Lower back pain

Unfortunatelly pain in the low back is perceived as something trivial and can be mistakenly dismissed as a self limiting conditions by patients and doctors alike.

LOW BACK PAIN (LBP) is a pain felt in the lower area of the spine. The pain in the lumbar spine can have multiple anatomical location. Pain from hip or pelvis as well is from thoracic spine can project to the area of lumbar vertebrae and is perceived as pain in the low back.

Symptoms

Symptoms will be dependent on which structures are irritated. Usually pain in the low back which changes location is functional in origin.

Low back pain with radiation into the leg, burning sensation, numbness and tingling should always be taken very seriously and requires immediate medical attention.

Causes

Low back pain can be caused by structural pathology such as: herniated or protruded disc, arthritis of the lumbar joints. It can also be caused by pinched nerve within or around the structures of spinal canal or spinal foramens. It could also be functional such as muscular or ligsmentous pain.

Chronic LBP

Chronic LBP is usual a result of combination of following factors:

Poor, inadequate and untimely treatment, poor beliefs, poor copping strategies, overuse of structural diagnosis as well as emotional stress.

Diagnosis

Diagnosis of LBP is almost always clinical with exception of very severe pain with numbness, tingling, radiation and loss of strength.

Differential diagnosis

Rarely low back pain can arise from structures inside the viscera (organs), however dysfunction of motility of visceral organs as well as breathing can be an important causative factor in LBP. Most often differential diagnosis requires the differentiation of anatomical areas below or above the lowback as well as carefully examination of the whole locomotor system.

The most common differential diagnoses

Treatment of low back pain

Since low back pain is so multifactorial individual approach is paramount.

The successful treatment of low back pain is one that addresses the cause rather then the symptoms. In order to attack the cause two factors must be identified:

1) movement dysfunction

2) pain generator- structure irritated during specific movement (ligament, muscle, joint, nerve,disc and etc…) Since multiple structures can refer pain to low back, primary load transfer failure must be identified. The spinal stability system has to be addressed from perspective of dynamic stability rather then the core strength

At NYDN we provide very individual and comprehensive approach based on our meticulous examination skills and most integrative treatment . We combine most advanced scientifically proven low back treatment methods such as:

DNS (dynamic neuromuscular stabilization), ISM (integrated system model approach), clinical Pilates, structural integration, postural retraining, myofascial release and acupuncture just to name a few.

Caren

Meet CAREN, our computer assisted rehabilitation environment. CAREN takes patient diagnosis and treatment to a whole new level by challenging motor neurons to adapt. First developed by the US military to help wounded warriors recover from amputations and other extremity traumas, CAREN is now available to the public.

Because human gait patterns can be impaired by trauma, disease, or age-related natural decline, gait analysis helps physical therapists identify impaired gait patterns. CAREN then provides a virtual reality environment for purposes of rehab. Rather than walking on a treadmill against the backdrop of the sights, sounds and smells of a clinical environment, CAREN patients are engaged and motivated as they steer a boat across a tranquil lake, drive a car down a city street, or take a nature hike along a rocky path. CAREN provides patients with a positive virtual reality rehab experience that translates to dramatically improved gait, balance and coordination.

From research we know that people with Low back pain (lbp) belong to different categories (or groups) and therefore should be treated with individual approach.

CAREN can successfully facilitate treatment of people with LBP which belong to following categories:

  1. 1. insufficient dynamic core activation
  2. 2. excessive core activation
  3. 3. Low back pain which results from gait (walking) impairment due to asymmetrical weight bearing such as with adaptation to healing by unweighting the injured extremity as well as many other types of weight bearing asymmetry
  4. 4. Loss of balance
  5. 5. Gravitational / postural disorders where there is an uneven distribution of trunk versus pelvis and feet as well as loss of control of the center of mass (COM) ober base of support (BOS) Lumbar fatigue: (rephrase for explanation) or may be leave it but isnt it to long?

