Chronic Low Back Pain Care and Prevention

by Reza Salajegheh, M.D.

Chronic Low Back Pain Care and Prevention

Low back pain is a universal issue that affects most individuals at some point in their lives. Eighty percent of the adult population will have at least one episode of severe low back pain. It is the leading cause of disability worldwide, and the number of people with low back pain is increasing.

This condition can be divided into two separate phenomena: acute pain and chronic pain. Chronic pain lasts longer than three to six months. Acute pain lasts less than three months.

The many different causes for chronic low back pain can overlap, making the diagnosis of the pain’s source difficult.

The number one risk factor for developing chronic low back pain is age. Similar to any other joint, bone, or muscular structure in the body, our backs tend to degenerate as we age, leading to a multitude of issues such as chronic low back pain.

However, not everyone will get chronic low back pain as they age. The second biggest risk factor is genetics. Some people despite their age maintain excellent disc and joint health. Some risk factors are out of our control.

There are some risk factors that you can control. Smoking significantly accelerates degeneration of your discs and joints. It robs your tissues of oxygen, which can lead to worsening osteoporosis, a condition causing bones to become weak and brittle.

There are also work or environmental factors that can increase the likelihood of developing chronic low back pain. For example, someone who plays higher risk sports or someone who works on a job where they’re doing a lot of bending, twisting, and lifting is more likely to suffer from low back pain. Those workers who sit at desks for work are not immune either. If they have poor ergonomics and do not take routine stand and stretch breaks, a worker with a desk job is at almost the same risk for low back pain as someone who bends, twists, and lifts with poor mechanics.

Fitness and obesity are important factors as well. A patient who might have poor discs and arthritis in their back but also has great core strength because they’re active is less likely to have chronic low back pain. Conversely, someone who is not in great shape and is overweight or obese is more likely to develop chronic low back pain due to the excess weight being put on their joints.

Pain perception is another key aspect to chronic low back pain. Psychological health is extremely important to managing someone’s pain. Seventy percent of the centers in your brain that are responsible for processing and interpreting pain signals also control emotional processing. Imagine what you’d feel if you won the lottery, and someone comes in and punches you in the arm. Now, imagine how you’d feel if you lost someone very dear to you, and some-one comes in and punches you in the arm. Those two scenarios are going to have very different pain experiences. Your emotional state plays a major role in your perception of pain. If you are in a positive mood, pain stemming from your low back may not feel as intense. On the other hand if you are in a negative mood, chronic low back pain may be excruciating.

When should you see a doctor?

If you have pain radiating down into your legs, if you have weakness in your legs, if you have a pins and needles sensation in your leg, if you have numbness in your legs or feet, or if the pain is significantly inhibiting your ability to do daily tasks, then it’s time to make an appointment with a specialist.

If you have sudden onset significant weakness in your lower extremities or you have sudden on-set loss of bowel/bladder control, please go to the emergency room.

Understanding the anatomy of the spine makes it easier to understand the potential causes of low back pain. The vertebrae and the discs are at the front of the spine, or the anterior. The lamina (the roof of the spinal canal that covers the spinal cord and nerves), the spinous processes (the bony projections off the back of each vertebra), and the facet joints (the joints that control how your spine moves around) are at the back of the spine, or the posterior. In the middle, between the anterior and posterior elements, are the spinal cord and the nerves that descend from the spinal cord.

Pain can be the result of the discs degenerating or bulging/protruding from the spine. Discs have their own nerve fibers, and you can have pain that results when those fibers are disrupted. You can also have facetogenic pain. Just like any other joints in your body, the facet joints can develop arthritis over time. As the facet joints break down, they can send pain signals. Your body’s natural reaction to joints breaking down is to overproduce bone at the joint area, a process called hypertrophy. When hypertrophy occurs, impingement, or a pinching pressure, of nerve roots that exit the spine and travel into the legs can follow. Nerve compression can also occur due to loss of disc height, and nerve root impingement from a disc bulging out and pushing up against said nerve can cause pain.

You may have pain that’s a result of inflammation and dysfunction in the joint between the base of your spine and pelvis called sacroiliac pain. During pregnancy, you can also develop myofascial pain which is pain of the muscles and ligaments due to a strain, tear, or overuse. Inflammatory responses caused by autoimmune conditions can be the cause of pain and include ankylosing spondylitis or rheumatoid arthritis.

Stressed anatomic elements, which include overstressed joints and discs as a result of obesity, poor posture, or pregnancy, may cause pain. There are also non-musculoskeletal causes for pain such as kidney stones or endometriosis (a disorder where tissue that usually grows inside the uterus grows outside the uterus).

What can we do to treat chronic low back pain?

There are many different ways to treat chronic low back pain. We go from more conservative treatment options to more aggressive ones, since patients can usually see results from the more conservative options. Patients often want a quick fix, but successful and appropriate care takes time and usually involves several different treatments.

We start with basic treatments such as non-steroidal anti-inflammatories, muscle relaxants, and nerve pain medications. Alongside the basic treatments are physical therapy, heat and ice, massage therapy, and transcutaneous electrical nerve stimulation (commonly seen with TENS ma-chines). You can also visit a chiropractor if you wish to do so. It’s also extremely important to learn better back hygiene and to adjust/correct those environmental factors that are leading to back pain issues.

If those options aren’t working, then we move forward with treatments such as steroid injections and nerve ablations, a process of using needles to disrupt a nerve’s ability to signal pain to your brain. If there’s an anatomic cause such as a nerve impingement due to a disc bulge, we can try other non-surgical options like weight loss where appropriate. Surgery is a last resort option, and we want to avoid it if possible.

Frequently asked questions

I drive for a living, and my back always hurts. What do you suggest?

Driving is one of the environmental factors that can impact your back. Make sure the seat in the vehicle you’re driving is in the right position for you. If it isn’t, make the proper adjustments and modifications such as adding additional padding underneath your buttocks or behind your back.

Make sure you are taking breaks from driving to stretch and rotate your back around. When you’re not on the road, work on your core strength and your posture.

When I have low back pain, why do I also feel pain in my hips or knees?

If you have low back pain, those facet joints in your low back can cause referred pain to your hips and knees. If that pain is radiating all the way down to your legs, it can also be due to nerve roots being impinged.

These are things we assess by talking to you during your appointment or by getting advanced imaging such as an MRI.

Running bothers my lower back, but I do not feel comfortable going to a gym yet due to COVID-19. What types of at-home cardio exercises do you recommend?

If you happen to have a private pool at home (many of us don’t), swimming is a great option be-cause it’s a high resistance but low impact environment. It doesn’t bother the joints as much. You can also try biking.

As far as the pain caused by running, you can try running in an environment where there’s less impact. Instead of running on pavement, try running on grass or dirt. You can also adjust your running shoes and see if that makes a difference.

What are some core strength exercises you recommend?

Core strengthening exercises are designed to strengthen the core without stressing those joints in the discs. You don’t want to do exercises where you’re doing a lot of bending or twisting (at least not at first).

You want to do exercises such as crunches where the low back is staying static, but you’re raising the top of your body to activate those upper abdominal muscles. You can also try leg raises where your back is staying flat on the floor, and you’re raising your legs up about six to twelve inches and holding them there.

For more exercises, consider consulting our physical therapists.

What should I look for in a new mattress?

Everyone’s musculoskeletal needs differ. Some people do better with firm mattresses, while others need a softer mattress. In a majority of cases of people who suffer from back pain, a firm mattress provides more relief. However, there are certainly exceptions to that rule.