Low Back Pain, a Learning Lab

Ouch my aching Back!” (Costanza’s mom from Seinfeld voice)

Knowledge is power
Give someone a fish and they can eat for a day, teach them to fish and they’ll never go hungry

Low back pain is one of the most common things I see in the office.

For people that are in severe pain with this issue, despite me being good at what I do, there is no miracle, one-stop, fix.

I know you all want and need “a miracle” when you’re hurting! I’ve been there. Despite what you’ve heard and tried, very few times per year do people walk out of my clinic with a one-time miracle fix. They do walk out with a much better idea of what their condition is and how to maximize their recovery and speed it up.

You don’t need a miracle, you need an education. Understanding this will keep you from doing the wrong thing and sabotaging your recovery.

This is my write-up on one of the most painful and most common conditions I see.

Low back pain is the number one reason for doctor’s visits. All doctors’ visits. It can be something as easy as “hey doc, I slept wrong and am kind of kinked.” to a quick glance at the cute girl in the gym while deadlifting (guilty) to severe pain that is nearly unbearable.

The trouble is – that low back pain almost always hurts in the same area and is pretty constant in the description of pain despite there being 20 different things that could be going on.

If you’ve ever had this before, I understand. I’ve been there. It can be horrible. If you haven’t, you’re lucky. I’m not trying to put the whammy on you here, but the odds are you will all have back pain sometime in your life – shit happens, so be forewarned and have the right information so you can better handle the issue.

As stated, this will happen sometime to most all of us. – It is incredibly common, In fact, the Red Cross estimates that approx. 90% of ALL people will have some type of
low back injury (most often some degree of disc injury) at least
once in their lives – I’d add to that with my experience and say 95% – that’s about everyone, so pay attention!

This article written is to help you with health information so from time to time I’m going to let you into the head of how we think as clinicians. Enjoy the ride.

Doctors SHOULD work like detectives.

We’re looking for information and clues to help us make the correct decision and correct treatment. We’re working off a flow chart. One finding leads to this pathway and decision but another leads to a different pathway and different treatment.

The better info we have the more clear of a picture we get and hopefully can solve the mystery that is your health. (clinical note: The better (not necessarily MORE) information…I know you fell off your bike when you were ten but I really don’t think that’s probably affecting you right now. Also, Low back pain is mostly NOT a hereditary condition – your mother, grandma, and her mom all had back pain because everyone gets back pain, odds are you didn’t inherit a weak back.

I deal mostly with muscle and joint issues – body pain, and low back pain is a common one for my clinic so I feel rather qualified in taking you into the mystery of this issue.

Back to the flow chart. The flow chart idea happens despite the pain – or it should…like I said at the beginning – back pain almost always feels the same, so I’m not trying to be an ass, I know it hurts, it’s just that where it hurts and it’s grade on a scale of 1-10 doesn’t mean as much as WHY.

In the back, and truthfully anywhere in the ribs and neck, muscle tightness will be present too. That being said, just like pain, I don’t really make a decision based on muscle spasms either as that’s pretty much present every single time. BUT, muscle spasm is really easy to see and feel (you already know it’s tight, you told me – repeatedly, over and over – “it’s just so tight, really tight doc, it hurts and is tight!”)

I think this is where the mistake in a TON of low back issues occurs – the doctor/detective just fell for a coinciding clue not a causative clue.

Pain and spasm also have virtually nothing to do with the severity of the issue either – it just hurts. Some people hurt more and some people feel it less but often, THE AMOUNT OF PAIN DOES NOT COORELATE WITH THE SEVERITY OF THE PROBLEM.

OK, so let’s flowchart this baby.

Did you lose control of your bowels and/or bladder? Too medical for you? OK, easy to understand English here – Let me ask again – Did you pee or poop your pants?

If yes – call 911 right now – it’s an emergency so don’t wait – stop reading a website looking for medical advice – you need to be transported and you need a doctor NOW!

See how a flowchart for doctoring works?
Sometimes it’s that easy. Bleeding profusely from a body part? That’s a One-step flow chart, call 911 and do not pass Go.

