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The true cause of back pain

MagazineOctober 2015 (Vol. 26 Issue 7)The true cause of back pain

Chronic pain has become an international epidemic-an estimated one billion people across the globe suffer with it every day

Chronic pain has become an international epidemic-an estimated one billion people across the globe suffer with it every day. In fact, chronic pain has become the number two reason people seek medical care-second only to symptoms associated with the common cold. And what I've found over my 20 years of treating pain is that many of these people are suffering needlessly.

During my career, I have treated more than 14,000 patients, many of whom came to me as a last resort before surgery or as a follow-up after surgery that didn't resolve their pain. Many of them had been told that they would have to manage their pain by using drugs for the rest of their lives or, worse, that there was nothing left to try in their efforts to find relief-they would simply have to live with the pain.

In case after case, I heard the same story: the patient had gone to the doctor, and diagnostic tests like magnetic resonance imaging (MRI) scans and X-rays were done. A structural variation, such as a stenosis, herniated disc, meniscal tear or arthritis, was then found and became their diagnosis-it was the 'cause' of their pain and they were treated based on this.

Medications were used; injections, epidural nerve blocks, and a host of other treatments and procedures ensued. Some would mask the pain for a short time, but ultimately the pain returned, and surgery was presented as the only remaining option. And then they had a terrible choice to make: either have surgery that didn't assure pain relief or try to manage the pain.

In some cases, patients were told they would become paralyzed if surgery wasn't performed. Others were told that surgery may or may not help and that it was, in fact, completely up to them when and if to move forward. In all cases, the horrible decision was left completely in the patient's hands.

The thousands of people who came to me were hoping for what they considered a miracle. What they didn't know was that no miracles were needed. Resolving their pain was strictly a case of using logic and analysis to figure out the true cause of their pain so that it could be properly addressed.

In 90 to 95 per cent of cases where doctors had identified a structural problem as the cause of pain, I found something completely different. What I discovered as I worked with people was that most of the pain they experienced actually came from a muscle weakness or imbalance rather than structural problems.

Let me explain how this works. People perform tasks every day: they walk; they move from sitting to standing; they climb stairs; they do all sorts of simple actions that require groups of muscles to work together. When one muscle is weak or out of commission because of an injury such as a strain, people will still attempt to perform these tasks. However, to do this the body must call on other muscles to compensate and work more than they are supposed to. This is what leads to muscle weakness or imbalance. The strained muscle may then emit pain or even cause a misalignment of the joint surfaces the muscles are attached to, which can create pain at the joint.

By looking at a person's symptoms rather than the findings of a diagnostic test, I was able to determine whether the cause of the pain was structural or muscular. The evidence became clear that the vast majority of patients had muscle-related causes. In these cases I was able to identify which muscles needed to be built up to resolve the weakness or imbalance causing the pain. And by having patients implement some simple exercises, I could help them overcome the pain they were feeling. Using this process, I wasn't providing minor pain relief; I was providing complete pain resolution.

By looking at things like your range of motion, flexibility, walking patterns and posture, and combining this information with interpretation of your symptoms, you will soon be able to identify whether your pain is, in fact, muscular rather than structural. If it is muscular, as a majority of cases are, targeted strength training is the
only answer.

For those suffering from pain due to muscle-related causes, you have the power to treat your own pain naturally. And if you've already gone through surgery and still have pain, I hope this helps you see that there are other, safe and non-invasive ways to help yourself.

What is pain?

First of all, it's important to understand what pain is. In its simplest form, pain is an attempt by the body to create a conscious awareness of bodily distress so that an intervention can be performed to resolve the distress. So pain is simply a notice from your body telling you that something needs to be taken care of.

To get a bit more technical, when the function of a tissue is compromised, the tissue sends a signal that is picked up by nociceptors (pain receptors). These nociceptors then send this information to the brain, which translates it into the sensation of pain.

One of the greatest misperceptions about pain is that it is solely associated with nerves. Most people who experience pain come to me thinking that the pain must be coming from a nerve and that to deal with the pain, they have to deal with the nerve. This is simply not true. Pain receptors are found in their greatest abundance in connective tissue, and connective tissue can be found in almost every tissue of every organ. This connective tissue typically sits around the cells of the organs, allowing for input regarding the health of the organ. If there is a breakdown in the cell of an organ, it sends a pain message to the brain.

Besides nerves, most other tissues in the body also have the ability to send these warning signals. Think of the pain from a kidney stone, a heart attack, an upset stomach or a cut. It is the kidney, the heart, the stomach or the skin that is releasing pain signals, sending them through the pain receptors found in the connective tissue surrounding the cells that make up the tissues. Even muscles have the ability to send pain signals.

