Low Back Pain - Ask Dr. P - The Pain Doc

The Origins of Musculoskeletal Pain – Which Describes Yours?

by Pain Doc | Mar 7, 2014 | Hand and Wrist Pain, Low Back Pain, Myofascial Pain

Musculoskeletal pain refers to pain affecting the muscles, ligaments, tendons, joints and sometimes bones. Sometimes it is straight-forward; other times it is not. Before you convince yourself that you know the origin/cause of your musculoskeletal pain, consider the following:

Pain can be due to trauma/injury where the tissue itself is generating the pain due to ruptured cells and the effects of inflammation. This is the most unambiguous case because it is connected to an identifiable event. This pain can be acute, meaning relatively recent onset; sub-acute, referring to a state where the injury still is healing but pain and some swelling is still present; and chronic, which basically means symptoms that remain after the body has done all it can at the moment to heal the injury.

Pain can manifest in one area of your body due to abnormal movement in a distal location. The abnormal movement might be caused by a previous trauma event like a car accident or sports injury, it can be congenital (developed at birth) and it can be from repetitive movements required by a certain occupation or hobby/sport. Abnormal movement (called dyskinesia) can also arise from muscle imbalances, where one muscle loses strength due to inactivity, decreasing joint stability and facilitating excessive, restricted, or other abnormal movement of that joint, forcing distal joints to make up the difference in lost movement or compensate to create more stabilization. The distal muscle(s)/joint(s) then work in a fashion that they were not designed for, leading to strain, spasm and even injury to the muscle or joint.

This is the most tricky type of pain manifestation because it is often mis-diagnosed resulting in the wrong treatment approach and lack of resolution. An example of this is sciatica (pain in the buttock) from a spasmed piriformis muscle scissoring the sciatic nerve due to an unlevel pelvis coming from hyperactive same-side erector spinae musculature. If the back muscle and pelvic imbalance is not corrected and the patient simply gets massage to the piriformis muscle, you can see how this pain will never go away with this type of treatment.

Pain can be referred pain. In referred pain, the brain senses the pain to be in one area of the body when the abnormal site is actually in another area. Despite an increasing amount of literature on the subject, the mechanism of referred pain is still unknown. Going back to the heart attack example, myocardial infarction can cause referred pain to the left jaw and left arm. The image below illustrates commonly observed types of referred pain and their true source (credit to Wikipedia).

Pain can arise from hypoxia (insufficient oxygen to the tissues). An extreme example of this kind of pain is a myocardial infarction, or “heart attack” where a major artery to the heart muscle is blocked, preventing oxygen from reaching a section of the heart. Biochemical reactions take place when this happens, which generate pain.

Thoracic outlet syndrome is a condition where the nerves and blood vessels supplying the arm get compressed in the neck region by tight scalene muscles or the collar bone. The resulting hypoxia can contribute to pain in the arms and hands.

Pain can come from trigger points, also known as trigger sites or muscle knots, are described as “hyper-irritable spots in skeletal muscle that are associated with palpable nodules in taut bands of muscle fibers.” Trigger points are usually only a few centimeters in diameter.

Clinical textbooks on the subject establish the following requirements to meet the definition of trigger points:

Pain related to a discrete, irritable point in skeletal muscle or fascia, not caused by acute local trauma, inflammation, degeneration, neoplasm or infection.
The painful point can be felt as a nodule or band in the muscle, and a twitch response can be elicited on stimulation of the trigger point.
Palpation of the trigger point reproduces the patient’s complaint of pain, and the pain radiates in a distribution typical of the specific muscle harboring the trigger point.
The pain cannot be explained by findings on neurological examination.

As in referred pain, the mechanism of trigger points is still being debated. Trigger point tissues have been biopsied, and findings indicate the presence of hyperactive muscle spindles, special cells whose function is to detect the rate of lengthening in a contracting skeletal muscle and initiating the firing of complementary muscles to complete the desired goal.

Wikipedia gives a nice summary of what causes trigger points to form:

Activation of trigger points may be caused by a number of factors, including acute or chronic muscle overload, activation by other trigger points (key/satellite, primary/secondary), disease, psychological distress (via systemic inflammation), homeostatic imbalances, direct trauma to the region, collision trauma (such as a car crash which stresses many muscles and causes instant trigger points) radiculopathy, infections and health issues such as smoking.

