Treatment of Lower Back Pain
Osteopaths spend much of their time assessing and treating lower back pain due to its high incidence. There are many structures in the lower back which may give pain or refer pain to other parts of the body. These can become worse if not identified and treated sooner rather than later.
What makes up the low back?
Most of the lower back is made up from muscles that attach to, and surround, the spine. The spine is made up of bones called vertebrae. The vertebrae are roughly circular and between each vertebra is a 'disc'. The discs are made of strong rubber-like tissue which allows the spine to be fairly flexible. Strong ligaments also attach to adjacent vertebrae to give extra support and strength to the spine. The various muscles that are attached to the spine enable the spine to bend and move in various ways. The spinal cord, which contains the nerves that come from the brain, is protected by the spine. Nerves from the spinal cord come out from between the vertebrae to take and receive messages to various parts of the body.
Simple Low Back Pain
Most cases of acute low back pain are classed as 'simple low back pain' or 'non-specific low back pain'. Simple low back pain means that the pain is not due to any underlying disease that can be found. In some cases the cause may be a sprain or strain (an over-stretch) of a ligament or muscle. In other cases the cause may be a minor problem with a disc between two vertebrae, or a minor problem with a small 'facet' joint between two vertebrae. However, these causes of the pain are impossible to prove by tests and so it is often impossible for a doctor to say exactly where the pain is coming from, or exactly what is causing the pain.
Sometimes a pain may develop immediately after you lift something heavy, or after an awkward twisting movement. Sometimes you can just wake up with low back pain.
Simple does not mean that the pain is mild - the pain can range from mild to very bad. Typically, the pain is in one area of the lower back, but sometimes it spreads to the buttocks or thighs. The pain is usually eased by lying down flat, and is often made worse if you move your back, cough, or sneeze. So, simple back pain is 'mechanical' in the sense that it varies with posture or activity.
Most bouts of simple low back pain improve quickly, usually within a week or so. In most cases, the pain has either gone or has greatly eased within four weeks. However, once the pain has gone it is common to have further bouts of pain (recurrences) from time to time in the future. Also, it is common to have minor pains 'on and off' for quite some time after an initial bad bout of pain. In a small number of cases the pain persists for several months or longer (chronic back pain).
Nerve Root Pain
This means that a nerve coming from the spinal cord is irritated or pressed on. (This is often referred to as a 'trapped nerve'.) You feel pain along the course of the nerve. Therefore, you may feel pain down a leg to the calf or foot, and the pain in the leg or foot is often worse than the pain in the back. A common example is 'sciatica'. This is where a main nerve to the leg, the sciatic nerve, is irritated or pressed on.
Nerve root pain can range in severity from mild to very bad. Like with simple low back pain, nerve root pain is often eased by lying down flat, and is often made worse if you move your back, cough, or sneeze. The irritation or pressure on the nerve may also cause pins and needles, numbness or weakness in part of a buttock, leg or foot.
The cause of the irritation or pressure on a nerve may be due to inflammation caused by a ligament or muscle sprain. A 'slipped disc' is another well known cause. (A disc does not actually 'slip'). What happens is that part of the inner softer part of the disc bulges out (prolapses) through a weakness in the outer harder part of the disc. The prolapsed part of the disc can press on a nerve nearby. Other less common conditions can press on a nerve to cause nerve root pain.
Less Common Causes of Low Back Pain
Arthritis (inflammation of the joints) of the spine sometimes causes back pain. Osteoarthritis is the common form of arthritis and usually occurs in older people. Ankylosing spondylitis is another form of arthritis that can occur in young adults and causes pain and stiffness in the lower back. Rheumatoid arthritis may affect the spine, but you are likely to have other joints affected too.
Various uncommon bone disorders, tumours, infections, and pressure from structures near to the spine occasionally cause back pain.
How Can I tell what type of back pain I have?
Most cases of low back pain that develop suddenly (acutely) are due to simple low back pain. Many people just 'get on with it' and treat it themselves - and indeed most get better quickly. However, if in doubt, see your osteopath for a check-over and advice.
As a general guide, if any of the following occur then it may indicate that it may not be simple low back pain, and there may be a more serious underlying cause such as a nerve root problem, or another disorder. Therefore, tell a Doctor and your Osteopath if you have any of the following:
- The pain first develops under the age of 20 years or over the age of 55 years.
- Constant back pain that is not eased by lying down or resting.
- Pain that travels to the chest, or is higher in the back behind the chest.
- If the pain developed gradually, and slowly gets worse and worse over days or weeks. (Most cases of simple low back pain occur acutely, that is, suddenly.)