Protection against spinal injury requires proper anticipation of events, appropriate sensation of body position, and reasonable muscular responses. Lumbar fatigue is known to delay lumbar muscle responses to sudden loads. Patients with chronic low back trouble had significantly poorer ability than control subjects on the average to sense a change in lumbar position, which was noticed before and after the fatiguing procedure. This feature was found in patients and control subjects, but patients with low back trouble had poorer ability to sense a change in lumbar position than control subjects even when they were not fatigued.

Treatment of low back pain

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TESTIMONIAL

LOW BACK PAIN TREATMENT NYC

If you are human you will experience low back pain (LBP) one day. Low back pain is so common that it is number two ailments after common cold. The latest consensus of world scientific community has concluded that low back pain is a multi-factorial disease-affecting people of any age. However, don’t get scared most of lower back pain can be treated conservatively without use of drugs or medication. Also don’t get hung up on radiological diagnosis such as Magnetic Resonance Imaging (MRI). Fifty percent of people, who have bulged, protruded or herniated disk on the MRI don’t have any LBP. Other 35% of patients who have a herniated disk on their MRI actually hurt from other sources in their back. This type of pain is called a low back pain of non-disco genic origin.

FUNCTIONAL ANATOMY

The anatomical function of lower spine is now considered as a component of a larger lumbopelvic­-hip
complex. The hip, pelvis, lumbar spine, and ribcage are simply one functional system, in which movement in the individual segment must have an ability to be isolated or coupled when necessary. In fact
the healthy lumbopelvic-­hip complex can only exist if there is an ability to isolate or couple movements
between individual segments within the complex. Since lumbar spine is a segment in this functional
chain the isolation and integration of its movement is paramount for normal function.

INCIDENCE AND PREVALENCE

LBP is number one reason why people miss work.
Research has shown that every older person experiences pain in the lower back. The lifetime prevalence
of this symptom is thus 100%. In comparison, neck pain is two and a half times less frequent and pain
in mid back is thirty times less frequent.

ETIOLOGY (CAUSATION)

As mentioned above mechanical nature of LBP is well accepted and researched. According to few
studies there are over fifty causes of LBP of mechanical origin. Here are some examples:

  • INTERVERTEBRAL DISC DEGENERATION
  • SPRAINS AND STRAINS
  • BULGED OR HERNIATER DISC
  • LUMBAR RADICULOPATHY
  • SPONDYLOLISTHESIS
  • SCIATICA
  • SPINAL STENOSIS
  • SPONDYLOSIS

RISK FACTORS

  • Genetics
  • Non-optimal motor development in infancy (motor system never totally matured, very common)
  • Level of fitness (core musculature in particular)
  • Age
  • Occupational overload
  • Trauma
  • Repetitive strain by sporting activities
  • Pregnancy

SO WHAT CATEGORIES OF LOW BACK PAIN ARE THERE

  1. Mechanical LBP (most common)
  2. Myofascial LBP (very common)
  3. Pain induced by bulged or protruded or herniated disk
  4. Radicular pain
  5. Neuropathic pain
  6. Psychosomatic pain

LOW BACK PAIN OF MECHANICAL ORIGIN

Mechanical LBP is the pain induced by placing too much physical stress or strain on ligaments, muscles and joints in the lumbar spine and pelvis. Bad posture, poor mechanical habits, bad ergonomic conditions and improper bending and lifting techniques produce usually mechanical pain.
The phenomenon of Failed Load Transfer (FLT) is an example of mechanical low back pain. FLT is when the joint overloads results in inability of the body to control joint motion. Therefore when the joint is not timely stabilized it causes future overload of structures around the joint and superficial muscles have to take the slack to compensate for insufficient stabilization. The result is activation of pain receptors.

