treat back pain

If you found this blog article after going down a deep rabbit hole of investigating how to treat back pain without surgery, I hope you found us first. The adage “opinions are like assholes…everyone has them” originated after the first person searched “relieve back pain” on google. There’s a lot out there and from an experienced clinician’s educated opinion, most of this is all bad advice and information. The tips in this article can advise you on how to treat back pain without surgery.

The positive thing to glean from all this is that you’re not alone. Low back pain is the number one cause of disability globally. In fact, 70-80% of people will experience low back pain in their lifetime and continues to be one of the most common and most profitable health problems in primary care. No, I’m not expecting that to magically get rid of your back pain forever; however, there’s certainly more truth to that than when you typed “magic back pain fix” in your YouTube search earlier. In fact, many studies have found that health information on the Internet varied highly in quality, reliability, accuracy, and readability.

For context, we’re given a blog topic to write on with many of the top-ranking results for the topic. We found an article by John Hopkins Medicine that even spread misinformation about chronic back pain being “age-related”. If this was the case, every person of age would have chronic back pain which is not true at all. We must watch studies being biased even as they are heavily funded by specific groups to illustrate points in their favor.

Fear not though! We’re only funded by ourselves and the clients that we work with daily who experience low back pain, among many other ailments. In this post, we are going to cover a lot of topics including how low back pain is more than just pain and how we might classify various kinds of low back pain. Another topic includes treatment interventions with their success rates. The most important is how your provider should be speaking to you about your pain. I’m going to be very explicit with you. This may take a while to read because quite frankly, low back pain isn’t simple. Treating back pain is not simple and neither is experiencing back pain. Read at your own pace. We certainly hope you learn more from this, but even more so, inspires more questions.

What Is Low Back Pain? – Much More Than Tissues & Your Body

I don’t think we need to spend much time on where our low back is. The low back is defined as “the area below the lower ribs and above the gluteal folds”. The issue we’ve run into over the last few decades is how we present low back pain to the general population. Fear mongering and misinformation has created this image that low back pain is a disease that couldn’t be more wrong. Low back pain is a symptom, not a disease. Depending on your situation, you can treat back pain without surgery. Read that one more time. The clinician’s job is to provide educated information, inspire confidence, and provide a plan to navigate through these symptoms. There are plenty of solutions – it is possible to treat back pain without surgery.

Commonly, for worse more than better, most people are presented with pathoanatomy6 meaning “what’s wrong with you and your body”. The problem with this is exponential in that it creates a mindset of learned helplessness (“I’m sick and I’ll always have chronic back pain”), devalues someone’s self-worth (“I’m weak and I’ll never live up to being the best person I can be now”), and fragility (“I have to be very careful, or I will throw my back out”). We include these phrases because I hear them all the time. Clients have been told many things from past practitioners they’ve worked with.

Imagine having an electric shock device that’s attached to you for the rest of your life and you’ll never know when someone is going to press this imaginary button to shock you. You would live in fear too. In one study, they concluded that “For the vast majority of people with low back pain, it is currently not possible to accurately identify the specific nociceptive source”. Translated that simply means, we have no idea what is causing your pain. Pain can manifest from more than just bones, muscles, tendons, and ligaments. You’ve surely had that “gut feeling” when you’ve either done something you shouldn’t have or possibly felt symptoms of anxiety. Low back pain is a symptom. You may be able to treat your back pain without surgery.

A practitioner that works with you should follow a model of care called the Bio-Psycho-Social model of care meaning that they take not only what they find on a physical exam into consideration but also genetic factors, comorbidities (do you have something else that may lead to having low back pain), psychological factors (your identity to yourself and mental health), and social factors (your identity to others and societal values). You can find a great illustration of this here.