- In addition to back pain, you have:
- Weakness of any muscles in a leg or foot.
- Numbness (lack of feeling) in part or parts of a buttock, around the anus, or in a leg or foot.
- Problems with your bladder or bowels such as not being able to pass urine or loss of control (incontinence).
- Weight loss, fever, or if you feel generally unwell.
- Recent history of violent trauma or injury to the back.
- You have or have had a cancer of any part of the body.
- You have taken steroid tablets for more than a few months.
- If you have a poor immune system. For example, if you are on chemotherapy or have HIV/AIDS.
- If you are unsure about any symptom.
Cauda Equina Syndrome - rare, but an emergency
Cauda equina syndrome is a particularly serious type of nerve root problem. This is a rare disorder where the nerves at the very bottom of the spinal cord are pressed on. This syndrome can cause low back pain plus: problems with bowel and bladder function (usually unable to pass urine), numbness in the 'saddle' area (around the anus), and weakness in one or both legs. This syndrome needs urgent treatment to preserve the nerves to the bladder and bowel from becoming permanently damaged. See a doctor immediately if you develop these symptoms.
Treatment of Neck Pain
Here at the clinic we see many patients with various pains and aches in the neck along with tension headaches.
Non-Specific Neck Pain
Many people develop a stiff and painful neck for no obvious reason. It may happen after sleeping or sitting in a draught or perhaps after a minor twisting injury, for example while cleaning or gardening. The underlying cause for this type of neck pain is not fully understood, so it is called 'non-specific neck pain'. Having non-specific neck pain does not mean that your neck is damaged and often it happens in people whose necks would appear completely normal under an x-ray. It is the most common type of neck pain and often disappears after a few days. If it doesn't resolve within a couple of days it is wise to have an examination and treatment before the body begins compensating with altered posture.
With everyday use over many years the discs and the facet joints become worn. This wear varies from person to person. The discs become thinner and this causes the spaces between the vertebrae to become narrower. Also, 'spurs' of bone, known as osteophytes form at the edges of the vertebrae and the facet joints. In a way this is a particular form of osteoarthritis but it is known as Cervical spondylosis.
This type of injury often follows a rear-end collision in a car. In this type of collision, first the body is carried forward and the head flips backwards. Then, as the body stops, the head is thrown forwards. Following a whiplash injury there is often a delay before the pain and stiffness start. Although whiplash can badly damage your neck, the majority of people who suffer these shunt accidents do not have major damage. In most cases injuries feel better within a few weeks or months. Seat belts and properly adjusted headrests in cars have significantly reduced the damage from whiplash injuries.
Most muscles of the body relax completely when they are not being used but some muscles (known as 'anti-gravity muscles') have to work all the time in order to keep your body upright. Muscles at the back of your neck must always be tensed, otherwise your head would fall forwards when you are sitting or standing. When these muscles work too hard or are not strong enough, it can cause neck pain and tension headaches. People who are worried or under stress often sub-consciously tighten their muscles more than is necessary to hold their head upright. Tension headaches are very common and are often wrongly called migraines. Working at a computer station and sitting slumped with head forward loads the neck muscles and may create tension headaches.
After assessing the function and quality of neck and joint movement, we check the muscle and fascial tension along with its relationship to the spine and head. We apply soft tissue massage to soften muscle tension with positional release for the fascia. We may follow this up with articulation and manipulation for joint release where necessary. We also use gentle Cranial Osteopathic techniques to rebalance the rhythmic function of the spine and cranium. Recommended exercises for correcting poor posture are also a part of treatment and consultation.
About your injury
Disc injuries (prolapse, herniation, slipped disc) occur most commonly in the low back and are a common source of back pain. Repeated, prolonged or excessive bending, lifting and sitting slumped can lead to degeneration of the outer fibres of the disc. This weakness can, in turn, lead to a sudden prolapse of the gel-like fluid in the centre of the disc. When this occurs, the pressure and inflammation from the fluid can irritate the nerves in the low back and cause Sciatica.
How did it happen?
These injuries are usually caused by bending and lifting akwardly. People who sit badly and have poor core stability are more vulnerable than others.
What are the symptoms?
Typical symptoms include low back pain with muscle spasms. Pain is made worse by trivial movements such as brushing teeth, putting shoes and socks on, walking up stairs, sitting for long periods, bending, coughing and sneezing. The pain may be relieved by changing position. If the herniation or prolapse is extensive, nerve root impingement can cause shooting pains, weakness and pins and needles down the leg and in the foot.
What should I do?