Finally, there are more highly-complex causes of pain related to dysfunction of the central nervous system, sympathetic nerves, biochemical and hormonal issues, and even psychosomatic. These types of cases are difficult to diagnose and are often treated using pharmacological agents, and on the other side of the spectrum, holistic approaches with mixed results.

NO MATTER what pain you may be experiencing, know that it always, always helps to detoxify your body as best you can via a nutritionally-dense diet centered on naturally-occurring, non-GMO, organic unprocessed food sources; reducing your processed sugar and grain intake; regular exercise, getting enough sunshine to your body; targeted supplementation, meditation or other relaxation methods, and even nurturing social support. This is the theme of this blog, because there is no shortage of treatment methods for pain and not enough emphasis coming from doctors or the government on prevention, wellness and health optimization; i.e. Healthy Lifestyle Education.

In the next couple of blog posts, I will talk about real, practical ways you can reduce your pain without the help of your doctor by making strategic lifestyle modifications. Your body has a potent array of disease-fighting systems and has an innate ability to repair and regenerate itself. The problem is that in many pain sufferers, these systems are burdened by unhealthy habits and are not running at their full potential. Imagine what can happen if those systems were brought back on line, constantly doing what they are naturally programmed to do– protect you and keep you alive; fighting germs, cancer cells and developing diseases; and repairing injured sites so that you can function better. Isn’t this a goal worthy of your efforts?

More to come, stay tuned!

Dr. Perez

Whole Body Vibration for Back Pain

by Pain Doc | Mar 21, 2011 | Low Back Pain

Whole body vibration, or WBV is popular in the fitness, health, and beauty industries. It involves standing stationary or doing exercises on a motorized platform that vibrates at different frequencies and amplitudes (basically, different speeds and intensities).

Research on the benefits of whole body vibration are mixed, but a significant number of studies point to definite benefits including increased muscle strength, increased blood circulation to the leg muscles and skin, increased bone density, reduced muscle atrophy following bed rest and in space, improved postural control in older individuals, and reduced chronic lower back pain. However, at least one study warns of potential adverse health effects of “excessive” whole body vibration training.

The WBV machine consists of a platform, handle grips and control panel. You do exercises like squats with both feet on the platform, or alternating lunges with the front foot placed on the platform while it vibrates at a set frequency. Depending on the model, a WBV machine can vibrate in the z-axis (or straight up and down direction– most intense), x and y axis (front to back, side to side), or teeter-totter (like a seesaw action). Amplitude (height differential of the platform in one vibrational cycle) and frequency (number of cycles per second).

Two popular models are the durable, commercial-grade PowerFit VB588 Whole Body Vibration Machine and the less expensive but lower quality home use model, PowerFit PFM002. If money is not an option, you can get the Power Plate – Pro5 – Model 565273 which is the brand that is found in exclusive fitness centers throughout the world.

There are generally three classifications of whole body vibration machines: High Energy Lineal, found mostly in commercial vibration training studios and gyms. The vibration direction is lineal/upward eliciting a strong stretch-reflex contraction in muscle fibres targeted by the positions of training program. 2. Premium Speed Pivotal, (teeter-totter movement) used for physiotherapy work at lower speeds and exercise workouts at “premium” speed, up to 27 Hz. Both commercial and home units are available. 3. Medium Energy Lineal, the majority of lineal platforms produced. These are usually made of plastic; some have 3-D vibration which is low quality. They give slower and less consistent results. 4. Low Speed Pivotal units. These can give “therapy” benefits. Other machine types are low Energy/Low amplitude lineal and Low energy/High amplitude lineal with varying uses from osteoporosis prevention, therapy for improved blood circulation and flexibility and limited fitness training. I am not certain if this classification system is used by the various manufacturers of WBV machines.