We will get further into detail about further classifying low back pain later, but statistically speaking, <1% of cases in primary care are a specific spine pathology, ~ 5-10% are radicular syndromes, and an overwhelming ~ 90-95% are non-specific low back pain. You can find this illustration below in figure 1. Before we start thinking we are clearly in the <1% category, let us talk in the next section about more defining features and that if you’re reading this, you’re likely in the 90-95% percentile.

Figure 1 (Bardin et al., 2017)

Classifying Low Back Pain – Complicated to Simple

We’ve all heard terms like Sciatica, disc herniation, disc degeneration, stenosis, bone on bone, chronic back pain, and subluxation with virtually no context to what they mean and if they apply to you.

Most stories we hear are you’re given this diagnosis with either no explanation at all or you’re given a very inaccurate example of a jelly doughnut spilling everywhere or your X-Ray with lines and circles everywhere that looks like Post Malone’s face tattoos put up next to the “perfect posture” with fine lines. You leave feeling weak, defeated, and broke because you were told that the only person that can fix you is the “Doctor” (or a cult leader) standing across from you that wants you to refinance your house, rename your firstborn to Aligned, and leave your job so you can come in 4 times a week for a month, 3 times a week for the next two months, and 2 times a week for the rest of your life. Just remember, you may be able to treat your back pain without surgery.

You can clearly tell that this fires us up. Below, let’s cover each triage category we stated above, what we see with each, and how this can’t always define our back pain.

Specific Spinal Pathology – The <1% Group

We want to reiterate that this population is less than 1% of people with low back pain. A clinician’s job is to rule you out of this group rather than ruling in. To do this we have what are called red flags. One might have these in their dating or personal life as well like, “if they act like a serial killer and they look like a serial killer…they might be a serial killer, so we should move on”.

For the diagnoses, we see in this group: vertebral fracture, malignancy, spinal infection, axial spondyloarthritis, and cauda equina syndrome. These are some (meaning not excluding others and if you feel you need to seek a professional medical opinion, please do so) red flags we like to rule out to make sure you’re in the right clinic. Keeping in mind that 80% of acute low back pain have at least one red flag but less than 1% have a serious disorder.

  • Change in bowel or bladder habits
  • Unusual bleeding or discharge
  • Prolonged corticoid steroid use
  • Severe night pain or inability to rest
  • Unexplained weight loss
  • History of cancer/malignancy
  • Severe trauma
  • Fever/chills
  • Perineal numbness or saddle paresthesia
  • Older age (>65 years for men, >75 years for women)

Again, these are just some red flags. Simply because you’re a 67-year-old male doesn’t mean you have one of these diagnoses. Your clinician should look for a combination of signs and symptoms that increase their suspicion. Less convincing evidence of cancer or fracture, typically a suggestion for a trial of therapy for 1-2 weeks with review.

Radicular Syndromes – The ~ 5-10% Group

This group commonly involves nerve root irritation and involvement. This is where we find people who ACTUALLY have sciatica compared to pain referral. Sciatica is extremely overdiagnosed. Let’s break down the three different subsets of radicular syndromes.

  • Radicular pain – mainly on one side and specific dermatomal-dominant pain location (pain following a specific pathway), positive nerve tension test (straight leg raise with pain at <45 degrees), leg pain typically worse than back pain, and pain increases with cough, sneeze, or strain4
  • Radiculopathy – nerve root irritation involving numbness commonly in a distal dermatome (meaning feel it in my leg but the problem is higher up), weakness or loss of function (like drop foot), sensory loss in the same pattern, weakness of muscle strength along nerve root and reduced reflexes. These symptoms can often accompany a radicular pain problem which makes them more confusing
  • Stenosis – often bilateral leg pain or cramping with or without low back pain, commonly exacerbated by extended postures (like standing or walking for long periods) and relieved by flexion (like sitting, bending forward, and recumbent posture), neurogenic claudication (meaning compression of the spinal nerves)

This was a lot to digest, but your clinician should be looking for these things during their examination. Even with testing being positive, research shows a very favorable prognosis for all three of these when managed conservatively. If symptoms are disabling and persisted longer than 6 weeks or seem to be progressing or more severe, referral to a spine surgeon is warranted.