- Avoid sitting for long periods
- Avoid low seats with poor back support (sofas and cars in particular)
- Avoid strenuous lifting
- Keep a straight back and bend the knees when bending
- Take regular gentle walks
- Ice the low back using a bag of frozen peas or ice pack wrapped in a tea towel. Do this for 10 minutes every hour
- Take some anti-inflammatory medication such as Nurofen
- Consult an Osteopath for some physical therapy and advice on stretching and strengthening exercises
A 'trapped nerve' is a common and unpleasant condition in which a nerve can be irritated by either the chemical or mechanical effects of inflammed tissues. Symptoms that may suggest that you have trapped nerve include:
- Neck pain and stiffness with a combination of radiating pain, tingling, numbness and weakness down the arm, forearm and fingers
- Low back pain and stiffness, also, with a combination of radiating pain, tingling, numbness and weakness down the buttock, thigh, legs and feet.
A typical case history of a patient presenting with a trapped nerve may sound like this:
'I woke up one morning with an incredibly stiff neck. I could hardly turn it. It took me a lot longer to get changed for work - brushing my teeth, putting my jacket on and reaching for things were particularly painful. I took some Nurofen which seemed to free off my neck a bit but later in the day, I started to get a pain down my arm and a couple of my fingers went numb. Although the stiffness has improved somewhat, I'm still getting these symptoms down my arm 3 days on.'
Sciatica is another example of a trapped nerve. Sciatica can be caused by a number of different injuries such as a slipped disc, arthritis, a sacro-iliac injury or a muscle tear in the low back.
Because there are many injuries that can cause a 'trapped nerve' it it worthwhile visiting an Osteopath to determine the root cause of the symptoms. If the Osteopath is unsure, you may be referred to have an x-ray, MRI scan or ultrasound to confirm the diagnosis.
Once a diagnosis is made, a treatment plan can be hatched that will firstly reduce the pain and discomfort and secondly help to prevent recurrence of the injury.
Headaches (Cephalgia) and Migraines
Many patients present at the clinic with neck pains, back pains and related headaches or migraines. We are lucky to be able to help many of our patients to overcome and prevent the onset and recurrence of some headaches and migraines by addressing the root causes. We hope the following article may help patients to determine if they may self help or seek our assistance.
Before the various causes are discussed an example of a patient presenting in the clinic may be useful:
'Miss X is a 27 year old lady who arrived in dire straits having suffered continuously from a headache for over two years. She had exhausted many sources of help and was currently under the care of a Consultant Neurologist. The treatment was heavy duty analgesics which were helping slightly but reproduced side-effects of drowsiness. Sadly this should have been the prime of Miss X's life, however she was avoiding socialising and understandably so. After an in depth consultation it was decided that the root cause of these headaches was coming as a result of poor seating posture at the desk causing restriction of the joints in her neck with contraction of the posterior musculature of the neck. A treatment plan was put together and commenced immediately. Miss X was treated weekly for 4 sessions and by this time the headaches had resolved by 60%, a further 2 treatments reduced the headaches to background annoyance. Regular check ups every 3 months have resulted in analgesics not being necessary. The last visit Miss X had was for knee pain and has no reported headache for 3 months'.
Headaches originating from the Neck (Cervicogenic-Cephalgia)
These are benign headaches unrelated to increased inter-cranial pressure, infection or haemorrhage. They usually begin as a vague ache in the base of the head (occipital area) or top of the neck. Within hours, it progresses over the top of the skull to involve the entire head. People may complain of pain behind the eyes on one or both sides. The headache usually worsens as the day progresses yet improves with lying down and sleeping. If severe it may trigger Migraine style symptoms of nausea, photophobia or vomiting. There are a number of trigger areas for the onset of this these forms of headaches.
- Muscular attachments from Cervical or Thoracic Spine to the periosteum of the occiput
- Restricted Facet joints in the Cervical Spine
- Restricted function of the Cervical or Thoracic Spine
- Restriction of blood supply
- Poor venous drainage from the Intracranium
- Dural restrictions within the Cervical Spine and internal cranium
- Restricted function of the joints of the various yet distinct 29 bones of the skull
The causes are often a combination of poor seating postures, week abdominal muscles, long hours in front of a computer and stressful status.
Treatment of patients with headaches takes a whole body approach. A combination of soft tissue techniques, articulation, manipulation, stretching and gentle Cranial Osteopathy plus advice on stretching exercise and correct posture and seating positions.
A full discussion of headaches in their various forms would fill an extremely large textbook. It is well beyond the scope of this webpage to encompass all the causes of headaches and or migraines. Therefore this presentation is limited to the poorly understood but surprisingly common phenomenon of headaches originating from the neck.