So, should you try whole body vibration if you have chronic back pain? My advice is to check with your doctor first. If you are cleared by your doctor, start conservatively– low amplitude, and only for a minute or two; standing only. Take note of how you feel. Most of the studies done thus far on these machines involved fairly extensive time periods, like 6-12 weeks of daily usage, so if you plan to use WBV to reduce back pain your body needs to be able to take it. If you are able to work up to 5-10 minutes on the machine without feeling nauseous, more pain, dizzy or any other adverse symptom, do it for a week and re-evaluate. If all is OK, try exercises like simple squats on the platform. If you feel improvement in your lower back pain, then congratulations, your particular situation responds to whole body vibration. However, there are no studies that I am aware of that track the long-term effects of WBV therapy on chronic lower back pain. So, a good rule of thumb is to do it daily for at least two weeks, symptoms permitting; and then do it less periodically for maintenance. Obviously, at the first onset of any adverse reaction from using WBV, stop immediately and report it to your doctor.

Some of the possible ways whole body vibration resistance exercises can help reduce back pain is by increasing blood flow to the muscles, exercising the muscles, and bombarding sensory input to the back muscles thereby breaking any “learned” abnormal neurological patterns to the muscles.

Even if you don’t have back pain, whole body vibration offers other proven health benefits like improved blood circulation, decreased muscle weakness from body inactivity, and improved postural balance. It would therefore make a nice addition to your home exercise equipment.

Back Pain as a Result of Brain-Muscle Miscommunication

by Pain Doc | Mar 13, 2011 | Low Back Pain

Most people who have general back pain and stiffness don’t question it enough; i.e. wonder why they have it. All they want is for it to go away in the quickest amount of time. A person suffering from back pain will first wait and see if it goes away with rest and time, and if it’s really bad, over the counter medications. If this doesn’t work, he will make an appointment with his primary care physician, who will usually prescribe pain medication and muscle relaxants to address the symptom (not the cause). The patient may be referred for physical therapy, which typically consists of modality application (heat, ice, lumbar traction, electric muscle stimulation and possibly low level laser) and exercises. Some people with lower back pain consult a chiropractor, who will address the problem usually be employing some form of spinal manipulation; and some will seek an acupuncturist.

But what if all these treatment forms are on the wrong track; i.e, they are based on errant assumptions? What if there is more to the back pain than sore muscles and stiff joints?

If you suffer from back pain; particularly lower back pain, it may be the result of dysfunctional nerve signals coming from the brain. The brain controls voluntary and involuntary contraction of your muscles, like a finely tuned machine run by a super fast computer. It’s analogous to a world-class conductor conducting a symphony so that every note, tempo, and timing is perfect.

If the nerve impulses (millions of them occur just standing) are dysfunctional, it can cause certain muscle groups to contract when they aren’t supposed to, forcing joint surfaces together and limiting their movement. It can cause one side to be inactive, resulting in unbalanced muscle tone. Abnormally functioning nerve signals to the muscles can throw off the synchronization of muscle contraction, which would be a big problem right in the middle of moving a heavy piece of furniture.

I believe that most cases of gradually occurring lower back pain are the result of degraded communication between the brain (cerebral cortex and cerebellum) and the musculoskeletal system. Even if the onset of pain was a specific incident such as bending forward to pick something up, it is secondary to a malfunctioning brain-muscle communication.

So, what does one do? Realize that for lower back pain, one shouldn’t simply focus on external means to reduce the pain; whether it be pharmacological (drugs) or manual (physical therapy, chiropractic). These methods can help reduce the pain and make you feel better, but if they don’t address the true problem, the pain is guaranteed to return.

Somatics is a form of therapy that treats muscular conditions by attempting to remove emotional or subconscious factors that may be contributing to the problem. The idea here is that the brain’s ability to properly regulate the body’s muscular function has been compromised by an old injury; inactivity, or harmful thought patterns. Somatic therapy addresses the problem by attempting to restore the connection using specific exercises, concentration, and breathing techniques.

If you have lower back pain that just won’t respond permanently to physical therapy or chiropractic, consider Hanna somatic exercises. This technique seeks to restore proper brain-muscle function using deliberate, specific targeted exercises (not your typical strengthening and stretching exercises). The system is taught by Lawrence Gold, a certified Hanna Somatics practitioner and is available on DVD or internet download. A sample of one of the exercises can be found here.