Now let’s get into the more common and classical decision-making type stuff. Again we’ll use classic low back pain.

Next question. Does it hurt to take a deep breath in? How about taking a deep breath and now bearing down as if you were pushing out against a weight belt? (like holding in a sneeze for you non-workout types)

If yes, I would then ask if Advil (Ibuprofen) or Aleve (naproxen) seems to help at all or take the edge off a little bit. Yes? And it’s tough to change positions? Especially getting out of bed? If yes, guess what? Most likely you have an inflammation component.

This is important because if you are inflamed you do not want to be stretching, sitting in a hot tub, sitting with car seat heaters on, getting your friends/spouse or friend’s spouse to massage you or anything else that makes more blood come to the area. Even though you are tight. I know, you told me already remember?

Dude, you’re inflamed – don’t keep yourself inflamed, do the opposite.

I know, I know that’s obvious huh? Then why does 90% of everyone with back pain always do the wrong thing? Admit it, you do too – you did it wrong because heat and massage and stuff like that is more therapeutic, meaning it all feels good. Yeah feels good but is wrong – it doesn’t help you.

You’re inflamed brother. I already proved it…ibuprofen or naproxen doesn’t have pain relievers, they’re just ANTI-inflammatories so stop doing PRO-Inflammatory stuff. It slows down the whole process.

Here’s what you have to know – if getting out of bed or changing positions hurts and you have the “old guy” position for a minute or two (bent over) AND Bearing down like you’re pushing against a weight belt (called Valsalva) AND anti-inflammatories seem to help OR pro-inflammatory makes you worse (as in a “hot shower felt great for like 10 minutes and then I was worse”) then my flowchart would suggest a low grade but painful issue that involves the disc.

HOLD ON>>>”DID YOU JUST SAY DISC??” (scared eyes)

It’s super common at all levels of athletics and all ages of people despite job, health, weight, etc. Everyone gets this. Clinically we call this in my office a “disc torsion” or strain. This is my term and is named aptly to finally KILL the outdated and tired “slipped disc” we’ve all heard about.
This term needs to die – it’s from your great grandad’s day and as clinicians, especially chiropractors, we love it. A “slipped disc” is easy to show you on a plastic model and demonstrate with the appropriate amount of head bobbing and understanding from you the patient. The trouble is, you’re not anything like my plastic skeleton. The discs are attached at both ends and don’t “slip”- they strain – like an old played-out ace bandage – fibers strain and weaken and cause problems. What you’ve never heard of the slipped disc analogy? Fantastic – OH WAIT! You had the jelly donut analogy, didn’t you? Crap – unlearn that one too.

Don’t freak out just yet because I said disc – this isn’t your grandma’s chronic disc that has been going on for years – it’s an acute (meaning just happened recently) and temporary condition. You just have to treat it right.

I’m HUGE into education about clinical issues. You have to learn about this thing or you’re going to do the wrong thing and be at the mercy of well-intentioned but misinformed “experts.” Look these hurt – no one leaves my office Day 1 with a disc strain saying they feel great – NOPE – these hurt and take time – My clients leave with information and come back again because I taught them something and took the fear away..

Here, learn a little about this.

The discs are the shock absorbers and more
importantly the spacers in our spinal column.
They space out the vertebrae so that nerves can run to and from the spinal cord in order to
ensure that our brain knows what’s happening
all over our bodies.

These nerves are responsible for our movement,
our cell reproduction, our touch and
temperature sensations and as many of you know that have experienced it, our PAIN sensation!

What happens when a disc is herniated is that some of the tough outer covering (the annular fibers) are torn and this allows the jelly-like material in the inside (the nucleus
pulposus) to ooze out.

Unfortunately, as far as pain goes, these feel horrible and you will almost always experience a severe muscle spasm.

