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A Comprehensive Guide to Low Back Pain

- Pained & Inflamed
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Low back pain is one of the most common types of joint pain worldwide, and most of us will experience it at some point in our lives. While this may sound concerning, it shouldn’t be! Most episodes of low back pain are short-term and low risk. This guide will provide some insight into low back pain, so you are better prepared to manage an episode, should it occur.

What is your low back?

Lower back anatomy

Your low back, also called your lumbar spine, connects your backbone to your pelvis. If you place your hands on your back between your lowest rib and your hip bones, you’re in the right spot. This part of your back is made up of several bones, joints, nerves, and muscles, including:

  • Vertebrae: Your low back contains 5 bones called vertebrae, labeled L1 to L5. These bones make up your lumbar spine. Above these 5 vertebrae is your thoracic spine, and below is your sacrum, which attaches to your pelvis.  
  • Intervertebral discs: Between each vertebra are discs—small, round cushions that absorb shock and pressure as you move around.
  • Spinal cord: Stacked one atop of another, your vertebrae form a small passageway called the spinal canal. Your spinal cord and spinal nerves pass through here.  
  • Nerves: Nerve roots branch out at each vertebral level; like your vertebrae, these nerves are also labeled L1 to L5. These nerves control movement and sensation in your lower body.
  • Facet joints and ligaments: Each vertebra in the lower back connects to the vertebra above and below via small joints called facet joints. Several ligaments act like a rope to provide extra support to these bony connections.
  • Muscles: On all sides of the lumbar spine are muscles that help support your trunk and allow you to move your torso and legs in different directions.

Common causes of low back pain

This may come as a surprise, but in most cases of low back pain, the specific cause (or causes) is unclear. This kind of pain is referred to as non-specific low back pain. Possible culprits causing this kind of pain could include one or more of the following:  

  • Injury to a muscle (sometimes called a strain)
  • Injury to a ligament (sometimes called a sprain)
  • Age-related changes to intervertebral discs  
  • Age-related changes to joints of the spine (arthritis)  

But not knowing the specific cause of low back pain doesn’t mean it won’t improve! Our bodies are strong and resilient, especially with the right information and support.

In most cases of low back pain, the specific cause (or causes) is unclear.

Only a small portion of low back pain cases have a specific cause (Hartvigsen 2018). A medical care team will listen to and evaluate you to see if a specific cause can be identified. Experiencing back pain with leg symptoms such as pain, numbness/tingling, or muscle weakness, for example, may indicate involvement of one or more of the spinal nerves in the lower back. Nerve involvement can happen with conditions like sciatica or spinal stenosis. Conditions which are not related to your bones, muscles, or joints—like kidney stones—can also cause low back pain. In addition, there are many other factors that can contribute to or worsen low back pain including your environment, lifestyle, mental health, and overall physical health.

This is why it is important to get a thorough medical evaluation. A medical doctor can help you understand what is causing your pain and get you started on the right course of treatment.  

Do I need imaging?

When back pain strikes, you may think you need an image (like an x-ray, MRI, or CT scan) to understand what is causing your pain. But in most cases of low back pain, imaging is not necessary.

According to the American College of Physicians, imaging for individuals with low back pain is indicated only if there are “severe progressive neurologic deficits or signs or symptoms that suggest a serious or specific underlying condition” (Chou 2011). Neurological deficits refer to changes in reflexes, sensation, and muscle function. This is something your health care team assesses during a clinical exam.  

In most cases of low back pain, imaging such as an x-ray, MRI, or CT scan is not necessary.

Imaging is costly, and X-rays and CT scans can expose you to unnecessary radiation, so they should only be used if truly necessary. In most cases, imaging will not help determine the kind of treatment you might need, such as physical therapy, an anti-inflammatory diet, stress reduction, or improved sleep. Instead, your care team considers your clinical exam, best practices, and what matters to you as an individual to determine the appropriate treatment options.  

Additionally, imaging can cause more harm than good. It is quite common to find “abnormalities” on an X-ray or an MRI. Most of the time, these abnormalities are not related to a person’s symptoms and end up causing unnecessary worry and self-doubt (Flynn, 2011). Keep in mind that many people who have no pain at all have abnormalities on imaging. One study found that 50 percent of 40-year-olds and 69 percent of 60-year-olds who were not in pain had a bulging disc on imaging (Brinjikji, 2015). This tells us that often these findings may be a normal part of aging versus problems that need to be solved. If you do end up having imaging, know that the picture does not need to be clear of issues for you to feel your best!  