Recommended Back Exercises

by Pain Doc | Jan 18, 2011 | Low Back Pain

I am a firm believer that strengthening and conditioning the core, back and leg muscles is the best way to guard against getting back pain.

If you’re prone to having your back “go out”, then these exercises are the best way to guard against recurrence. Don’t wait until you get degenerative disc disease, because once you reach this point the chances of living a pain- free life take a big nosedive. The reason is that the best exercises for strengthening your back are more risky for those with disc degeneration.

What typically happens is the disc degeneration patient will naturally stay cautious or apprehensive and will avoid back exercises for fear of re-injuring his back. This eventually leads to back muscle weakness and loss of muscle coordination–precursors for back injury and chronic pain.

So, if you don’t have back pain or degenerative joint disease (weak, thinning and/or herniated discs with accompanying bone spurs and cartilage degeneration) consider yourself lucky. Make sure your exercise regimen involves engaging the primary muscles of the trunk primarily, and the whole body, secondarily.

Do functional exercises which force the muscle groups to work synergistically rather independently. Such exercises can mimic common body movements; for example, carrying something on your shoulder while walking.

In strengthening the back, I like to do squats using a 20 lb bar on my back with feet apart in different distances.

Throwing a 12 lb. medicine ball using your whole upper body is another great functional exercise. Get a partner and have him stand 10 feet to your right. Throw the ball to your partner while using your core as well as arms. This simple exercise will strengthen your abs, your paraspinals, arms, and even your leg muscles.

Next, use a Freemotion or similar cable-weight machine where you can raise an arm above your head. With both hands, grip the cable handle and swing it down towards your feet, as though you were chopping wood with an axe. Boy, this is a great exercise as you will feel just about every muscle in your back, arms and chest work together to move the weight.

What to Do if You Have a Bulging Disk

by Pain Doc | Sep 13, 2010 | Low Back Pain

Image via Wikipedia

Lower back pain presents in a range of severity depending on the structures generating the pain.

A simple sprain/strain can still cause extreme pain, swelling, and immobilization for a couple of days but should completely resolve after a few weeks with proper care and rest. Lumbar sprain/strains are associated with lifting something heavy, or even simply bending or twisting at the waist; weight lifting, sports injuries and trauma like a car accident. By definition, they are limited to injury to the muscles, fascia, tendons and ligaments. The pain is limited to the area of injury.

Image via Wikipedia

A lumbar disc bulge occurs when a disc “bulges” outwards due to weakness or injury. A disc is a tough, fibrous ligament that holds the lumbar vertebrae together at the vertebral body. The disc’s outer periphery, called the annulus, resembles a slice of an onion, with multiple rings of fibrous tissue encasing a jelly-like material called the nucleus pulposus. While tough and strong, it allows movement of the individual vertebrae.

By definition, a disc bulge is still intact and has not ruptured (as opposed to a disc herniation or rupture). The bulge represents a weakened area in the annulus that allows the nucleus to gravitate towards a section of the periphery, usually the posterior (rear-facing) edge, facing the spinal canal (where nerve tissue is present). It can be a broad-based bulge, or a more focal bulge. If it is greater than 5mm (measured from the edge of the vertebral body to the tip of the bulge) it is clinically significant. Many people have disc bulges and have no back pain at all; in fact, it is normal for the discs to bulge slightly in the weight bearing position (standing).

The problem occurs when the bulge contacts nerve structures. If large enough, they can contact the thecal sac (contains the spinal cord and cauda equina) by bulging backwards into the canal, and they can press on spinal nerve roots by bulging to the sides. The spinal nerve roots branch out in pairs from either side and exit holes formed between adjacent vertebrae called vertebral foramen, or lateral canals. A disc bulging to the posterior and side can narrow this opening and pinch the nerve root causing pain to travel down the buttock or leg, depending on which nerve root.

