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MELVIN R. MANNING, M.D.
SPINAL DISORDERS, TEXAS SPORTS MEDICINE
DIPLOMATE, American Board of Physical Medicine and
Rehabilitation
FELLOW, American Academy of Physical Medicine and Rehabilitation
ASSISTANT TEAM PHYSICIAN, Dallas Mavericks
INTERVENTIONAL SPINE, BACK PAIN SPECIALIST
Low back pain in the United States
- 80% of Americans experience Low Back Pain (LBP) in their lives.
- LBP is second only to the common cold as a cause of lost work time; it is the fifth most frequent cause for hospitalization and the third most common reason to undergo a surgical procedure.
- Productivity losses from chronic LBP approach $28 billion annually in the United States.
- Low back pain rates of recurrence reach as high as 50% if the year following the initial episode.
- Low back pain is a clinical challenge in that it occurs across various population segments. It is associated with heavy physical work, stationary work postures, vibration, psychosocial work factors, smoking, and obesity.
Anatomy of the Low Back (Lumbar Spine)
- Vertebrae. The 24 moveable bones of the spine; 7 Cervical, 12 Thoracic, and 5 Lumbar. Below the lumbar spine is a triangular bone called the sacrum. The sacrum is wedged between the two halves of the pelvis.
- Intervertebral discs. The cartilage shock absorbers between the vertebrae. Consists of an outer, layered annulus fibrosus and an inner, gelatinous nucleus pulposus.
- Facet joints. Joints along the back of the spine attaching the vertebrae above with the one below.
- Ligaments. Strong connective tissue, attaching bone to bone, responsible for stability.
- Muscles. Contractile tissue allowing for movement and stability. Large muscle groups are responsible for gross movements while small muscles are responsible for stabilizing the spine from segment to segment, preventing excessive motion.
Common terms
- Degenerative Joint Disease (DJD) / Degenerative Disc Disease (DDD). DJD and DDD are commonly used terms to describe degenerative changes which take place in the discs between the vertebrae. While these changes may be present in an individual with low back pain, it may not be the cause of pain. Degenerative changes in the spine are a normal process of the aging spine and are seen in X-Rays in the fourth decade of life.
- Disc bulge. When the inner layer of the disc (nucleus pulposus) pushes against the outer layer (annulus fibrosus) beyond its normal border. This results in a bulge appearance on MRI.
- Disc herniation. When the inner layer of the disc (nucleus pulposus) passes through small tears in the outer layer, displacing the disc material.
Dispelling myths regarding low back pain
- MRI and low back pain
- Myth. MRI is the best way to determine what's causing pain.
- Fact. MRI is a valuable diagnostic tool. However, it will show abnormalities which may not be the cause of pain. For example, disc bulges and herniations are present in normal, pain free individuals. It is a normal process in the aging spine. The presence of a bulge or herniation on an MRI does not mean that the bulge or herniation is the cause of pain. This does not mean that imaging should not be ordered. MRI and X-Ray are appropriate when red flags (see below) are present or if low back pain is not improving with a trial of conservative care.
- Bed rest and low back pain
- Myth. Treatments which promote rest is the best treatment for low back pain.
- Fact. Medical management of low back pain focuses on pharmaceuticals such as muscle relaxers, anti-inflammatory and pain medication. Quite often, there is a recommendation of rest. With the exception of severe low back pain cases, this treatment paradigm is flawed. Most patients do not need these drugs for uncomplicated low back pain and very few patients require bed rest. Bed rest should be reserved for severe cases and still should not be more than 2-3 days. Muscles atrophy (waste) when not used.
The earlier the return to normal activity, the better the long term outcome. Even while in pain, it is better to resume and maintain normal activities. Several national guidelines on low back pain conclude that rest leads to muscle deconditioning and can impair recovery.
Your doctor should recommend a list of home care instructions, activity modification, positional/ postural maneuvers, and gentle exercises which will help you get through the initial days of pain. There should also be a plan in place of implementing a therapeutic exercise program to minimize the chance of recurrence.
- Exercise and low back pain
- Myth. Exercise will make low back pain worse.
- Fact. Most back pain is due to muscular instability and weakness. The appropriate exercise is important. They should focus on strengthening the deep muscles of the abdomen and low back. Consult with a health care professional who is well versed in therapeutic exercise and will give you one on one instructions.
Exercise may make your back sore but it is important to differentiate between hurt and harm. Increase in sharp pain or a change in symptoms during or after exercise are indications to stop that particular exercise.
- Chronic low back pain
- Myth. Once I have back pain, I will always have back pain.
- Fact. A proper attitude, a properly rehabilitated low back, weight/lifestyle control, and performing the appropriate preventative exercises should result in return to pain free activity.
The Chronic Pain Cascade
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