An excellent paper written by Ginevra L. Liptan, MD, director of the Frida Center for Fibromyalgia in Oregon, speaks directly to the power of pain receptors in connective tissue by focusing on pain receptors in the fascia of muscle as the cause of the pain associated with fibromyalgia. In plain English, what she says is that the pain of fibromyalgia can be attributed not to a nervous system dysfunction, but rather to an oversensitization of the pain receptors surrounding muscle.1 Basically, this means any stimulation will activate pain sensors.

Sadly, the idea that all tissues can emit pain is something that hasn't been taken into account in our current pain-treatment procedures. If there's an obvious cause for the pain, such as a broken bone due to an accident or the patient has suffered a heart attack, then diagnosis is pretty simple. But in the case of pain that is not attributable to a specific incident or tissue damage associated with an incident, the diagnostic tests used to identify the cause of pain focus mostly on structural abnormalities that might affect nerves.

The primary tools for identifying these structural issues are MRI scans and X-rays. Using these techniques, doctors look for things like pinched nerves due to herniated discs or stenosis in the neck or back. Chronic pain that arises anywhere in the body (especially in the limbs) is considered a 'neuropathy'-structural damage to the nerves-stemming from the spine. This is also true if the symptoms are described as tingling, burning or numbness.

In reality, non-systemic pain-pain not related to a disease, such as the pain associated with cancer, kidney stones or irritable bowel syndrome-can come from a number of different sources. It can be muscular, neurological or structural.
However, in our current pain-treatment system, there is no one speciality that looks at all these possibilities to determine which is correct, and there is no one specialist capable of identifying which tissue is emitting the pain. There are around 15 different specialities that claim to understand the causes of pain and how to treat it, including neurology, orthopaedics, rheumatology, physiatry (rehabilitation), podiatry, physical therapy, chiropractic and acupuncture, to name just a few. But the practitioners in each of these fields are trained to see pain only within their isolated educational and clinical experience. Not one of them is in a position to look at the big picture to identify the true cause of your pain.

If you were to go to each one of these specialists to find the cause of your pain, you would most likely be given several different and conflicting answers. If you go to a surgeon, you'll likely need surgery. This is because surgeons are trained to look at a situation through the lens of how surgery can help. This is simply what they know.

This splintered system of isolated specialists with their partial understandings of pain, combined with their non-valid methods of identifying the causes of pain, is the primary reason our current medical system is so ineffective at dealing with pain.

Happily, this is beginning to change. In in a stunning paper published in 2011, the American College of Physicians recommended that MRI no longer be used to identify the cause(s) of pain of the lower back. It noted that, in 84 per cent of patients with lower back pain, the pain could not be attributed to any spinal abnormality, such as a herniated disc, stenosis or disease. As the paper stated, "It is important to understand that the presence of imaging abnormalities need not mean that the abnormalities are responsible for symptoms."

The paper went on to note that diagnostic tests like these can lead to unnecessary treatments and procedures, and simply increase costs. It was also noted that the identification of structural abnormalities using complex medical terminology that is unknown to the layperson leads to unnecessary stress for patients.2

In one of the first studies to show a conflict between positive MRI findings and a correlation with pain, the researchers performed MRIs on people who had no pain at all. The scans showed that roughly 70 per cent of these people had either bulging or herniated discs. But if this is so, then it can be extrapolated that in roughly 70 per cent of people with pain and a bulging or herniated disc, the pain must be coming from another source.

As the study authors concluded: "On MRI examination of the lumbar spine, many people without back pain have disk bulges or protrusions but not extrusions. Given the high prevalence of these findings and of back pain, the discovery by MRI of bulges or protrusions in people with low back pain may frequently be coincidental."3

A similar situation is seen with meniscal tears. In a 2008 study, Dr David Felson, professor of medicine and epidemiology at Boston University Medical School, and his team found that meniscal tears were just as common in people with knee osteoarthritis who did not complain of pain as they were in people with knee osteoarthritis who did have pain. The tears tended to happen along with arthritis and were part of the degenerative process itself. This means that repairing the tears would not eliminate the pain.4

An article in The New York Times quoted Felson as saying, "Every time we get a new technology that provides insights into structures we didn't encounter before, we end up saying, 'Oh, my God, look at all those abnormalities.' They might be dangerous. . . Some are, some aren't, but it ends up leading to a lot of care that's unnecessary."