Here is where pain gets weird.

We often use imaging (commonly X-Ray first, and if there are radicular symptoms or no signs of improvement after several weeks of a trial of care, advanced imaging ex. MRI) to further diagnose specificity. However, a study found that radiological signs of disc wear and tear (ex. degeneration 91%), bulges (56%), protrusion (32%), and annular tears (38%) are also common in pain-free patients.

Another study found there is “no agreement on what defines “normal” and “stenotic”, stenotic images can be seen in asymptomatic subjects, and there is limited correlation between anatomic findings and symptoms”. Bringing this back to when your Chiropractor or therapist throws up that X-Ray of yours. Now you know there is little correlation that dictates your pain. In fact, this might make your recovery harder. Mainly because we can’t even diagnose a disc bulge from an X-Ray in the first place. Are you frustrated yet? Let’s talk about where most of us fit into.

Non-Specific Low Back Pain – The ~90-95% Group

If you’re familiar with numbers and how they work, one can clearly see this is most people who experience back pain. There are no identifiable features for NSLBP and is mainly a diagnosis of exclusion from the previous two categories. We can treat this back pain without surgery.

We don’t actually like to use the term Non-Specific Low Back Pain even as most people want a name, and that term is unsettling meaning “we don’t know”. At Modern Movement Clinic, we treat back pain a bit differently than what you may have experienced before. We often call this ‘Mechanical Low Back Pain’ describing a simple example of load versus capacity.

Think of a teeter-totter or an old-school weight scale and how they work. On one side we have load defined as how much stress, volume, and intensity we are placing on an area like your low back. On the other side of this proverbial scale or playground equipment, we have capacity. The definition of capacity is how much load can this area tolerate. This is where the Biopsychosocial model can interplay as well.

If you’ve been gardening a lot (high load in a short period of time) with no exercise or strength training to adequately equip you to tolerate this load (aka increased capacity), it would make sense that your low back hurts. Additionally, if you’ve been stressed at work, haven’t been sleeping well, or anything that adds to your plate instead of taking away, this is load just as much as gardening for hours is. Therefore, sitting down and having a conversation with our practitioner to rationalize these things is important instead of going straight to “your bones are out of place” or “your scoliosis is the reason for your pain”. No one on earth is symmetrical and the overwhelming majority of people have increased curvature in their spines. You can read more about load and capacity here.

When working with someone with NSLBP or mechanical low back pain, the initial goal should be straightforward: what feels good and what doesn’t feel good. Pretty simple right? See how the medical system has drastically overcomplicated low back pain? We commonly put this in categories like “flexion intolerant” or “extension intolerant”. Here we also find areas we might want more mobile or build capacity in other areas. We find this doing functional movement testing. These are all ways we can treat back pain without surgery. Above all, education for all of these categories is paramount, including if we are not seeing a response and what the next steps are.

If you’re a clinician or clinician to be, or if you are just simply a curious person who wants to know further how to categorize NSLBP, refer to figure 2 below on how we categorize acute and persistent (also called chronic) low back pain.

Figure 1 (Bardin et al., 2017)

Not Responding to Conservative Care? – What’s Next

There’s a multitude of reasons why you may not be responding to conservative care. People have different response times to care. In fact, if you’re a great clinician, you don’t ever claim that you get anyone better. They get themselves better and the research proves that. A systematic review found that “responses seem to follow a common trend of early rapid improvement in symptoms that slows down and reached a plateau 6 months after the start of treatment, although the size of response varied widely”.

This same study by Artus and their crew found that “variation in treatment responses did not appear to be explained by different types of treatment”. This means that it didn’t really matter what the clinician did; they all saw similar responses to care.

The rationale behind this includes a few factors at play.