TREATMENT:

If your lower back pain is felt deep, and you can make it hurt more by bending your lower back backwards and to the side, you may have a disc bulge. You may or may not have pain and/or numbness going down the buttock and leg (same side of the pain). If it happened while lifting something heavy, the diagnosis is more likely. If you have extreme, unchanging pain with more constant leg pain or paresthesias (numbness, tingling) that does not get better with ice and rest, you may have a disc rupture (also called prolapse) where the inner nucleus had broken through the annulus and is in the spinal canal or lateral canal. If you have changes in your gait (walk) such as foot drop, weakness in your legs, difficulty walking upstairs, then the diagnosis of disc prolapse is more probable.

Disc bulges can be managed with conservative treatment like home care, chiropractic, and physical therapy. Disc prolapses should be evaluated by an orthopedic surgeon or neurosurgeon. An MRI should be ordered to evaluate the extent of the injury.

If you suspect you have a disc bulge, take care not to aggravate it. No heavy lifting, no jumping activities (basketball, badminton– anything where your feet leave the floor and land hard).

Discs usually bulge backwards (posterior), so do movements that encourage the bulge to move back to center. Lie on your back and bring both knees to your chest (ok to use your arms to grab your knees while they are bent, and pull and hold to your chest). This will put your lumbar spine in flexion, or a nice convex curl. Your back contour should be like that of an egg, and you should be able to rock back and forth. Maintain the pull, stretching your lower back into this curve. Hold for 30 seconds, then slowly extend your legs on the floor and rest for 15 seconds (optional: put a frozen ice gel pack covered with a kitchen towlette under your lower back during this exercise). Repeat six times. This will have the effect of creating separation between the posterior ends of the lumbar vertebrae, helping to reduce the bulge.

Next, stand and place your hands on your hips, and slowly arch your back backwards, putting your lumbar spine into extension— the opposite curvature as the previous exercise. Bend back until you can’t anymore, but don’t over do it. Hold this position for six seconds, then return to neutral. Repeat eight times. This will have the effect of bringing the posterior ends of the lumbar vertebrae closer together and pushing the nucleus back towards the center.

Do the above series of exercises three-four times a day for a week until the discomfort is gone. At this point, you should focus on doing things to strengthen the disc. Eating a wholesome, healthy diet with enough protein, fat and plant material will help; avoiding destructive activities like smoking, alcohol, and staying up late will enable optimum conditions for tissue healing. Gradually start doing exercises that improve lower back muscle conditioning and coordination.

Getting a series of 6-8 chiropractic adjustments to the lumbar spine may also be helpful in reducing your bulging disc.

How to manage lower back strain

by Pain Doc | Sep 9, 2010 | Low Back Pain

Low back pain is said to be the most common cause of lost work days, after the common cold. Most everyone has experienced an episode of lower back pain at some point in their life; millions suffer from chronic (ongoing; unending) lower back pain of some form.

The low back, or lumbar spine, is comprised of the last five (5) vertebrae in the spine. These vertebrae are the largest as they support most of the body’s torso weight. Like the cervical spine; i.e. neck (the first 7 bones of the spine), there are no rib attachments in the lumbar spine to limit movement, making the lumbar spine more moveable than the thoracic spine (torso), but less flexible than the cervical spine due to its larger, heavier vertebrae.

This unique lumbar spine design offers advantages and disadvantges. The obvious advantage is flexibility–you can bend (flex) your low back forward, backward, sideways, and can rotate it a few degrees to either side. The disadvantage is that with more movement, there are more opportunities to stress the joints of the lumbar spine (more moving parts) and therefore more chance of injury and pain. This includes potential injury/ trauma to the surrounding ligaments, joint capsules, cartilage lining the small joint surfaces; small facet joints, intervertebral discs, and the lumbar vertebrae themselves.

Therefore, low back pain can originate in one of several structures in the lower back:

the discs (strong fibro-cartilage ligaments that hold vertebrae together)
the facet joints (the “rear” joints of a vertebra, opposite the vertebral
Image via Wikipedia

bodies)
the pars– the small extensions of bone to either side of the vertebrae that form the upper and lower borders of the intervertebral foramen, and end in the lumbar facet joints
the surrounding muscles
the surrounding fascia (muscle covering)
the nerve roots inside the spinal canal
the vertebrae itself (compression fractures; vertebral end-plate fractures)

Today we’ll address lower back pain due to muscle and fascia strain. I’ll refer to this a low back or lumbar strain. This is a common cause of lower back pain and is more manageable than pain due to deeper spinal structures.

