Low back pain is the leading cause of disability worldwide. Nearly all Americans will suffer from back pain at some point in their life. That includes you. But back pain does not have to be disabling. In fact, most new cases of back pain will improve within a few weeks. Even for patients with chronic back pain, there is plenty of reason for hope.
The first step to overcoming back pain is education
As an intelligent consumer, you want to know what is going on with your body, and what can be done about it. The challenge with health concerns is that there are many causes of any given problem, and there is a lot we still don’t know. Back pain is no different. In fact, the most common diagnosis for back pain goes by the initials NSLBP - non-specific low back pain - meaning back pain that has no known cause or pathology. You might have noticed that’s not a very convincing diagnosis.
In fact, many experts believe that this is simply due to the lack of education medical doctors receive about spine pain and the time constraints placed on regular visits with your primary care doctor. You just can’t get to a specific cause of back pain in 15-20 minutes. Prof. Stuart McGill, a reknowned spine researcher, takes up to 3 hours to complete an initial evaluation on patients and athletes who come to see him.
The 4 Causes
While we can’t always be specific, we can confidently say that there are four general causes of low back pain: disc, nerve, muscle, and joint. Each has a different method of leading to back pain, as well as a different approach to resolve back pain. Let’s discuss these 4 causes in more detail.
Disc
Likely the most common cause of back pain in our modern age, degenerative disc disease or discogenic low back pain is attributed to 40 percent of low back pain cases.
The disc is a dense, spongy pad between the bones of the spine. The outer portion of the disc are like an onion with rings of tissue layered on top of each other. In the center of the disc is a glob of jelly-like material. When this material pushes outward, it can create cracks in the ring layers. If the cracks get deep enough, then it gets very sensitive.
Bending forward in the low back with a lot of weight is the most common way to create this type of injury. Overtime, this movement - called lumbar flexion - can become a painful movement even without added weight.
The treatment for flexion intolerant low back pain is straight forward and simple. The website FixYourOwnBack.com has a simple home test you can to get an idea whether your pain will respond to this treatment.
Nerve
This second cause of back pain is likely the most aggravating. It can feel like sharp, shooting pain, not only in the back but also down the back of the leg. It can even lead to numbness and tingling down the leg and weakness of muscles. *CAUTION: If you are experiencing numbness, tingling, or weakness, that has been getting worse; symptoms in the groin region; or if you have had trouble going to the bathroom, see a healthcare professional urgently.* Nerve pain occurs due to irritation of a nerve as it exits the spine. This can be caused by inflammation or narrowing of the space in between vertebrae due to bone spurs or a disc herniation. Unlike disc degeneration explained before, a herniated disc occurs when the jelly-like material presses through the outer layers of the disc and begins to bulge into the spinal canal or nerve root. This type of back pain is best resolved with a short bout of anti-inflammatory medication or supplements. It can also respond to similar treatment as disc degeneration, as well as lumbar traction, and chiropractic adjustments. Clinicians trained in the Clinical Neurodynamics may provide additional benefit and prevention.
Muscle
Another familiar cause of back pain is muscle soreness, tightness, or trigger points. This often feels like a deep ache on either side of the spine, usually in the low back. If you feel your back muscles you may find a tight, ropy section, or a single spot that feels knotted up. Pushing on these areas can often cause the pain to spread or travel up and down the muscle. These myofascial trigger points often result from parts of the muscle that are fatigued and become ischemic - meaning they lack oxygen. The resultant tightness of the muscle can decrease blood flow and causes pain signals to be sent to the brain. Many trigger points can be ‘released’ by applying direct pressure with a thumb or massage tool for 10-15 seconds, then release and repeat 3-5 times. There are a number of other soft tissue techniques that can be used to decrease pain from the back muscles. Frequent, good quality movement is important to prevent them from developing in the first place.
Joint
The last cause of back pain is, perhaps surprisingly, also one of the least common. That doesn’t mean it is uncommon or rare, however. Each vertebra in the spine has various protruding parts - we call them processes - that point in different directions. The spinous process are the bumps you feel in the middle of your back as you run your fingers down your spine, and they are just one small part of the bone! All together, there are 7 of these processes protruding off each of the lumbar vertebrae, and they fit together like puzzle pieces to form the spine. The interlocking pieces that connect the bones together are called facets. The place where the facets from 2 vertebrae come together is called a facet joint. If the facet joints become irritated, or do not move well, it can create pain or stiffness. This pain is often felt when leaning backwards or twisting. If this pain is felt in the lower back along the belt line, the sacroiliac facet (SI) joint may be the culprit. Joint pain responds best to chiropractic adjustment, postural modifications, and regular movement practice. There are alternatives to joint manipulation which often creates the familiar popping or cracking. Physical therapists and chiropractors are also trained in low-velocity techniques called mobilizations.
Summary
Now that you understand the potential causes of low back pain, it’s time to find someone who can help you determine what is causing your pain. Back pain is not always straight forward and can also be from a combination of these causes. Professional help is necessary to ensure the best results as well as proper follow-up care. Unfortunately, not all manual therapists are aware of the different causes of back pain and the different approaches necessary to appropriately treat each cause. Many chiropractors always treat with adjustments, even though only 2 of the 4 causes I’ve discussed warrant that approach. Massage therapists do an excellent job of addressing muscles and trigger points, but are not qualified to treat the joints with manipulation. If you feel that the pain you are feeling fits the first cause - Disc Pain - seek out a practitioner trained in the McKenzie Method of Manual Diagnosis & Therapy. This will most commonly be a physical therapist, though it is more common for chiropractors to be familiar with this approach. The other 3 causes - nerve, muscle, joint - can be treated by most other musculoskeletal practitioners - chiropractors, PTs, massage therapists, and physiatrists.
A qualified clinician should perform an in depth medical history, take the time to understand the origins of your current problem, and narrow down the cause with a series of physical tests. X-rays or MRI are rarely necessary to determine the cause of back pain or to find an effective treatment.