To test the suspicions that MRIs, which are done on almost every injured athlete or casual exerciser, might be rather misleading, Dr James Andrews, a widely known sports medicine orthopaedist in Gulf Breeze, Florida, scanned the shoulders of 31 perfectly healthy professional baseball pitchers. These pitchers were not injured and had no pain. But their MRIs found abnormal shoulder cartilage in 90 per cent of them and abnormal rotator-cuff tendons in 87 per cent. "If you want an excuse to operate on a pitcher's throwing shoulder, just get an MRI," Dr Andrews says.5

Getting to the source

Thankfully, a number of major medical groups have started to agree with the premise that herniated discs found on MRIs do not necessarily represent a cause of lower back pain. As the Cleveland Clinic Arthritis Advisor (July 2011 issue) noted, "Most back pain is muscular." The article goes on to say, "What has given spine surgery a bad name is people having fusions for back pain when there is no instability. They get an MRI because of the pain; it shows an abnormal disk and so they get a fusion. That's a terrible indication because you don't know that the disk is the source of the pain. Disk degeneration is a normal phenomenon of aging; everybody eventually suffers from it."6

While structural abnormalities can cause pain, we can only definitively know it's the cause if we determine some other things first. For every patient I see, I start by ignoring any diagnostic test findings. Instead, I ask them questions about their ability to move around and where the pain is being experienced, and also what makes that pain worse or better and whether there was a specific incident that brought on the symptom. I then use this information, along with the data I get from simple clinical tests that look at range of motion, flexibility, functional testing and posture, to understand the true source of the pain.

If the problem is muscle-based, there's so much more you can do on your own-without surgery or medication. For example, if you suffer from low back pain, take the following DIY tests (page 69) to find out if you have the same muscle imbalances as the majority of sufferers. If you do, see page 71 for the stretching and strengthening exercises that can help.

The truth about pain

One of the greatest misperceptions about pain is that it is solely associated with nerves. This is not true. Pain receptors are mostly found in connective tissue, and connective tissue can be found in nearly every tissue of every organ. This connective tissue typically sits around the cells of the organs, allowing for input regarding the health of the organ. If there is a breakdown in the cell of an organ, it sends a pain message to the brain.

Pain on both sides of the back

By far the most common reason for pain across the lower back is a muscle imbalance that develops between the quads and hip flexors (muscles on the front of the body) vs glutes and hamstrings (muscles on the back of the body).

This is a common scenario because most functional activities-whether it's climbing stairs, sitting down or getting up-are performed from the front. This causes the quads and hip flexors to be used more often, which then become stronger than the glutes and hamstrings. If this imbalance increases enough, the quads and hip flexors shorten. Because the quads attach to the front of the pelvis, their shortening pulls the front of the pelvis down, causing the back of the pelvis to rise. This then causes excessive arching of the lower back which, in turn, causes the lower back muscles to shorten.

Once shortened, the lower back muscles lose their ability to apply force and perform their task of supporting the torso. This causes these muscles to strain and emit pain across the lower back.

To verify whether this is the cause of your lower back pain, do the following clinical tests.

Posture analysis

The first indicator of a muscle imbalance between the quads and hamstrings is an abnormal positioning of the pelvis. There are two bony points that can be felt on the pelvic bone: the anterior superior iliac spine (ASIS) at the front of the pelvis, and the posterior superior iliac spine (PSIS) at the back of the pelvis.

When there is a muscle imbalance resulting from the quads being stronger than the hamstrings, the ASIS will be drawn down and sit much lower than the PSIS. To judge the alignment of your ASIS and PSIS, simply look at yourself from the side in the mirror, standing as you would normally stand. Feel for these two landmarks on your pelvis, and draw a line between the ASIS and PSIS. If the line angles up from front to back, this is a sign that you may have this imbalance. If this is the case, you will also notice an excessive arch or curve in your lower back.

Flexibility testing

Next, look at the flexibility of the quads and hamstrings. If the quads are very tight and the hamstrings are excessively flexible, this is another indicator that the quads are stronger than the hamstrings.

To test your quads' flexibility, stand holding on to a sturdy object with one hand and then grab the ankle of the leg on the other side. Try to pull your ankle to your buttocks. If you can't reach your heel to your buttocks while also keeping your knee slightly behind the hip, then your quads are tight.

To test your hamstrings, lie on your back with one knee bent and the foot of that leg on the surface where you're lying. Have somebody try to raise your other leg with the knee straight. You should be able to raise your leg until it is pointing straight up. This is considered the normal range of motion of the hamstrings. If you can go farther than straight up, then you are hyperflexible in the hamstrings.

Tight quads with either normal or hyperflexible hamstrings is an indication of a muscle imbalance between these muscles.

