Back pain, especially low back pain, has long been a scourge for us upright walking humans. (I suppose that before that knuckle pain might have been the big issue). Conventional treatments include: medications, physical therapy, and invasive procedures such as anesthesiologic injections, spinal cord stimulators, spinal medication pumps, and surgery. Complementary medicine has a wider array of options, and I have found that most chronic back pain can be managed primarily or exclusively via alternative techniques.
Before discussing specific options, we need to distinguish between acute and chronic back pain. Acute back pain refers to pain soon after its onset, while chronic back pain is pain that has been there for some time. The transition from acute to sub-acute to chronic back pain is gradual, and the precise division among these stages is somewhat arbitrary. However, acute and chronic back pain should be treated with distinctly different approaches.
I consider acute back pain treatment to be appropriate for up to 2 weeks after onset, sub-acute for about the first 6 weeks, and chronic thereafter. There are exceptions, such as someone who is continually aggravating their condition or has had a re-injury, where an acute treatment methodology may be necessary months or even years after initial onset.
With all back pain, an evaluation by an astute physician is critical. Most acute back pain is benign and musculoskeletal in origin. It generally originates from mechanical problems involving tight muscles, locked joints, sprained ligaments, bulging or herniated disks, and / or irritated nerves.
However, in an important minority of cases, more nefarious problems such as metastatic cancer, infections, metabolic disorders, fractures, or internal organ dysfunction may be the cause. These issues can be accurately ferreted out by a discerning examiner. Treatment in such cases is wholly different from what I will discuss below.
If acute back pain is of benign origin, a short period of rest may be appropriate. Studies have shown that spending several days in bed does not hasten recovery, and can in fact be counterproductive. It is therefore important for people to get out of bed the day after or even the day of an injury and start moving around.
However, that lying on one's back with knees raised on pillows or a chair so the hips and knees are at 90 degree angles (the so called 'Z position') can be helpful in taking down inflammation and mitigating pain. Application of ice to the effected area, 20 minutes on and 20 minutes off, can be quite helpful as well. As tempting as it may be to apply heat or slip into a hot bath, applying heat in the first 48 hours after an acute back injury is ill advised and will generally, in my experience, worsen the pain.
Many people need pain relievers after an acute back injury. Whereas natural herbal and homeopathic analgesics (as I will discuss below) can sometimes be sufficient, many if not most people also require pharmaceutical level analgesics. A short course of opiates, such as hydrocodone preparations, with or without anti-inflammatory drugs, can be extremely helpful with sleep and preventing pain from spiraling out of control.
Most techniques that can be effective in treating chronic back pain cannot be tolerated when the pain is acute, and can even produce contrary effects. One notable exception is acupuncture, which can be helpful in alleviating pain and spasm even in the most precipitous circumstances. Very gentle energetic hands on techniques, such as Reiki and Therapeutic Touch, may also afford a modicum of relief. More technical energetic techniques can also be helpful, such as cold laser application, pulsed ultrasound, and electrical devices such as T.E.N.S. (transcutaneous nerve stimulation) or Frequency Specific Microcurrent.
Most back pain will dissipate after the acute phase. However, when it doesn't and enters the subacute or chronic phases, an entirely different approach is required. Continuing the use of narcotic analgesics is harmful, as is restricting most activities of normal daily living.
Contrary to what is frequently touted in the conventional literature, my experience over the past 30 years in treating thousands of chronic pain patients has been that it is possible the majority of the time to determine from which structure(s) the pain is originating. And, this step of accurate assessment is critical for effective treatment.
The most common cause of chronic back pain, either alone or in combination with other causes, is something called myofascial pain dysfunction syndrome. Here, the pain originates from discrete tender spots in the muscles called trigger points. These spots tend to cause a deep, often unrelenting ache, which can be hard to precisely localize. The pain tends to get worse as the day goes on, and may be paradoxically better during activity, but worse afterwards. The pain frequently refers, meaning that trigger points in the low back or buttocks may send pain, numbness, or tingling into the pelvis or lower limbs, mimicking sciatica.
Myofascial pain dysfunction syndrome (MPDS) is notoriously resistant to pharmaceutical or natural analgesics, and will not go away with rest or a typical physical therapy exercise program. I have found that a combination of Rolfing or Counterstrain with Reciprocal Inhibition Optimization (R.I.O.) will alleviate MPDS the majority of the time. When this approach does not work, expertly performed Trigger Point Injections generally do.
People experience Rolfing® a bit like a deep tissue massage. However, it is quite different: Rolfers are not focused on softening tight muscles, but rather on releasing tight fascia, which is the connective tissue that surrounds the muscle. This allows the body in general, and the muscles specifically, to assume their most comfortable and efficient configuration. (Please note that there is a disturbing trend among some, particularly neophyte, Rolfers to incorporate treatments that have nothing to do with traditional Rolfing. I have found these approaches less effective and I would avoid them).
Counterstrain, officially termed Strain - Counterstrain or The Jones Technique®, is a therapy that takes of advantage of positional reflexes to very gently trick muscles into relaxing. When performed by those (often, though not exclusively physical therapists) who have mastered this treatment, it can be quite effective in promoting the release of tight muscles.
If Rolfing and Counterstrain work on the muscles, or hardware of the body, Reciprocal Inhibition Optimization (R.I.O.®) works on the brain, or software. Muscles do not move on their own, but in response to instructions from the brain via the spinal cord and peripheral nerves. These instructions conduct a symphony of movement: any motion requires an array of muscles to contract and relax with precise coordination. If the instructions become disordered, as they generally do in chronic pain problems, muscles become tight and painful. In my experience, R.I.O. can correct this critical aspect of dysfunction with unparalleled efficiency.