Do I need surgery?

The short answer: It’s unlikely!  Spine surgeries serve an important purpose in the medical world under the appropriate circumstances—specifically, when used in situations to prevent loss of neurological function (like when there is a severe and worsening loss of control of movement). Fortunately, these situations are rare emergencies.

The vast majority of low back pain with or without leg symptoms can be treated without surgery. If emergent conditions requiring surgery have been ruled out by your health care team, first-line treatment recommendations include remaining active, education about the nature of low back pain (like reading this article!), and supervised exercise such as physical therapy (Foster 2018). For most cases of low back pain, non-invasive treatment works very well, especially when combined with a whole-person approach that supports healthy habits like an anti-inflammatory diet, regular exercise, and optimal rest.

The vast majority of low back pain with or without leg symptoms can be treated without surgery.

Even for specific conditions like a disc herniation and spinal stenosis, there is no compelling evidence to recommend decompression surgeries (such as a discectomy, microdiscectomy, or laminectomy) over other nonsurgical treatment (Gugliotta 2016 , Zaina 2016, Ma 2017). Significant studies show that lumbar fusion (a surgery done to stabilize the bones of the lower back) is not recommended for the management of chronic low back pain and is no better than nonsurgical treatment options (Ibrahim 2008, Brox 2010, Mannion 2013).

Surgery is not without risk and should be considered as a last resort. One review found the rate of side effects after surgery for lumbar spinal stenosis ranged from 10 to 24 percent (Zaina 2016). In another study, 24 percent of participants ended up needing a second surgery within a five-year follow up time frame (Mannion 2010). If you are considering surgery, it is important to talk through these considerations with your surgeon and understand the risks involved, including the possibility of needing a second operation.

Surgery is not without risk and should be considered as a last resort.

Will I get better?

With the right information and support, the odds are in your favor! Most episodes of low back pain improve within a matter of weeks. There are some risk factors associated with an increased occurrence of low back pain including smoking, obesity, and low levels of physical activity (Hartvigsen 2018). Luckily, these are all risk factors that can be modified through lifestyle changes!

Even if you’ve been told you have a herniated disc, degenerative disc disease, or spinal stenosis, you can get better! There is evidence that herniated discs can regress and completely resolve without surgery (Chiu 2015). And remember, just because an “abnormality” was seen on imaging, this finding doesn’t mean you’re going to have pain.  

Common ways to treat low back pain

There are so many treatments options out there for low back pain, it can be hard to know which are worth your time and money. Here are the treatments that research has shown to be highly effective for the majority of low back problems:

Staying active

For both acute low back pain (starting less than six weeks ago) and persistent low back pain (greater than 12 weeks), one of the first-line treatment options is to stay active (meaning no bed rest). Although moving may feel counterintuitive when experiencing aches and pains, staying active is important. It helps improve your circulation, speeds healing, and reduces the risk of developing worsening stiffness.  

At Vori Health, licensed physical therapists work one-on-one with members to develop personalized movement programs. Vori members get easy access to exercises delivered straight to their accounts so they can manage pain and get back to moving freely and enjoying life again.

Pain education

First-line treatment also includes education about the nature of low back pain. Yes, just learning about the science of pain can improve how you feel. This is because pain is an experience that occurs in the brain. It warns us of a potential threat to our safety, but unfortunately, this signal can become a learned pattern in our bodies and occur without harmful stimuli. This commonly occurs with persistent pain.  

Research shows pain education sessions (from just one to multiple) can decrease pain levels and improve function (Louw 2011). Specific modalities such as cognitive behavioral therapy (CBT) and mindfulness-based stress reduction (MBSR) can help individuals reframe their experience with pain. Likewise, activities that encourage mindfulness such as Yoga, meditation, and acupuncture can also help build awareness and coping tools. At Vori Health, every clinician is specialty trained in pain education to empower members with the most effective ways to manage their symptoms.

Whole-person care

Carrying extra weight, poor nutrition, lack of sleep, smoking—research shows that these circumstances can all cause or worsen low back pain. For back pain treatment to be effective, it needs to be comprehensive and take into consideration an individual’s lifestyle, habits, and environment. If these factors are ignored or not supported, other solutions will only work as temporary band-aids.