Muscle testing

To test the quads and hamstrings for muscle strength, sit on a sturdy chair. You will need somebody to help you test your strength. Sit with one foot on the floor and one foot off the floor with the knee bent to about 70 degrees. Have your helper place one hand on top of the thigh and one in front of the ankle. Then try to straighten your knee while the helper tries to stop you at the ankle. This is a test of quad strength.

Now have the helper take his or her hand and put it behind the ankle. From the same starting position as before (knee bent to 70 degrees), try to bend your knee more while the helper tries to stop you. If the kicking out is much stronger than the pulling back, this is another indicator of a muscle imbalance causing pain in the lower back.

Palpation

Finally, you can palpate, or finger-probe, the lower back region to see if you can determine which tissue is emitting the pain signal. The quadratus lumborum, or QL, pair of muscles (one on each side) are the main muscles of the lower back region. Press along the whole muscle from its attachment to the rib cage to the attachment to the pelvis. Pain from such muscle strain may be felt at any point along the muscle. If the pain you are experiencing is increased by pressing on these muscles, this is final confirmation that the cause of the lower back pain is from strained lower back muscles, resulting from a muscle imbalance between the quads and hamstrings.

If you have determined that this is definitively the cause of your pain, the key to resolving it is to stretch the quads and strengthen the glutes, hamstrings and hip abductors. Do this by carrying out the following exercises.

Quad Stretch

Lie on a surface with the leg to be stretched hanging off the side and the other leg on the surface, knee bent and foot flat on the surface. Next, place a towel around the ankle of the leg to be stretched to give you something to hold on to.

Grab the towel and slowly begin to bend the knee toward the buttocks until a stretch is felt along the front of the thigh. Once you feel the stretch, hold it for 20 seconds and then return to the start position. Make sure your back does not arch when performing the stretch.

Hamstring Curl

In a seated position, focus the resistance at the back of the ankle. Make sure you are supported in the seat. Begin with the exercising leg pointing straight out with the knee unlocked. Begin to bend the knee until it reaches 90 degrees. Then return to the start position. To isolate the hamstrings better, point the toes of the exercising leg towards your face while performing the exercise. If using a seated hamstring curl exercise machine, make sure the pivot point of the machine is aligned with the knee joint.

Straight Leg Deadlifts

Start with your feet a little more than a shoulder-width apart and your toes pointing slightly out. You should be standing straight with your knees unlocked and your butt pushed back slightly. Focus the resistance to the front of your thighs. With your back straight while looking out in front of you, bend from the hips while keeping the resistance in your legs. Make sure your knees don't bend and the movement is coming from your hips.

As you pivot down, you should feel the weight shift to your heels. When you begin to feel tightness at the back of your thighs, begin to straighten back up to the start position. There is no specific point to come down to on the leg. To determine how far down you should go, bend until feel tightness at the back of your thighs. Make sure your back remains flat, not rounded. If it's rounded, you can strain your back and you will also go down farther than you could with a straight back.

Hip Extension

In a sitting or standing position, focus the resistance behind your knee. Start with the hip flexed to about 60 degrees: if you're sitting, bring the knee down towards the surface you're sitting on; if you're standing, bring the knee to about 10 degrees behind the hip. Return to the start position. If standing, make sure your back is rounded, and the knee of the leg you're standing on is unlocked.

Hip Abduction

This can be performed either lying on your side or standing. To do the exercise correctly, make sure you don't go too far when moving your leg outwards. There is a false idea that a bigger range of motion is better, but in this case, too much range of motion means you're using the lower back muscle to make the movement, not the gluteus medius (hip muscle). The gluteus medius can only move the leg out to a point parallel with the hip joint. Any further outward movement beyond that is using the lower back muscle.

To do the exercise, lie on your side with the knee of the bottom leg bent and the top leg straight. The top leg should run in a continuous, straight line from the torso. If the leg is angled in front of the torso, you are using a muscle other than gluteus medius. Raise the top leg off the supporting leg until it is parallel to the floor. Turn the leg slightly in so the heel is the first part of the foot that is moving. This puts the gluteus medius in the optimal position to raise the leg. Once your leg is parallel to the floor, lower it back down onto the supporting leg.

REFERENCES:

J Bodyw Mov Ther, 2010; 14: 3-12
Ann Intern Med, 2011; 154: 181-9
N Engl J Med, 1994; 331: 69-73
N Engl J Med, 2008; 359: 1108-15
Kolata G. 'Sports Medicine Said to Overuse M.R.I.'s'. The New York Times, 28 October 2011
Cleveland Clinic Arthritis Advisor. 'When is Back Surgery a Good Idea?' July 2011; www.arthritis-advisor.com/issues/10_7/features/733-1.html


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