Ah! The dreaded low back pain situation. The part of our body that experiences turbulent bouts of aches and pain that comes and goes and can range from mild to severe. The ongoing mystery to why some individuals experience endless episodes of low back pain versus some who never experience any at all remain a feat to many medical researchers and providers. There has been so many individuals who tried every type of treatments possible but still experience the same problem. So, let's look at why low back pain can be so simple, yet complicated.
Low Back Pain (LBP) is extremely common and affects about an average of 8-10% of the US population with an estimate of a one year recurrence of 24-80%. Origins of low back pain is derived from many possibilities including stress, structural damages, work demands, or even anxiety. Low back pain has an enormous impact on individuals, families, communities, and governments around the world. It is estimated that the prevalence of low back will continue to increase in the coming years.
Many medical researchers have honed down on the possible risk factors that can expose an individual to low back pain. These include:
Age: onset of LBP usually occurs in individuals 30 years or older. A part of this is due to the start of the "aging" process where the body start exhibiting structural degeneration.
Weight: extra weight and obesity tends to increase pressure on the low back making it more prone to injuries.
Overall health: individuals who have good healthy habits and are active tend to experience less low back pain. There's also a direct correlation between mental & emotional well-being to incidences of LBP.
Occupation: individuals who have jobs that are require heavy lifting, use of vibratory machinery, constant sitting, or frequent bending tend to have more cases of low back problems.
Congenital Reasons: some individuals are born with structural problems such as scoliosis. Individuals with structural deformities tend to have higher risks of developing back pain.
Past Injuries: people who had previous injuries or trauma to the low back tend to have a higher rate of recurrence in LBP.
Causes of low back pain are endless, but most of the time they are not life threatening and are usually mechanical in nature. In a 2015 NHIS Occupational Health Survey on workers with frequent severe low back pain, 90% of the cases were noted to be non-specific, meaning there was no specific diseases that caused it, with further implications that LBP was due to a mechanical structural fault. I can possibly name 20+ diagnoses and mechanical causes of LBP, but to make this simpler, I created a chart which categorizes the causes of LBP into 3 compartments followed by some common conditions.
As you can see, mechanical LBP is further divided into acute vs chronic conditions. The difference between acute and chronic low back pain is based on duration. Acute LBP lasts less than 1 month while chronic low back pain lasts greater than 3 months. Most of the time acute vs chronic low back require different types of treatment methods.
Now that we gained a simple understanding of LBP and how LBP is diagnosed, let’s talk about treatments. How can we treat LBP and why is it so complicated? Before I go on a rant about this, I would like to state that the rest of this blog post will be dedicated to my opinions, which are based on my experiences working with low back patients for the past 10 years.
There are many treatment methods for low back pain which include physical therapy, chiropractic adjustments, surgeries, epidurals, steroid injections, acupuncture, etc. Most of these treatment methods work and get individuals back to their A game quickly. However, many a times they don’t and here’s why it gets complicated:
Wrong Diagnosis: How many times did you receive an Xray, MRI, or CAT scan that revealed something? Be it herniated discs, disc degenerations, or a case of mild spinal stenosis and your medical provider immediately determines that that’s the source of your LBP, without using any further diagnostic tools or assessments. You’re then sent to get “treated.” You get the treatments and there is NO significant change in your symptoms. Why? Because the source of the LBP was never from the structural “abnormalities” shown by the radiographic images. MRIs, CAT Scans, and Xrays have their own false negatives and positives. And just because your radiographic images revealed the dreaded “herniated disc,” does NOT mean you are symptomatic, hence you were being treated for the WRONG diagnosis. You may feel slightly better with all the palliative treatments, but never FULLY BETTER. In order to provide the “best and proper treatments” you need to get the correct diagnosis. A good medical provider will use deductive reasoning through various radiographic images, proper assessment of your body, and a really GOOD subjective understanding of the patient’s medical history and report of symptoms.
Biopsychosocial Factors: Many medical providers tend to look at the physical reasons to why an individual experiences LBP or recurrent episodes of it. Despite having the CORRECT diagnosis, many clinicians fail to understand and incorporate the emotional and social aspects of an individual to the treatment protocol. The mental health status of an individual contributes heavily to how much progress an individual makes when getting treatment. Unless you tackle both the mental and physical aspect of LBP, the amount of progress with treatment can be hindered.
Patience & Determination: I am going to throw this responsibility back to my patients (no offense). I always tell my patients that “I am NOT a rocket scientist. I am a medical provider who can ONLY provide the proper exercise prescription for you to get better.” As a physical therapist, I can give the most extensive and individualized exercise program to battle LBP, but it ONLY works if my patients DO IT. Physical therapy requires patience and determination, as change is NOT immediate. Progress takes TWO to be accomplished. If you don’t do the WORK, there is NO CHANGE. A good analogy would be when a medical doctor prescribes drugs to help your illness but YOU DON’T TAKE IT! Then ask yourself, what’s the point?
Keeping Up: I always offer my patients a maintenance program because MOST of the time when a patient is discharged, they tend to forget the exercises given to them to PREVENT recurrence. In my 10+ years working with LBP patients, I can count with my two hands the number of patients who have fully gained independence in maintaining a LBP free life. Most patients, unfortunately return back to my office in a year or two with LBP recurrence. When asked if they did the exercises I gave to them upon discharge, their answer is always “NO” with massive guilt on their face. I am not blaming them as we all know something call “life” gets in the way, but if that’s the case, keep your expectations low.
Dependency on Medications: I am not against surgeries or epidurals, but I am overall a physical therapist and a smidge biased. I wholeheartedly believe that pain caused by mechanical or structural changes require a mechanical/structural active approach. Many a times individuals get an epidural and feel GREAT! Pain is GONE and they even forget the reason why they were seeing a doctor. But slowly and surely they will MOVE in a certain way and LBP returns. At that point, they will go running back to their doctor hoping to get another injection. The truth is, epidurals are temporary. They are given to HELP you with PAIN, not FIX the source of the PAIN. Epidurals are given to provide an individual with pain relief, such that they can participate in activities that were initially limited. To utilize this pain-free time properly, patients should REALLY engage in proper exercises to build their physical tolerance preventing recurrence.
The Unfortunate 1%: Sometimes even if you seek help from the best diagnostician, get the best and most proper treatment methods, and do everything right, you just may be that unlucky 1% that never fully recover. And this is where the mystery lies. Because there are so many factors which stem from all aspects of life ranging from genetics to environmental factors, we as medical providers simply DO NOT HAVE ALL THE ANSWERS. And that is why we as medical providers NEVER say we are 100% SURE!
Bottom Line is that if you experience low back pain, don't be discouraged. Just because there is a 1% chance that you may not fully recover, doesn't mean you shouldn't aim for that 99% that you will get better. Chances are, people with LBP do and will get better with treatment. If you seek the "right" medical provider who can diagnose you correctly, get the proper treatments, and be patient while diligently following the plan of care, chances are you will be that individual who will fully recover while preventing future recurrences.