Ask the Osteopath: Lower Back Pain

Lower back pain

Lower back Pain… where do I start, as an osteopath lower back pain is something I treat very frequently. It is actually the most common reason why people see an osteopath (Orrock, 2009). Lower back pain is an incredibly common problem with 8 in 10 people experiencing it, at some point in their lifetime. It is so common to have lower back pain for more than 3 months that it is now considered an epidemic (Waddell et al,1996) and also makes up half of lower back pain patients.

Anatomy:

Your lower back is the area of your spine between your ribs and your pelvis and is made up of 5 bones. Each of the bones (vertebrae) is separated by an intervertebral disc, which acts as a shock absorber. Similar to the rest of your body your lower back is also supported by the muscles, tendons (linking muscles to bone) and ligaments (linking bone to bone). The main purpose of your lower back is to support the weight of your upper body. As well as help the forces dissipate through your spine and allow for movements from your upper body as well as from your pelvis and legs to pass through to the other areas of your spine.

Who is affected?

Anyone can experience lower back pain but it is four times more likely in people over the age of 50 compared to people that are between the ages of 18 – 30 (Meucci et el 2015). Women are also more likely to experience it due to factors like pregnacy, child care responsibilities as well as having a lower muscle and bone mass. Therefore increasing the risk of bone conditions such as osteoporosis (Almeida et al 2008). Lower socioeconomic living conditions and education have also been identified as risk factors. Furthermore smoking and obesity have also been linked to lower back pain with the nicotine causing increase degeneration and obesity causing increased pressure on the joints from an increased body weight. An enviromental cause that is playing a more significant role in developing lower back pain than ever before is having a sedentary lifesytle including intensive computer or desk based work (Heneweer et al 2009).

Causes: Lower Back Pain

There are many causes of lower back pain depending on the cause of the pain, the symptoms you experience will be different. While I have listed the different potential causes for lower back pain separately it is often multi-factorial and you are likely to have a cross over of a few different elements. For example, if your joint is inflamed it is very likely your muscle will be tense and tight as it tries to protect the joint causing a mixed picture with joint and muscle inflammation.

Bone

Another cause of lower back pain comes from the vertebrae or spinal bones themselves. This is no different from anywhere else in your body and can be from a fracture or bone disease like osteoporosis or osteopenia. These conditions will normally be picked up from an x-ray, DEXA scan or blood test as part of routine check ups.

Joint Inflammation

The most common causes of pain in the lower back is often from the facet joint (the joint between two of the spine bones or vertebrae). It is often most painful to lean backwards or to the side though it can hurt on all movements. However the symptoms are normally relatively local to the lower back or buttock areas and do not radiate down the leg. The joint can cause pain for several reasons including from awkward or quick movements, arthritis and bone conditions. One of the joints that can cause Lower back pain is the sacro-illaic joint for more information check out my previous blog post.

Osteoarthritis – Wear and Repair

Similar to any joint in your body you can get osteoarthritis in your lower back. The main cause is overuse of the joint this can be due to years of use, repetitive movements from leisure or work activities (Ashraf et al 2014). For more information check out my guide to osteoarthritis or in the article page where you can download it for free. Osteoarthritis can present in the same way as joint inflammation. However it is often associated more with stiffness especially in the mornings. If the joints are significantly worn then it can lead to spinal stenosis or can affect the nerve roots exiting the spine.

Systemic

In some cases your lower back pain may not actually be originating from the structure in your lower back. If you have seen a osteopath or any other health practitioner about your lower back pain and they start asking you what seems like random irreverent questions about toilet habits, yes both ones and twos, menstrual cycle or your heart health this is why. Sometimes organs around your lower back either from your abdomen or pelvis can refer pain to your lower back. Therefore you can think you have just pulled a muscle but it maybe coming from underlying condition. Some examples of these organs are your kidneys, ovaries, appendix and pancreas.

Muscle + Ligaments

People often underestimate the muscles and ligaments when it comes to causing their pain. The muscles can be incredibly painful, this is due to the large blood supply that your muscles have. The cause is often a sudden movement or contraction of the muscles or tightening of the ligament. Your muscle will often be very tight if your joint is inflamed as it tries to protect the joint. The muscles work harder so you don’t have to use that joint as much. Your ligaments work to control the movements of the bones it attaches to and can be over-strained if they have to work too hard. It will often be very painful especially doing movements including bending and twisting. However, if the muscles and ligaments are a main cause of your pain then when you lie down it should ease the pain slightly.