People commonly seek care when pain is worst and logic would serve that symptoms following treatment would reduce, especially with time. We call this the ‘natural history’ or ‘clinical course’ of pain. When you sprain your ankle or get a cut, it gets better with time. We promote optimism in many forms at Modern Movement Clinic. Not only through treating back pain but pain relief, in general, to make pain manageable.

If we spent our time talking about how hard something is going to be, your first thought might be “this on top of everything else in my life right now?!”, clearly making things seem insurmountable. For example, if losing weight was the goal and we started out by telling you how overweight you are, how much you’re going to cut out in life and diet, it might seem pointless to even make the effort and you forget the reason why we had the goal in the first place.

Other factors they found in the Artus study were “nonspecific effects of treatments”. “Some of these factors relate to characteristics of the pain problem or to the patients themselves such as their beliefs, expectations, and experiences with other illnesses, previous episodes of the illness or with previous use of the current treatment or other treatments”. Breaking this all down means what does the patient know thus far or what have they been told along with what treatments have been done to them prior if having previous experience and what was the overall outlook and effects of that?

See how pain gets complicated?

This is why dry needling has become such a popular therapeutic intervention along with cupping and compression wrapping, yet there is not a lot of sufficient evidence of their effectiveness. Remember, these are all ways to treat back pain without surgery. This is not to say they can’t be effective for someone; however, we often claim these modalities as the reason for success or recovery. “It can also be influenced by factors related to the practitioners providing the treatment such as their previous experience with the use of the treatment and their expectation and knowledge of the clinical course of the illness”. We can loop this back to the dating red flags example, if your clinician can’t give you evidence-based reasoning for what they’re doing, red flag.

We’ve talked about all the ways one might get better with care but not everyone finds success initially. We referred above to how then you might be referred for advanced imaging. You might also be referred to a spine specialist or pain management specialist for consultation as well. Their goal should be to treat back pain without surgery… If it is a possibility to do so under the presenting circumstances. We will not cover every intervention available; however, we will be covering two with transforaminal epidural steroid injections and lumbar fusion surgery along with what the research has shown in their effectiveness.

Transforaminal Epidural Steroid Injections

These are commonly the next step for radiculopathy or radicular pain and not responding to around four weeks of conservative care. One goal in treatment for this presentation is working on ‘centralizing’ the pain; this meaning the pain down the leg or distally comes closer to the center or origin. Steroid injections or TESIs “contain contrast material, local anesthetic, and steroids and target the inflamed nerve root under fluoroscopy guidance”. This same study that provided the definition found moderate evidence for short-term relief; however, long-term was unclear. This was just the steroid injection alone. They went on to find that about 65% needed a second injection where we commonly have the option of around four.

Of all the patients involved, 16% fell into the group of being completely resolved, and close to half had pain centralized and pain was significantly less. These groups received the injections in conjunction with Mechanical Diagnosis and Therapy (MDT). This refers to the “what feels good” and “what does not feel good” during our assessment where we may provide a repeatable motion or position to get into the centralize the pain.

Lumbar Fusion

This is not the only invasive surgical procedure but one we wanted to cover as the evidence shows that there is no real evidence of effectiveness of lumbar fusion compare with conservative treatment.

This procedure is becoming less and less performed as surgeons are becoming well versed with modern surgical procedures. The most common fusion is a posterolateral fusion with or without screw or bone fixation and also anterolateral interbody fusion using bone transplant. Most of this means what direction are they coming from and what are they using to do the fusion.

This same study concluded “Previous systematic review on the topic have been unable to draw strong conclusions on the effectiveness of LF. This is understandable as it is not possible for any review to reach a robust agreement by analyzing the results of four high-quality studies in a situation when one study reports that intervention as effective, another reports worsening of the outcome and two studies suggest that intervention does not have any effect”.

