Back pain is a common health problem and affects most people at some point during their lives. Among those seeking back pain relief alternatives, most choose chiropractic treatment for lower back pain. It is estimated that more than 60% of the population can experience back pain at some point in their lives. The general trend in people with lower back pain is to not seek treatment until the pain is severe and disabling. At this point, they go to a family doctor who may prescribe pain medication and anti-inflammatory drugs or refer for an injection, which can provide temporary relief. However, the problem with only receiving a temporary ‘fix’ is that the pain will reoccur as the drugs wear off, however the patient often sees this as the best and only option so continues to see the family doctor for the same treatment, which again provides only temporary relief. The worldwide studies confirm that if a patient does not feel an improvement in their symptoms in the first 5 visits to their family doctor then they are unlikely to ever get relief from the pain.
Overview of lower back pain
When speaking to patients about their lower back pain, a chiropractor can, metaphorically, string together a series of snapshots, each image a contributory factor to that patient’s pain. It might be an accident or a minor injury that produced a sudden jolt. It might be recurring stresses that have an effect over time. The patient’s pain could be traced to a genetic factor – an abnormal structural characteristic that is actually inherited. It could be a combination of factors. Often, a lower back pain injury will affect the patient’s activity level, the degree of severity varying depending on the activity. A person who is led to a more sedentary lifestyle due to pain may have an episode simply because he lifted a bag of groceries the wrong way; whereas a more active individual might be confined to bed rest after a more severe injury. There is a tendency for healing of the soft tissues (muscles, tendons, and ligaments) to take longer as a person gets older. Though it is an over-generalization, it is often said that lower back pain is a self-limiting condition, meaning that the body is able to heal itself. Often times this healing is guided by the relief of pain; i.e. when the pain is gone, the patient feels that he is better. This can be a pitfall; the absence of pain is not a good indicator of tissue healing. This leads to a high recurrence rate of lower back pain and a chronic condition. A severe injury can heal completely yet the pain, and the patient’s perception of the condition, has become so ingrained that it resurfaces with changes in activity or weather, or it becomes a constant painful reminder of what it used to be. This can become a case of failed rehabilitation.
Importance of seeking treatment
It is important that anyone suffering from any form of lower back pain seeks treatment to gain an accurate diagnosis of the pain rather than just ignoring it. This is because you may have the same pain as someone else but the causes and structure of the pain could be totally different. By seeking treatment, you also reduce the risk of re-occurrence of low back pain and reduce long-term pain and disability discussed in the previous paragraph. Research shows that where there is heavy patient involvement in decision making and positive outcomes of understanding their pain, they discharge themselves from treatment earlier than those who are passive in decision making. By gaining a good understanding of the pain, it will enable better management of the pain.
Lower back pain causes more global disability than any other condition. It is the most common reason for work absence in the UK. Most lower back pains are mechanical and are due to injury to the lower back or a disorder such as joint a disc which is the most common cause of leg pain often referred to as sciatica. Non-specific lower back pain is where there is no precise diagnosis such as a prolapsed disc. Around 90% of acute low back pain will improve in 6 weeks and will not have a serious cause. However, it can be very distressing and many people suffer with more persistent or recurrent low back pain. Recurrence of disability and work absenteeism is higher amongst people who have had back pain at some point compared to those who have not experienced it.
Causes of Lower Back Pain
Intervertebral discs act as shock absorbers between the vertebrae. The outside of the disc is a tough cartilage called the annulus, and the inside is a gel-like substance called the nucleus. A herniated disc occurs when the annulus is weak or torn, and the nucleus pushes through it, putting pressure on the surrounding nerve. This can cause severe back pain as well as nerve impingement.
Muscular strain and sprain are the most common causes of acute lower back pain. This usually happens through lifting a heavy object or a sudden movement that puts undue stress on the lower back. The force from the movement or the additional weight can cause the muscles or ligaments to stretch too far or tear, this subsequently causes pain. The severity of the pain does not necessarily correlate to the gravity of the injury, and in many cases, people with very severe muscular damage have said they only felt a twinge at the time. This kind of injury is not usually serious, but it can cause recurrent pain and make the person more susceptible to further injury if it is not dealt with properly.