Nerve Root Compression

Nerve root compression or lumbar radicular pain is often labelled under the term “sciatica”. While the sciatic nerve does steam from your lower back and runs down your leg it will change its name along the course from your L4 vertebrae to your toes. However the sciatic nerve itself may not necessarily be the exact nerve causing your pain, it may be come other nerve roots that exit your lower back at any level. Nerve root compression is when the nerve that exits the spine get partly squashed or compressed, which causes the characteristic sharp electric pain. (Barnsley, 2002). This recreates the classic nerve pain that’s usually very sharp, shooting and occasionally burning in nature. A herniated or prolapsed disc is the most common causes of this type of nerve pain (Shanathana et al 2012).

Disc

The dreaded D word, Disc! This is often the word that my patients are hoping doesn’t come out of my mouth when I am explaining the cause of their pain. It doesn’t have to be scary or terrible, a large proportion of people will have a scan of their lower back as a part of other investigations and it will show a problem with their disc despite not having any back pain. It is also very important to remember it is a sliding scale and that there are degrees of discal damage. The symptoms of a disc problem include nerve compression, which causes sharp, shooting and radiating pain usually into the buttock and or down your leg. Furthermore you can also get symptoms such as numbness, weakness, tingling and burning pain. Often the symptoms you feel into the leg can be more painful than the pain into your actual lower back.

My favourite way to describe it, which steams from my love of food is this:

Your disc is like a sugar covered jammy doughnut that sits between the bones of your spine. You start of with the sugar coming off the top, easily and commonly done if your not going to eat it straight away and its no big deal. The next would be some more wear and tear the doughnut gets a get squashed nothing major the jam is still inside but its just a bit worse for wear and a bit less pretty. The next step would be when the jam comes out again there are stages depending on how much and fast the jam comes out.

This is when you get your prolapsed or herniated discs, again the degree depends of the amount of jam or if you want to be scientific the nucleus pulposus (the core in the disc, it’s actually a very similar to jam in consistency).

Diagnosis

A medical practitioner often diagnoses lower back pain clinically. As an osteopath I would take a full case history and ask lots of questions about your pain. This would include how you did it (onset) and if you have had lower back pain before. Then I would get you to do some movements as different structures will be stressed differently in different positions, therefore giving an indicator which structures are most affected. Afterwards I would do some physical exams where I move and feel your spine move and the muscles around it.

You can get imaging for your lower back HOWEVER I must stress the however there is research (Van de Berg, 2014) out there to show that the amount of damage does not always correlate to the pain or the symptoms that you are feeling (Jensen et al 1994). It is something to bare in mind, do not be disheartened if the scan comes back clear and your are in the most excruciating pain you have ever felt. You are not crazy; it is not in your head for a second and your not alone. It is one of the many things that even with the vast amount of research into lower back pain researchers just don’t quite understand yet. Scans can be very useful especially in identifying the structure and degree of the injury. (Flynn et al, 2011). Sometimes having a scan whether it is a MRI or X-ray is vital in your management plans to help decide the next course of action, which may include surgery in some cases (Shubha et al 2012).

What can Osteopaths do to help?

As I mentioned before lower back pain is the most common reason patients come to see an osteopath. (Cypress, 1983) On a review by (Balon et al 1998) which looked at the most common interventions that osteopaths use when treating lower back pain it showed a combination of soft tissue massage, joint articulation, manipulation including high velocity thrusts and education. The ‘clicking’ or high velocity thrusts that most people associate with osteopaths has a vast amount of research proving to be significant in reducing lower back pain as well as the mechanisms behind it (Licciardone et al 2005). Osteopathy is included in the NICE and European guidelines for treating lower back pain both acute (new injuries) and chronic (more than 3 months). In an appointment we will also give you advice including exercises, ways to prevent you from re-injuring your back, education to make sure you understand what has happened as well as discussing and overcoming elements that may have predisposed you to your pain like your desk set up. To read more on ergonomic and desk set up look an my previous blog post.

You can download this guide at: The A State of Health Clinic’s Website.

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