The problem with any additional intervention however is, is whether it addressing the cause of the person’s low back pain in the first place. This same study did not find any evidence of fusion being more effective in reducing perceived disability related to chronic low back pain compared to conservative care. Even in the TESIs study by van Helvoirt et al, the 15 patients who did not respond favorably to steroid injection who underwent surgery to treat back pain reported “statistically significant positive effects for pain in the leg and back but not for disability, anxiety, and depression after the TESIs”.

How do we work on disability, anxiety, and depression? This takes us to our final section (pause for applause), how should someone manage you and your low back pain. The things that can treat back pain without surgery.

Managing the Person with Low Back Pain – Why n = 1

I’m reluctant to say this because this entire blog post has been about providing evidence through studies and care… We live in a data world where we haven’t fully accounted for the human condition. We see a lot of people where they’re immediately given muscle relaxants or pain medications. They are told to go on anti-inflammatory diets because of processed foods. People are advised to lose weight or get nerve stimulation or whatever the latest local tv ad is. Even worse they are just given a handout of exercises with virtually no instruction or examination to see if this person fits into these movements. “Fix Your (Insert Body Part or Perceived Flaw) With Just This”.

We can’t always blame the practitioner as the insurance model of care has become harder and harder to manage quality care with the patient. Reimbursements rates from insurance companies are so low at clinic and hospital levels. They have to choose quantity of patients over quality meaning most are high volume where you have 15 minutes or less to spend with the person in front of you. A person going through years of low back pain can’t possibly summate everything they’ve experienced and are experiencing in that amount of time.

It’s hard for the clinician’s too, believe us because we’ve been there. You have to meet quotas of number of patients in a day. Of these patients, you won’t be able to do their notes during the visit because you’re working with them. Notes start to mount up. Insurance companies want to see improvement in something as preposterous as 4 visits for a person who has had pain for many years. The therapist goes to work from sunup to sundown, eating food and going to the bathroom when they can (which they can’t ever), only to go home and must work on notes. We’re not saying all this for you to feel sorry for the therapist. We are saying this because it is the reality and why working outside of insurance commonly provides a higher quality of care for everyone, clinician and client/patient.

In a study by Darlow et al, they worked on comparing the clinical effectiveness and cost-effectiveness of an approach called Fear Reduction Exercise Early (FREE) with general practitioners. Typically the first place one might stop with low back pain. This FREE approach provided evidence-based education and advice to the GP. It encouranges them to suggest activity, work participation, integrating a biopsychosocial approach and discouraging interventions with low beneficial value. This resulted in “significant reduction in patient fear avoidance at 2 weeks in”. In addition, “nonsignificant trends for reduced imaging and reduced specialist referral were also observed”. They did not find improvement in disability or pain outcomes more than usual care; however, this study was not done in conjunction with therapeutic intervention with a physical therapist or evidence-based chiropractor. Simply changing the mindset but of the General Physician can alter the track of the patient’s mindset to recovery.

What else is important to the person in front of us? A study by French and colleagues looked at just that by arranging a study, polling experts in the field and consumers and cross comparing the two. Experts considered remaining active, reassurance that back pain is a normal experience and not necessarily related to serious harm, how to identify features that may indicate more serious pathology requiring expert assessment, and avoidance of unnecessary imaging to be the top four messages. Consumers however prioritized being able to identify more serious pathology and principles of managing the pain and messages about avoiding imaging to be least important.

One statement that really jumped out to us in this study was, “In general, it seemed that people with low back pain placed emphasis on gaining knowledge of “what can you do for me,” whereas experts placed emphasis on “what can you do for yourself”. Can we as clinicians really blame you? We live in a world where you take this to fix that. The problem is that side effects of that means you must take this thing to work with that. On social media, there are endless videos of “Fix Your Low Back Pain with This” among other click bait videos claiming to have solved and worldwide problem.

