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The Cure for Chronic Low Back Pain by Jason Gruss, MD, FAAPMR
It is estimated that 85% of Americans will experience lower back pain at some point in their lives. Of these 35% will become chronic back pain sufferers. By definition chronic lower back pain is any pain that lasts for more than 13 weeks. At First Health we also include short-term but recurring back pain that occurs two or more times per year. While many of us suffer from back pain most is of the acute or short-term variety. Back pain caught early with proper care can be treated relatively easily and effectively.
Acute back pain often becomes chronic when the initial episode is not properly treated and the problem lingers. Most patients with long-term lower back pain make adjustments to their posture, gait and daily activities. This in an effort to minimize the discomfort while performing relatively normal chores and duties. In a relatively short period of time these “adaptive” changes in normal body mechanics become the new normal. In other words, they become permanent. The fact is that our joints and muscles weren’t designed to function in this adaptive manner.
The spine is a complex maze of small joints and tiny muscles that work in close synchronization with each other. Somewhat akin to the transmission on a high-end auto where gears are meshed in close tolerance to perform smoothly and quietly. When one or more vertebra or its component intervertebral disc fails to function in harmony with other spinal segments scraping, inflammation and eventually deterioration occur. Hence the cycle of recurring or chronic back pain.
The process happens something like this: the initial injury typically involves spinal malfunction, muscle spasm, minor tissue damage or an inflammatory reaction. More often than not there is a combination of a few of the aforementioned maladies. Failure to properly address the initial injury results in adaptive changes as described above. After time these adaptive changes become fixed and muscles, tendons and ligaments become altered, joint surfaces begin to deteriorate, intervertebral discs begin to wear thin and chronic tissue swelling prevails. The affected area of the spine which was designed to function in harmony no longer participates in normal movement. The result is pain from a variety of sources and reasons.
The rehabilitation process has to address all of the components of the malady or treatment is doomed to failure. Our most successful patients are those who follow our standard protocol, a protocol that we developed over the last ten years.
Treatment begins with relieving the pain as the primary focus. Pain is most often the result of inflamed tissue caused by muscle spasm and joint immobility. This typically means reducing tissue and nerve swelling. We have found that combining the appropriate use of conventional medicine through the use of short-term anti-spasmodic, analgesic or anti-inflammatory medications with chiropractic manipulation or gentle spinal traction works well to start.
When enough pain-free movement is achieved, typically within a few weeks to a month, our physical therapists begin the process of restoring normal muscle and tendon balance. More often than not we find shortened, taut muscles on one side and an adaptive elongation and weakness of muscles on the opposite side. We always start with gentle stretching of the shortened, overly taut muscles and once accomplished we begin strengthening the opposing muscle groups. For any lasting results these muscular imbalances must be corrected.
Once full active pain-free range of motion is achieved we begin the process of strengthening the patient’s core. The core musculature supports and stabilizes the spine. Without proper core support and stabilization posture, gait and function remain altered. This too creates a higher likelihood of re-injury.
The last step, and the most often skipped one, is called proprioceptive retraining or neuromuscular re-education. In this vital step we begin teaching your back, legs and trunk to work in harmony again. It’s like trying to lift up your auto with a bad car jack: if you do succeed in getting your car off the ground it more than likely will fall before you actually get the spare tire on. We train your body to work together again as it once did. This step is critical in minimizing the chance of recurrence. Without this step simple things like picking up a pencil or slipping off a curb can re-aggravate the condition.
Patients who have been elsewhere are amazed at our process. We’ve found that treating back pain effectively requires a closely synchronized team approach. Missing any of the important sequential steps above will most often result in failure!
By following the procedure outlined above we can help patients avoid surgery most of the time. Surgery is always the very last step because once done it’s not reversible. Depending on the type of surgery required the results are often less than gratifying and treatment after surgery is typically ineffective. One of the prime reasons surgery fails is because most patients who require surgery are very badly deconditioned. The surgery may remove the offending tissue but the supporting structure is still weak and unbalanced. We work to retrain the spinal mechanisms and then if necessary recommend the most minimally invasive procedures. Luckily surgeons today have become quite proficient with arthroscopic instruments that are minimally invasive so the need for radical intervention has been greatly reduced.