MYOFASCIAL LOW BACK PAIN

Myofascial pain is pain characterized by pain projection, which is called, referred pain. The singular substrate or myofascial pain is a local taut band located within a muscle tissue and causing referred pain upon palpation. The taut bend is caused by endplate dysfunction. Commonly myofascial pain causes projection (referral) of the pain to the particular area of the low back from several different muscles creating composite pain area. Each muscle has a very distinct pain referral, however since referral from different muscles have overlapping areas this type of pain can be confusing and often time mimics some other type of LBP.

PROTRUDED OR HERNIATED DISK PAIN

Spinal disk pathology is very diverse and confusing in nomenclature since its radiological description rarely matches clinical presentation. Usually the pain from the ruptured disk that does not compress or inflame the spinal nerve is caused by tear in the fibers of annulus fibrous (outer layer of the disc) that are richly innervated by pain receptors.

RADICULAR PAIN (spinal radiculopathy)

Radicular pain may or may not have a lumbar component. It is caused by inflammatory or mechanical irritation of the meningeal covering of the spinal nerve root by the ruptured disk. Pain with radiculopathy is usually very strong and may be accompanied by numbness, tingling and loss of muscle strength. Radicular pain is the most difficult pain to treat. It usually takes longer to heal and may require multidisciplinary intervention.

NEUROPATHIC PAIN

Neuropathic low back pain is placed in the chronic pain category even though it feels different then musculoskeletal chronic back pain. Neuropathic pain is nerve like pain, which continues to hurt even when the source of the original pain has disappeared. The sensory part of the nerve gets to be overexcited and continues to send faulty warnings signals to the brain.

LOW BACK PAIN OF PSYCHOSOMATIC ORIGIN

The word psyche (soul) and soma (body) refers both to the emotional/cognitive and to the physical
aspect of an individual. It is postulated by science that back pain of psychosomatic origin is when the emotional conflict is resolved by pain in the low back. Most chronic LBP is ether purely or
partially psychosomatic in origin. LBP of psychosomatic origin is a phenomenon, which is hard for patients to accept because the nature of physical pain can draw attention or compassion from other people unlike the psychological issues. This type of LBP is unfortunately does not suit our modern medical system and even though thoroughly researched and proven by science still has not found its optimal treatment. Many doctors who deal with low back pain fail to recognize this type of pain simply because it does not suit their treatment model.

DIAGNOSIS

Diagnosis of LBP is usually clinical unless clear signs of radicular involvement are present. Although tumors in the spine and visceral diseases which refer pain into the lumbar spine are rare (3% of all back pain). However when suspected it necessitates immediate diagnostic imaging. Radicular syndrome of moderate to high severity with neurological signs may also require magnetic resonance imaging (MRI).

TREATMENT

In the past LBP treatment was performed according to patho­-anatomical model (the treatment was conducted based on results of radiological findings, X-rays and MRI). This led to very poor outcomes, patient frustration and pain cornification. Fortunately the scientific community proved that this model is completely obsolete because patients with LBP are not homogeneous and therefore basing the treatment on patho­anatomical model is a complete misunderstanding led by development of MRI technology. In late 90ies the new model was developed which was based on dividing patients with LBP into defined subgroups. These subgroups were described above as LBP categories. Further on variety of different studies defined the best interventions for following groups. It is believed that when LBP is properly categorized and treated accordingly the results are far more superior and more immediate. When clinicians follow this model and therapist majority of chronic LBP can be prevented. Unfortunately this model is still slowly becoming mainstream because of socioeconomic reasons.

TREATMENT AT NYDNRehab

At NYDNRehab we have been treating lower back pain for sixteen years. In our unique experience we maintain that there are no two patients alike, even when it concerns patients with the same pathology. Based on our cutting edge functional diagnostic skills and reach clinical experience we create individual treatment plan, which corresponds to particular individual and low back pain category rather than structural radiological diagnosis. Our method is based on variety of evidence based low back pain physical therapy approaches such as Dynamic Neuromuscular Stabilization, Integrated System Model approach, Movement System Impairment, Clinical Pilates approach as well as variety of different manual chiropractic and osteopathic techniques.

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