To Conclude: Treat Back Pain Without Surgery

Thus, we bring it back to the rabbit hole you may have crawled out of… Watching endless hours of people jamming hard objects into their intestines. They are saying you need these specific shoes or lifts or orthotics because your leg is short, stretch this magic muscle that might fit onto your Daily Wordle, and go on and on and on. Our best advice is to find someone that resonates with you. Someone that listens to you and what your goals are. Above all someone that provides the education and optimism you need for recovery. Our hope is that they are evidence-based but above all, leave you feeling more confident about who you are and what you need to do to get better. All of this with a focus to treat back pain without surgery. After all this reading, you’ve found that nothing gets you better but you. Just make sure you have someone to help facilitate that for you.

Citations:

Hartvigsen, J., Hancock, M. J., Kongsted, A., Louw, Q., Ferreira, M. L., Genevay, S., Hoy, D., Karppinen, J., Pransky, G., Sieper, J., Smeets, R. J., Underwood, M., Buchbinder, R., Hartvigsen, J., Cherkin, D., Foster, N. E., Maher, C. G., Underwood, M., van Tulder, M., … Woolf, A. (2018). What low back pain is and why we need to pay attention. The Lancet, 391(10137), 2356–2367. https://doi.org/10.1016/s01406736(18)30480-x

French, S. D., Nielsen, M., Hall, L., Nicolson, P. J. A., van Tulder, M., Bennell, K. L., Hinman, R. S., Maher, C. G., Jull, G., & Hodges, P. W. (2019). Essential key messages about diagnosis, imaging, and self-care for people with low back pain: A modified Delphi Study of consumer and expert opinions. Pain, 160(12), 2787–2797. https://doi.org/10.1097/j.pain.0000000000001663

Artus, M., van der Windt, D. A., Jordan, K. P., & Hay, E. M. (2010). Low back pain symptoms show a similar pattern of improvement following a wide range of primary care treatments: A systematic review of randomized clinical trials. Rheumatology, 49(12),2346–2356. https://doi.org/10.1093/rheumatology/keq245

Bardin, L. D., King, P., & Maher, C. G. (2017). Diagnostic triage for low back pain: A practical approach for primary care. Medical Journal of Australia, 206(6), 268–273. https://doi.org/10.5694/mja16.00828

Genevay, S., Courvoisier, D. S., Konstantinou, K., Kovacs, F. M., Marty, M., Rainville, J., Norberg, M., Kaux, J.-F., Cha, T. D., Katz, J. N., & Atlas, S. J. (2018). Clinical classification criteria for neurogenic claudication caused by lumbar spinal stenosis. the N-class criteria. The Spine Journal, 18(6), 941–947. https://doi.org/10.1016/j.spinee.2017.10.003

Stynes, S., Konstantinou, K., & Dunn, K. M. (2016). Classification of patients with low back-related Leg pain: A systematic review. BMC Musculoskeletal Disorders, 17(1).https://doi.org/10.1186/s12891-016-1074-z

van Helvoirt, H., Apeldoorn, A. T., Ostelo, R. W., Knol, D. L., Arts, M. P., Kamper, S. J., & van Tulder, M. W. (2014). Transforaminal epidural steroid injections followed by mechanical diagnosis and therapy to prevent surgery for lumbar disc herniation. PainMedicine, 15(7), 1100–1108. https://doi.org/10.1111/pme.12450

Saltychev, M., Eskola, M., & Laimi, K. (2014). Lumbar fusion compared with conservative treatment in patients with chronic low back pain. International Journal ofRehabilitation Research, 37(1), 2–8. https://doi.org/10.1097/mrr.0b013e328363ba4b

Darlow, B., Stanley, J., Dean, S., Abbott, J. H., Garrett, S., Wilson, R., Mathieson, F., & Dowell, A. (2019). The fear reduction exercised early (free) approach to management of low back pain in general practice: A pragmatic cluster-randomised controlled trial. PLOS Medicine, 16(9). https://doi.org/10.1371/journal.pmed.1002897

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