Trigger Point Injections, invented over a half century ago by President Kennedy's great personal physician, Dr. Janet Travell, are the show stopper for eradicating myofascial trigger points. The local anesthetic procaine is injected in small amounts into trigger points. This, combined with a muscle specific stretching program, will generally alleviate the trigger point pain within 6-12 treatment sessions.
Other substances can be injected to perform trigger point injections. In my years of performing over a million (literally) trigger point injections, I have used local anesthetics such as lidocaine and marcaine, as well as saline, Sarapin® (a pitcher plant extract), Vitamin B12, magnesium, and Traumeel® (a homeopathic). I have not found a selective advantage to any of these over procaine; though, the most important element to a successful trigger point injection is the accuracy of the procedure, rather than the substance used.
Corticosteroids should never be used for trigger point injections. They do not enhance the technique, and biopsy studies have shown that they can lead to muscle damage and scarring. Botox is now also used for trigger point injections. It is a systemic toxin, and I believe its use should be reserved for circumstances where the muscles involved cannot be adequately stretched.
In all likelihood, the next most common cause of back pain is joint dysfunction. The sacroiliac joints in the pelvis or facet joints of the spine can get stuck, directly or indirectly causing pain. Manipulation, either chiropractic or osteopathic, is the treatment of choice for this condition. (As far as which is more effective, the general rule of thumb, both here and elsewhere, is that the practitioner is more important than the technique). Studies have shown that people with back pain are significantly more satisfied with chiropractic treatment than conventional treatment for back pain.
Ligament sprains, which may occur after an acute injury, or the cumulative effects of minor insults over the years, are actually tears that create instability in the spine. This can lead to abnormal motion causing pain, as well as hasten the development of degenerative or osteoarthritis.
Though studies have been mixed, I find nutrients that support joints and ligaments such as glucosamine, chondroitin, MSM, hyaluronic acid, and combination extracts such as Ligaplex® can be helpful. Natural anti-inflammatories, such as boswellia, turmeric, willow back extract, ginger, bromelain, green lipped muscle extract, and hops organic acids, among others, can be helpful in alleviating the inflammatory aspect of this pain.
Two of my favorite preparations are the proprietary formulas Relief® and Pain Release® (both available at Rising Health). Homeopathics, such as Traumeel®, Arnica, Nux vomica, and Bryonia may be used orally or topically as well. Essential oils such as peppermint, wintergreen, and menthol, may be used alone or in combination topically with herbs, including capsaicin (chili pepper extract) with some efficacy.
A combination of thoughtful stretching and core conditioning exercises, such as with yoga and Pilates, for example, can sometimes keep the muscles flexible and the spine stable enough to afford relief. If this is unsuccessful, however, prolotherapy may be indicated.
Prolotherapy involves injections into the ligaments to stimulate their repair. Classically, a concentrated dextrose (sugar) solution has been used. More recently, a technique called Platelet Rich Plasma (PRP) is gaining favor, in which the patient's own blood is collected, platelets (the type of blood cell involved in clotting) are extracted, and injected into the ligaments. Preliminary results suggest that it may be more effective, but it is definitely more uncomfortable (a euphemism for painful), more involved and more expensive. My opinion is that it should be reserved for when dextrose fails.
Disk bulges or herniations are a favorite culprit for back pain among orthopedists, and can indeed be problematic. However, some studies, including a famous one published decades ago in the New England Journal of Medicine, found that many people without back pain have disk bulges or herniations, so one needs to be careful that the clinical pattern of the pain fits the imaging findings.
Most pain from disk herniations will resolve without surgery, though if the disk is resulting in significant pressure on nerve roots causing loss of feeling, weakness, or bladder or bowel dysfunction, surgery may be necessary. I have found that very high dose Bromelain (an anti-inflammatory enzyme from pineapples) or an extraordinary consumption of fresh pineapple itself, can result in remarkable improvement in cases of acute disk herniation.
Irritated nerves from a variety of causes can be a source for back pain. If they result in what is called radiculopathy, that is, pain, tingling and / or numbness going into an extremity, then a treatment called PENS (Percutaneous Electrical Nerve Stimluation) can be helpful. It involves the use of electrical stimulation through a specifically placed pattern of acupuncture needles. Though I have found PENS to be more effective than traditional acupuncture for radiculopathy, either PENS or traditional Chinese medicine techniques such as acupuncture, moxa (the use of heat to acupuncture points), cupping (suction cups applied to the back), or gua sha (gentle scraping of the skin with a blunt object) can be helpful if the pain is confined to the back.
When pain is severe enough to require medications, topical creams, which can be custom blended by a compounding pharmacist, should be considered. This is generally safer than using these medications systemically (e.g., orally). Similarly, if surgery is deemed necessary, a spine surgeon (generally a neurosurgeon or specially trained orthopedist) who will use the most precise, minimal, and least invasive procedure will generally get you the best result.
Finally, any discussion about pain should include strategies for managing the pain, as pain cannot always be fully eradicated. This includes: relaxation techniques; coping skills instruction; pain behavior control and wellness behavior reinforcement; and cognitive behavioral therapy, which involves learning to think differently about your situation. Each of these is a topic in and of itself. A pain management trained physician, relaxation therapist (both of which we have at Rising Health) or a pain psychologist can help guide you in this realm.
Chronic back pain is admittedly a complex problem, but one which can be precisely addressed by a skilled physician, allowing you to follow a path towards progressive relief the vast majority of the time. I have seen people improve after years, even decades of suffering, able to put their back back in the background, where it belongs!
Yours in health,
D.N.
Oh, My Aching Back!
News Flashes