The causes of lower back pain can be incredibly diverse. There are many things that can go wrong with the lower back, and they are one of the primary causes of chronic back pain. While many aspects of modern life (such as the desk-bound nature of work and a sedentary lifestyle) are conducive to lower back disorders, athletes and active people are also susceptible to these problems due to the constant and sometimes sudden and jarring movements that can injure the back.
Muscular strain and sprain
Muscles facilitate motion and bear the weight of the body. The lower back carries a greater share of the body’s weight, and the farther it is from the point of support, the heavier the load. Strains are caused when muscle fibers are abnormally stretched or torn. Chronic strains lead to muscular weakness, which predisposes individuals to further injury. Acute strains are a result of a sudden trauma (e.g. lifting a heavy object) and cause intense pain. Although the area is still inflamed, the body’s reaction to heal the injury usually produces an abundance of scar tissue which is a less than optimal solution to the problem. It is not as elastic or as strong as normal muscle tissue and can lead to re-injury and an increased likelihood of structural damage in the future. Sprains are a result of the traumatic injury to the area. They involve the overstretching or tearing of ligaments, and cause varying degrees of ligament damage. As a response to ligament trauma, the body makes an attempt to prevent further damage by stabilizing the area. This is achieved by the body’s muscle system bracing the injured joint, an action which if sustained over long periods can lead to muscular fatigue and spinal imbalance. The most common sprain injury in the lower back is to the sacroiliac joint. Since the joint is so close to the spine, an injury of this nature can have effects on the surrounding area and is often the cause of a misdiagnosed referred pain to the buttock or leg.
Herniated discs
Also, a case study published in the 2008 Chiropractic & Osteopathy Journal reported the resolution of symptoms and a decrease in size of a paracentral disc herniation in a patient who was getting low back and leg pain. This patient was treated with flexion distraction (same table used at our clinic) three times a week for four weeks. On the 12th visit (of 16), the patient reported 50% decreased pain and on his 16th visit, he reported 80% decrease in both back and leg pain. An MRI taken at this time showed partial resolution of the herniation. Flexion distraction can be felt as a stretching of the spine and is a very relaxing procedure, ask the doctors if this is appropriate for your condition. This particular patient’s only regret was not signing up for care earlier!
Fortunately, most chiropractic patients with a herniated disc do not require surgery. The procedures used at our clinic are non-surgical and have been very effective. A study published in the Journal of Manipulative and Physiological Therapeutics found 80% of the participants with herniated disc and sciatica had good to excellent results with chiropractic adjustments!
A herniated disc often is more painful than a bulging disc because the soft inner core has leaked out and is irritating the nerve. This can cause severe pain in the buttock, down the back of the leg and in the foot (often called sciatica).
Degenerative conditions
Degenerative disc disease is medically described, possibly more harshly than it should be, as the normal changes in the disc caused by aging. It is where the spongy intervertebral discs that separate the vertebrae deteriorate, and the body copes with this by forming bone spurs also known as osteophytes. This can cause stiffness in the back and slight pain, however it becomes more serious if the spurs start to compress spinal nerves. This can lead to leg pain and weakness and in worst case scenarios create further debilitating conditions such as spinal stenosis and osteoarthritis. Chiropractic care can be very effective in relieving pain and improving the mobility of those with degenerative disc disease. A study conducted by the National College of Chiropractic in Illinois found that directional preference exercises were more effective than McKenzie exercises for those with degenerative disc disease. It also found that those undergoing the directional preference exercises were three times less likely to require surgery. This is particularly significant as surgery is often the go-to treatment for those with low back pain attributed to degenerative disc disease and conditions regarding it. Chiropractic care can therefore provide a means of pain management avoiding surgical outcomes, and in some cases be a form of treatment for placing the spine in the direction needed to avoid the provocation of irritating nerves and causing more pain.
Chiropractic Techniques for Lower Back Pain
For many years, the popping noise heard during a chiropractic spinal adjustment was believed to be the sound of two bones rubbing together. As a result, there was concern that the treatment was traumatizing to the spine and its surrounding muscles. In an effort to find out exactly what was happening during a spinal manipulation, a study was conducted using MRI imaging to capture the events of an upper lumbar spinal manipulation. The imaging clearly revealed that the popping noise heard was the sound of gas being released from the joint, and it also displayed that the treatment was not traumatic to the muscles or the spine. The same study also showed that the joint was gapped as the chiropractic physician had intended, which restored normal movement to the joint.