This is why our Care Teams at Vori take a 360° approach to back pain. Our doctors and medical experts help members zoom out and understand all the factors that could be causing or worsening  pain. We partner with members to develop a comprehensive, step-by-step plan to get to the bottom of your pain so you can get back to doing what you love.

Medication

There are also medication options for chronic low back pain, which should be discussed with your health care team. Some medications such as NSAIDs, are not recommended for long term use because of their effects on other areas of your body. Opioids should be used with significant caution and only in very limited cases for both new onset and persistent low back pain.

The Vori Health solution

At Vori Health, we use a team approach to address your low back pain and support you as a whole person. Your Care Team includes an expert muscle and joint doctor, physical therapist, health coach, and registered dietitian nutritionist. With this comprehensive approach, you and your care team can develop an effective treatment plan, including a look at other factors in your life that may be contributing to your low back pain.

We get to the bottom of your pain. We ask what matters to you, so we can help you achieve your real life goals—without any unnecessary steps. If you’re experiencing low back pain, schedule a visit to talk to a Care Team and learn what our personalized approach can do for you.

References:

  • Brinjikji 2005: Brinjikji W, et al. Systematic literature review of imaging features of spinal degeneration in asymptomatic populations. American Journal of Neuroradiology 2015;36(4):811–816.
  • Brox 2010: Brox J, Nygaard Ø, Holm I, Keller A, Ingebrigtsen T, Reikerås O. Four-year follow-up of surgical versus non-surgical therapy for chronic low back pain. Ann Rheum Dis. 2010;69(9):1643-1648.  
  • Chou 2011: Chou R, Qaseem A, Owens D, Shekelle P, Guidelines C. Clinical Guideline Diagnostic Imaging for Low Back Pain: Advice for High-Value Health Care From the American College of Physicians. Annals of Internal Medicine 2011;154:181–190.  
  • Chiu 2015: Chiu C, Chuang T, Chang K, Wu C, Lin P, Hsu W. The probability of spontaneous regression of lumbar herniated disc: a systematic review. Clin Rehabil 2015;29(2):184-195.  
  • Foster 2018: Foster N, et al. Prevention and treatment of low back pain: evidence, challenges, and promising directions. The Lancet 2018;391(10137):2368-2383.  
  • Gugliotta 2016: Gugliotta M, et al. Surgical versus conservative treatment for lumbar disc herniation: a prospective cohort study”. BMJ Open 2016;6(12):e012938.  
  • Hartvigsen 2018: Hartvigsen J, et al. What low back pain is and why we need to pay attention. The Lancet 2018;391(10137):2356-2367.  
  • Ibrahim 2008: Ibrahim T, et al. Surgical versus nonsurgical treatment for chronic low back pain: a meta-analysis of randomized trials. Int Orthop 2008;32:107-113.
  • Kaiser Permanente, 2022: Cognitive Behavioral Therapy for Pain Management, https://healthy.kaiserpermanente.org/health-wellness/health-encyclopedia/he.cognitive-behavioral-therapy-for-pain-management.tv3092, accessed November 30, 2022.  
  • Louw 2011: Louw A, et al. The Effect of Neuroscience Education on Pain, Disability, Anxiety, and Stress in Chronic Musculoskeletal Pain. Arch Phys Med Rehabil 2011;92:2041-2056.
  • Ma 2017: Ma X, Zhao X, Ma J, Li F, Wang Y, Lu B. Effectiveness of surgery versus conservative treatment for lumbar spinal stenosis: A system review and meta-analysis of randomized controlled trials. Int J Surg. 2017;44:329-338.  
  • Mannion 2010: Mannion A, et al. Five-year outcome of surgical decompression of the lumbar spine without fusion. Eur Spine J 2010;19:1883-1891
  • Mannion 2013: Mannion A, Brox J, Fairbank J. Comparison of spinal fusion and nonoperative treatment in patients with chronic low back pain: long-term follow-up of three randomized controlled trials. Spine J. 2013;13(11):1438-48.  
  • Zaina 2016: Zaina F, Tomkins-Lane C, Carragee E, Negrini S. Surgical versus non-surgical treatment for lumbar spinal stenosis. Cochrane Database of Systematic Reviews 2016; 1:CD010264.

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