderstandings exist in the broader community. This is unhelpful when it comes time to sort out your own lower back pain. We all know the well-intentioned neighbour/friend/colleague who is happy to regale with their own forays into back care and the disasters that will befall you. Rarely does a month go by without a "new back pain miracle cure" hitting the newstand, internet or 6.30 pm current affairs program.

The facts are that back pain is complicated and highly individual. Rarely does it fall within neat confines. Your back pain is yours. It is not the same as your neighbours who is giving you the benefit of their experience. This is why you need to seek the care of a back pain specialist.

A competent chiropractor is a back pain specialist. They can guide you through the processes that will result in a diagnosis followed up by the appropriate care for your problem.

Common Myths and Facts of Lower Back Pain

1. Lower back pain only happens to heavy physical workers like plumbers and carpenters.

Sorry but no. Make no mistake, these workers get lower back pain but so do office workers, police officers, politicians, the unemployed and even chiropractors. This reflects the fact that many things can initiate lower back pain including heavy work. Lower back pain is often caused by sitting too long, working in awkward positions, working below your knees, being overweight and poor furniture or use of furniture.

Fact; Anyone can get lower back pain

2. A Heat Bag will fix my problem

It is amusing how we can be so well educated and yet have difficulty applying well known principles. Most people have been exposed to some level of first-aid procedures or at very least have seen their damaged sporting stars on the side of some playing arena with an ice-pack on an injured limb. Very well informed parents will tell you how to look after their young child who has had some form of accident and hurt themselves.

However, the number of people who have acute back pain who use heat to soothe their pain is staggering. For some reason the community knows to use ice on a sprained knee, ankle or elbow but somehow the lower back enjoys different physiological processes? Not so.

Fact; Acute lower back pain probably needs ice therapy.

3. I'm active and walk. I shouldn't get lower back pain.

Activity through work and/or exercise is in the most, good for you. It does not guarantee you a life with no back pain. General body conditioning of the muscles and joints is far better than doing nothing. However, some sports and jobs can be hard on a body. Golf, tennis and football all have their risks as does the nurse working at a bedside for a shift. Continue to train and condition your back to create the stable foundation for your head and limbs.

Fact; Lower back pain happens to fit and unfit people.

4. I have pain in my buttock and leg so l must have sciatica.

Sciatica occurs because there is direct irritation to the nerve roots from the lumbar spinal level at some point during their passage from the spine and including when they join together and form the sciatic nerve. It causes a pain of predictable pattern that readily identifies with sciatica.

There are other ways that pain can be sent down the leg that do not involve the sciatic nerve and therefore are not sciatica. A common one is a referral of pain associated with facet joint dysfunction in the lumbar spine. Another is an osteoarthritic is capable of creating leg pain.

The clinician needs to have the skills to distinguish which is which.

Fact; Not all pain referred into the leg is sciatica.

5. I will have lower back pain forever.

While most of us will have an episode of lower back pain at least once in our life and probably even once per year, the majority of cases are self-limiting. That is to say that the lower back pain will have a time frame of less than six weeks regardless of how you manage the problem. Some people do go on to suffer ongoing or chronic lower back pain. Many of these are managed poorly and permit needless constraints on the sufferers life.

Fact;   Lower back pain is not permanent in most cases.

6. Back surgery is a disaster.

Over a number of years lower back pain and surgery have had a poor record of success. This however has been rapidly changing for the better. No doubt some of the improvement has been due to the advent of better imaging such as MRI's and surgical procedures with comparatively small entry wound. The most important reason though is that the decision making process of whether to have surgery or not has become much more accurate. These days surgery is not done because "nothing else has worked so we may as well try surgery". It is done for very specific purpose only. Most episodes of lower back pain do not  qualify for surgery as a choice.

Fact; Back surgery for the right reasons is a good choice

7. The x-ray says nothing is wrong with my back.

X-rays are one tool of investigation of lower back pain. They give indications of alignment, congenital (from birth) abnormalities or variants, fractures, tumours, bone density and arthritic change. They are however a static picture. They do not tell us how the spine moves as we go about our lives. It can be compared to taking a photograph of your car motor. It may look fine in the photo, however it would be a brave person to buy that motor based on a static image. You would want to hear it start and then test it to get the complete picture.

Fact; x-rays are a useful tool to examine a back but are a poor tool to predict lower back pain.

8. I need to go to the gym to strengthen my back.

Many sufferers of lower back pain have deconditioned spines. Years of poor habits combined with increasingly sedentary lives and weight gain can all take their toll. Back conditioning can be done at a gym but it is not necessary. The process needs to involve careful assessment of the condition in conjunction with examination of the person. For example the person may have a facet joint condition, be 15 kg's overweight, be 55 years of age and work as a gardener. They will need a different program from the 25 year old athlete suffering a disc condition with hypertonic hip flexors. Both people can be treated with or without a gym. In fact for the long-term many people are far better off to have a brief (less than ten minutes) but permanent home-based exercise program, a bit like brushing your teeth, to look after their spines and keep them well conditioned.