Spinal adjustment has been used as a treatment for low back pain for many years. The goal of the treatment is to restore normal motion to a restricted vertebral joint. When the movement of a joint is restricted, it is not uncommon for the chiropractic physician to feel a slight resistance in the joint and to hear or feel a popping noise. This is the release of gas that occurs when the joint space is opened up and the joint is moved. This is similar to opening a can of soda and experiencing a release of gas and then the beverage returning to a normal state.
Spinal adjustments
Chiropractors use many techniques to for chronic lower back pain treatment. The main technique, called an adjustment or manipulation, is a quick, precise pressure on the spine. In the 1990s, a treatment evolved using a special tool to apply force to the spine without thrusting into it. Now a newer form of adjustment (and manipulation) technique has evolved for nearly all manual methods, including the original ones. In it, the patient and the table are manipulated in such a way that the direction, speed, amplitude, and leverage for the thrust are largely generated by gravitational force; as a result, an apparent (or cavitation) sound is often heard, which is simply the release of gas (nitrogen, oxygen, and carbon dioxide) within the joint. This newer low-force method is safer, because it does not increase the risk of injury due to applied force, and is also easier on the patient, especially those with fragile or osteoporotic bone. Adjustment (and manipulation) is thought to relieve pain and restore normal movement of the spine. Step two involves a procedure to teach the patient how to protect his or her back—by avoiding re-injury and damage—and to maintain a normal and healthy way of life. In order to accomplish this, the chiropractor will assess the patient’s understanding of the defense and maintenance measures by asking him or her to explain the information given and to carry out the instructions, while under observation. Step two, albeit not requiring an adjustment or manipulation of the spine, is often continued throughout the treatment program and may involve all or any of the techniques described in treating the primary complaint and specific somatic dysfunction.
Mobilization techniques
As we deal with a pathoanatomical diagnosis of the lumbar disc syndrome we will be able to access the level of impairment at the disc and plan mobilization techniques that are appropriate. For a disc that has failed to limit pain and disability at the acute stage due to massive annular tears and subsequent massive leakage of nuclear material one technique that has produced good outcomes in the acute stage and positive MRI changes is an attempt to move the nuclear material posteriorly and off the sensitive annular tears. 21 This was achieved using a slow targeted form of physiotherapy and chiropractic L4/5 SNAG (Sustained Natural Apophyseal Glide) on a patient with referral to the left foot. He was asked to see if he could create or increase the peripheralization of the symptoms while the chiropractor applied a posterior and slight left target specific mobilization of the lumbar spine to induce more left leg symptoms. An increase in the patients left leg referral was sought at each treatment; there was a notable decrease in the amount of left leg symptoms between treatments and on the fourth.
Chiropractors use various types of mobilization to restore movement of the injured joints. The most common type of mobilization is defined as a manually applied slow movement to attain a new joint position. High velocity low amplitude thrust techniques are also taught to chiropractors, where the joint is taken to and through its restricted range of movement lacking in normal movement. One form of thrust technique where the doctor uses his body weight to impart force is called drop table technique; a specialized table is used with sections that can drop a short distance when the chiropractor gives a quick thrust on the joint. If a certain form of mobilization is clearly not beneficial after one to five treatments, Jack Tar conceived an algorithm of a logical sequence of other techniques to improve outcome, after the fifth treatment referred the failed patients for injection or repeat replacement of thoracolumbar disc to avoid surgery.
Soft tissue therapy
Muscle energy is a technique designed to fatigue and stretch hypertonic (tight) muscles. This is done through the patient lying in a specific position and the chiropractor asking the patient to contract the affected muscle in a specific direction for 3-5 seconds against resistance provided by the chiropractor. After this, there is a relaxation phase of 10-15 seconds where the muscle is stretched to a new position. This is repeated several times until the desired change in muscle tension is noted. This can be a very effective way to reduce tightness and change and lengthen the position of a muscle, especially in chronic conditions.