In the many cases of lower back strain that I’ve treated over the years, the patient describes a sudden onset of pain after bending at the waist reaching for something. In other cases, the pain starts a day after doing something like weight lifting, running or rock climbing.

Medically speaking, a muscle sprain-strain occurs when muscle fibers tear during contraction and subsequently release inflammation.

The convention for naming soft tissue injuries is that strain refers to injury to a muscle and tendon while sprain refers to injury to ligaments, which connect bone to bone. Since muscles, ligaments and tendons typically get injured all at once in a typical injury due to their anatomical proximity to one another, doctors refer to these types of injuries as sprain-strain injuries.

Sprain-strain severity is described as Grade I, Grade II and Grade III, with Grade III being the most severe and refers to complete rupture of a tendon or ligament. Most lumbar strains are Grade I and II.

Inflammation is meant to contain/ quarantine an injury and is actually an important process in the healing phase (tissue regeneration). The problem is that it releases chemicals that irritate nerves and surrounding tissues, and stiffens adjacent muscles and joints. The inflammatory response can “overshoot” causing the patient to needlessly suffer.

If you go to your doctor complaining of lower back strain, and tests do not indicate damage to deeper structures (discs, facet joints, nerve roots, bone) then you will most likely be prescribed pain blockers (usually NSAIDs- non-steroidal anti-inflammatories), rest, and ice. Your doctor will likely put you on “temporary disability” which means no heavy lifting, bending at the waist, and other activities that put stress on the lower back. Sometimes muscle relaxants are prescribed, if there are complaints of spasm and stiffness. You will be told that it should resolve on its own, and most cases do.

TREATMENT:

At first onset of straining your back, apply ice for 20 minutes every two hours of the waking day. The easiest way in my opinion is to get a large freezer ziplock back, fill a third of it with ice cubes, put about a cup of water in the back and zip it closed (get as much air out as possible before closing shut).

Lie down so that your exposed (no clothing) lower back is directly on top of the bag. Bend your knees or put a pillow under them for comfort. This flattens the lower back and allows it to make good contact with the icepack. (Optional: put a neck roll under your neck for comfort). Do this for 1-2 days.

On the second day, you can introduce gentle stretches while you ice. After your 20 minutes of icing, try lifting your knees to your chest, pulling them gently towards you with your hands. Hold for 5 seconds; repeat five times. Then, keeping your feet together (you are still lying on your back), knees bent, let the knees fall to the right side, gently twisting the lower back; reverse sides. Do five times to each side. What these movements do is orient any scar tissue that develops, in the direction of contraction.

On the third day, assuming pain is still present, you can try using heat. I recommend an infrared lamp. This is radiant heat that penetrates deeper than a hotpack.

If you need to get pain free even sooner, I suggest using the 120 LED (Light Emitting Diode) wrap. This popular home therapy device used red light therapy + infrared heat, which goes beyond simply blood circulation increase. The red light diodes inhibit inflammation and increase cellular metabolism (energy production, waste removal) which means speedier tissue healing.

After a week, your lower back strain should be 60-90% better. If it is only 25% or so improved after a week, the injury is likely worse than originally thought; and deeper soft tissues may be involved. In this case, consider using Pulsed EMF to further enhance tissue healing.

Last thought: I believe that if someone strains his lower back by simply bending forward, it indicates that the back muscles, and probably core/abdominal muscles need better conditioning. It’s not all about strength, it’s also muscle coordination in response to varying loads; for example, picking up a piece of heavy luggage. Those with excellent muscle coordination (there are five major muscle groups that have to work together to move the lower back) are less likely to injure their backs like this. Interestingly, research shows that osteoarthritis, or degenerative joint disease in the lumbar spine, is related to poor lower back muscle coordination. And it makes sense– your muscles move and support your lumbar spine. Poor support and coordination between muscles (erector spinae group, abdominals, etc.) can cause your spinal joints to bear more stress than normal during every day movements.

So, the best strategy is to prevent getting lower back strain by strengthening AND conditioning (improve coordination of) your lower back muscles by doing functional exercises.