The good news is that most injuries aren’t this variety – most are grades 1 or 2, what we would call “DISC TORSION”
Now look, I know people get disc surgery all the time but truthfully many of these issues aren’t surgical, they are strained. You know when you see on the NFL Injury reserve ticker that (insert player) is out with “back spasms” and you think.. “WHAT? That dude gets paid 150G for one game and scored me 15 on fantasy last week and he’s out with back spasms????” C’mon. Yep, they have a disc torsion or disc strain but we tend as doctors not to say scary words like disc or sciatica to high-level athletes – it gets in their head and they make it worse than it is. Like you do.

The symptoms are as follows:
– some pain (sometimes a lot of pain) – tough to get out of bed or change position – coughing and sneezing may hurt – usually moderate to severe spasm (locking up) of the muscles on both sides of the lower spine – Muscle weakness, usually very slight on one side and you may notice different sensation on one side than the other. The vast majorities of these types of injuries are very treatable but will take a little time.

You see, with these injuries, it’s not the bulging of the disc, like a jelly donut pushing on the nerves as much as it is the inflammation around the injury that causes the pain.
That’s why anti-inflammatory medication seems to help a large number of people and why ICE, not Heat, will work much better, also speeding the healing process up.

Let me repeat… ICE, not heat. These are inflammatory conditions, and initially, stretch, massage, and heat will bring more inflammation to the area. Have you tried the hot shower? Yeah, feels good right away but 10 minutes later, watch out!

I feel this is probably THE most mistreated condition we all see as health care providers. It’s definitely the one I’ve done the most in my experience and BY FAR the thing I’ve lectured on the most.
Anything to the low back causes spasm. A lot of muscle spasm and because of this, most doctors, therapists, and chiropractors as well as helpful friends and family recommend heat, stretch and massage.
Realize, that the muscles are spasmed only to protect the back/neck – they will relax when the inflammation part of the injury is gone. How long does that take? Usually 1 week or more – I would personally not suggest any heat until you have had 3 good days in a row!

We all see low back pain and we see a lot of these disc torsion variety.
Most disc injuries are treatable and the patient will respond quickly if the
treatment is done correctly.
(Like I said, most are not treated correctly at home!)
Something else important to know about these conditions is that they almost never respond by feeling better and better each day.
Compare it to when you have sprained an ankle in the past. Each day seems to feel a little better, like a stair-step progression of pain.

That’s a terrible comparison and disc injuries don’t respond like this at all. They have huge waves of up and down pain where at times you will feel almost completely healed and then may get hit hard and feel bad again. This can happen even in the course of a single day. It seems to follow a 10-hour pattern of yoyo pain, so be ready for it.

These also hurt a lot as you change position. Especially when getting out of bed and out of the car. In fact, that’s part of the way I flow chart diagnosis this issue.
The pain and spasm with these issues can be severe but feel comfortable that this is a small and easy issue and will go away.

YOUR back problem is neither unique nor exceptional. It sucks yes, but we’ve seen this a million times, it will get better – it’s just SCARY and hurts. Let me elaborate. Let’s say 15 years ago if you were in an auto accident and went to an attorney they would almost INSIST you got an MRI. The MRI would show a disc bulge, herniation or annular fiber strain (pretty much all the same thing) and would then add to your case that you were severely jacked up.

The problem is that by the time you are 30 years old -most likely you have a small disc bulge or strain somewhere. So having MRI evidence doesn’t mean as much anymore – it could be an old issue, not something that just cropped up recently. It’s normal. Right? If everyone pretty much has this finding and nearly everyone isn’t currently in pain, guess what?

It’s normal.

I have a disc bulge. My wife does. We’re not screwed up in the least. I can do a tough mudder and lift 200 pounds above my head. I’m not crippled nor screwed up, I’m normal. Look, despite being a chiropractor and being married to a chiropractor and being surrounded by a bunch of great guys that do this stuff every day, I’ll still get the same disc strain described above every decade or so – like I said – nearly everyone will have this at some time.

It’s not your weak back or the fact you played HS football or the auto accident you had in 2002 – it just happens. Multiple times in your lifetime. Hurts? Yes. Debilitating and Life-altering? , No.
So get it fixed, stop using a hot bath, shower, or hot tub and wondering why it has lasted 3 weeks.

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