Trigger points are specific points located in tight bands of muscle fibers. When pressure is applied, pain is felt in other parts of the body. To treat these points, gentle pressure is applied by the chiropractor using his thumbs or fingers. The pressure is often increased for 10-30 seconds at a time and repeated during the treatment. Trigger point therapy is used to relieve the pain and reduce the frequency of muscle tightness. This is an effective method of reducing back pain and tightness. It is also used to treat pain in other muscles and conditions such as tension headaches and fibromyalgia.
There are a variety of soft tissue techniques employed by chiropractors to ease back pain and tightness. Some of the more common ones include trigger point therapy, muscle energy therapy, myofascial release, and erector spinae muscle relaxation. These techniques are often used in conjunction with spinal adjustments and exercise to relieve back pain.
Benefits and Effectiveness of Chiropractic Treatment
Long-term management of lower back pain is the ideal approach for all patients. In doing so, patients will be able to experience a decrease in the frequency and severity of pain in the future. Long-term management is a realistic approach through the use of chiropractic care. Its non-invasive techniques make it safe and effective for patients of all ages. This type of care attempts to promote healing on a tissue and cellular level. It is designed to correct mechanical dysfunctions in the body, which in turn can prevent or minimize the pain. An RCT in 2006 led by Santilli et al. showed that patients with chronic lower back pain showed improvement after chiropractic care in regards to pain and disability. The study went on to recommend that chiropractic therapy be considered a valuable treatment option for the majority of patients with lower back pain.
The most common techniques used in chiropractic treatments are spinal manipulation and physical adjustments. These procedures are designed to affect the body in a way that helps alleviate pain. Two prior studies, outlined in Manga (2004), support the combined use of chiropractic manipulation with other treatments, such as pharmaceuticals, for acute and chronic lower back pain. They showed that chiropractic therapy was more effective than therapy used alone. The findings in direct relation to using chiropractic care for lower back pain suggest that spinal manipulation may be a useful tool for lowering pain levels.
Patients seek chiropractic treatment for a variety of reasons. Some are looking to alleviate pain, some are looking to improve mobility, and others are looking to regain their health. Provided the variety of people looking for the kind of care that chiropractors offer, it’s only natural that there would be a variety of treatments available. But before beginning any treatment, it is important to discuss the benefits of chiropractic care with your chiropractor.
Pain relief and improved mobility
One of the primary benefits of seeing a chiropractor is to relieve the pain. The purpose of the chiropractic treatment is to reduce the pain, so though the damage that caused the pain is still there, the patient is often less troubled by it. Chiropractic treatment is known to be quite potent at reducing the pain and discomfort, especially at the initial stage of a back complaint. This is the part of the treatment which makes it very appealing to patients, as pain is what has caused the limitations to certain activities. By reducing the pain, the patient is free to try to resume normal life. Pain relief in chiropractic care is achieved through a variety of methods. The chiropractor will use soft tissue therapy as well as manipulation. Lifestyle changes will be a topic of discussion; the patient may have to alter their sleeping patterns and posture, there will also be recommendations of certain exercises to increase muscle strength, all of this will aid in reducing pain levels and increase mobility levels.
Lower back pain is a common condition, which affects anyone from the very active to the very inactive people. The people who are affected by back pain are often at a loss to know how they could have hurt their back. It is said that many people experience back pain because the muscles in the back have been left inactive which then makes them more susceptible to injury. Whatever the cause, the one common factor in people who are affected by back pain is the disruption to their lives. If you have experienced lower back pain, I’m sure it will resonate with you when people describe severe back pain as ‘crippling’. Often the simplest of activities, things that you usually take for granted, become difficult or even impossible to perform. Whether it is something as simple as bending over to tie your shoes or as painful as walking or standing for long periods, back pain can impede all normal functions of life. This is where chiropractic treatment comes in.