Fact; Back strengthening is important. It needs to be guided and monitored. It can be done at a gym or at home.

9. Just see my chiropractor and l won't have to change anything in my lifestyle.

Many of us are on the lookout for the silver bullet that lets us off the hook. There are none. The lifestyle that caused your lower back pain will continue to cause more pain if no changes are made. You may get away with it for a while, even years. Eventually the accumulated stress, injury and compensations will cause the spine plenty of grief. Some escape, most don't.

Fact; Personal lifestyle is a major contributor to lower back pain. Just seeing your chiropractor and making no changes to lifestyle will not have a satisfactory outcome in the long term.

10. Lifting heavy things is the major cause of lower back pain.

There is no doubt that lifting heavy objects can cause lower back pain. Numerically however far more people hurt their back lifting light objects or reaching and twisting with or without any weight involvement. People who have to lift heavy objects are more likely to examine their surroundings and a least have some thought about what they are about to lift. The safety factor is not so obvious to people lifting light objects. With little attention paid to leverage impacts, people will willingly reach and twist without considering their spine. Reaching into the back seat of your car is as much a risk of hurting your lower back as is picking up a pot plant.

Fact; More people hurt their back lifting light things than heavy things.


The Anatomy of the Lower Back

The structure of the lower back is based upon 5 block-shaped vertebrae numbered L1 (Lumbar vertebrae 1) being the highest through to L5 being the lowest. They are comparatively heavy and solid vertebrae as they have to support a lot of weight. The five vertebrae are separated by thick discs made of fibrocartilage. The disc between L1 and L2 is known as the L1/2 disc and so on as we go down. The last disc is called the L5/S1 disc or lumbosacral disc since it separates L5 from the first sacral vertebrae called S1.

So we have a spinal column of vertebrae with discs in between. Each vertebrae has a  large hole called the vertebral foramen which allows for the protected passage of the spinal cord to carry information from and to the brain. At the level of each disc the spinal cord throws of a pair of nerve roots ( one to the left and one to the right) which leave the spinal column to join other nerve roots and form nerves. The nerves make their way around the body to send and receive information.

Movement is possible between vertebrae. This is facilitated by the boney interaction that exists. Each vertebrae has an inferior (lower) articular process with a facet on it that abuts the superior (upper) articular process facet of the vertebrae below. The facet joint that results from this arrangement has a certain orientation that in general is particular for each spinal joint level. The shape, size and angle of a cervical joints is very different from thoracic joints for example. However, the orientation of the T2/3 joint is even slightly different from the T3/4 joint as are all the other adjacent joints in the spine. These differences mean that the movement and natural position of each joint is unique to that joint.


What are the Risk Factors of Lower Back Pain?

There are a number of factors that raise your risk of getting lower back pain. These include;


The Types of Lower Back Pain

The types and causes of lower back pain are many and varied with some very common and some very rare. The list below is not exhaustive but covers the most prevalent in our society.

1.Musculoskeletal and Mechanical;
Most lower back pain has a musculo-skeletal origin with involvement of the muscles, ligaments, joints, discs or nerves of the spine. In many cases it is difficult to separate the responsible entity. For example it can be very difficult to ascertain if an injury is a small muscle strain or a minor facet joint sprain.

2. Tumour;

There are however some very serious causes of lower back pain that do not originate in the spine. Lower back pain can be produced by primary tumours of the spine or metastatic tumours from other parts of the body. The most common primary tumour of the spine is multiple myeloma. About 65% of all  spinal tumours are metastic from prostate, lung, kidney and breast tumours. A lot of spinal tumour patients complain of night pain that disturbs sleep and is not altered by changing the bodies position.

3. Arthritic Conditions

4. Visceral Referred Pain

Flags that indicate the potential for lower back pain of visceral origin are "pain not relieved by rest, the absence of trauma, and the presence of associated visceral symptomatology." Specific laboratory tests must be ordered to identify the individual pathologies. Some of the most prevalent visceral causes of lower back pain are;

5. Infection Processes

Infection of the skeleton (osteomyelitis) is not very common in countries with high general health standards. It does however still occur, predominantly in the newborn, drug addicted, alcoholic or immunosuppressed.

Most osteomyelitis is via the bloodstream with any number of potential micro-organisms such as staphylococcus aureus, hemophilis influenzae, diplococcus pneumoniae and mycobacteria being common.

Other sources of osteomyelitis include;

6. Nutritional, Metabolic and Endocrine Disorders

7. Fracture

Fractures of the lower back vertebrae occur and need to be diagnosed properly.Compression fractures are common with trauma such as falling from heights. These don't have to be high. Compression fractures can occur falling from a chair, particularly amongst the aged. Also common at the lower back level are fractures of the "pars interarticularis". This results in the injury known as spondylolithesis where one vertebrae appears to "slip" on top of the one below it.


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1. Low Back Pain in Australian Adults. Prevalence and Associated Disability
Journal of Manipulative and Physiological Therapeutics, Volume 27, Issue 4, Pages 238-244
B. Walker, R. Muller, W. Grant

 

 

 

 

 

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