Non-invasive and drug-free approach
Chiropractic is a health care profession that focuses on disorders of the musculoskeletal system and the nervous system, and the effects of these disorders on general health. Chiropractic care is a drug-free, non-invasive form of treatment, with an aim to alleviate pain and discomfort by looking at the underlying issues causing the symptoms. Chiropractors have a wide array of techniques or tools to help locate, analyze and correct vertebral misalignments including spinal adjustments, manual manipulation, muscle release techniques and the use of adjunctive modalities. This type of treatment is both appealing and beneficial to patients who are looking for a healthier approach or those who are trying to avoid invasive procedures. Starting with a complete analysis of the patient’s health history, current health conditions, medications and surgical history, chiropractors can work with patients to determine the best course of action to get the patient back to health. This often includes changes to the patient’s health and lifestyle habits. Any type of treatment must have the well-being of the patient as first priority, and this is vastly easier to achieve when you are dealing with a patient through a non-invasive, drug-free condition. Chiropractic care is widely recognized as one of the safest, drug-free, non-invasive therapies available for the treatment of neuromusculoskeletal complaints. A systematic review funded by the Ontario Ministry of Health found that acupuncture, massage therapy, and chiropractic therapy are the most cost-effective treatments for musculoskeletal conditions. The literature and clinical trials strongly support spinal manipulation as offering an effective treatment plan for lower back pain. With the emphasis on a more holistic approach to healing, chiropractic treatment will apply to the patient’s well-being on a larger scale, both chronic and acute conditions, and potentially have an effect on prevention of future incidences of lower back pain.
Long-term management and prevention
In conclusion, long-term management with a prevention focus is the best approach for any patient with a spinal disorder looking for health maintenance and an improvement in the quality of life. The conservative procedures used in chiropractic are low cost and high benefit for any patient. Treatment is safe and a valuable experience with patient improvement for any chiropractor of any skill level.
Exercise in spinal disorders is defined as activity that is done for the purpose of maintaining or improving overall health and conditioning. This includes aerobic, resistance, flexibility, and specific functional conditioning exercises. The benefits of exercise in general are prevention of cardiovascular disease, diabetes, and obesity. Aerobic exercises would more specifically be beneficial to a patient with a lumbar disc herniation. The use of oxygen consumption in an activity moves in conjunction with the heart and lungs, and an improvement of maximum oxygen consumption is seen with chronic aerobic exercise. This type of exercise is safe and has a low cost with high long-term benefits, and there have been adjunct benefits in those with chronic musculoskeletal pain or fibromyalgia, so it is proven to be highly effective. For a patient with a simple lower back muscle strain, an early start to exercise or a movement into more vigorous exercise is equal to an early return to work. An iatrogenic opinion is often that the back is too weak to withstand the exercise when there is no factual evidence to support it. To prevent lower back pain with an L4/5 spondylosis and/or spondylolisthesis, it would be wise to use a lumbar support belt to prevent further slippage of the vertebrae during activity. Due to the wide array of benefits, chiropractors always encourage exercise as a general prevention tool, and they will provide specific recommendations for exercises for a patient’s spinal disorder.
Another biomechanical stress that the body may incur is due to an activity in which someone overuses one part of the body in a repetitive fashion. This type of activity may lead to microtrauma, which can only be detected when it is seen as a major injury, so it is best to avoid the progression of an injury from the initial stage. An example of this type of injury and how a chiropractor would address it is a runner with pain in the iliotibial band syndrome. Iliotibial band syndrome is due to the repeated bending and straightening of the knee. A chiropractor would show this patient special stretching techniques and a way to self-massage the iliotibial band and consider that the patient should change his/her running routes. As iliotibial band syndrome is only a few centimeters of progression from knee pain, this advice would aid in injury prevention. With prevention of this malady, a runner can be more successful in running with more decades in his life. Imagine a sprinter who has pain in his herniated disc and sciatica and also peripheralization of symptoms into a moderate spondylosis on his first MRI. The sprinter is merely a youth of old age but was faced with the poor advice of back surgery, which would only further disable him. Our sprinter needs the best way to save his career and his well-being with the best conservative procedures for his low back problem.
Patient education is a primary focus of chiropractic. Chiropractors attempt to change the patient’s attitudes and habits related to health, which may lead to a more stable spinal condition. Often, work in the form of employment or housework is a factor in an individual’s back problem. Job-related stress, in the form of deadlines, project management, and even the physical environment, are also factors. Chiropractors provide advice on effective stress management at work and home, and on how to ergonomically protect the body from the repetitive stresses at home or work that may lead to injury. This advice may include exercise and how to modify an exercise routine, proper nutrition and dieting, and biomechanical and postural proper instruction. These lifestyle modifications affect general wellness and an improvement in the quality of life.
