Identifying and treating the root cause of low-back pain

Photo Cred: Jack Williamsn/Pixabay

By Avery St. Onge

Low-back pain is one of the most common ailments in the United States. According to the National Center for Complementary and Integrative Health (NCCIH), 80 percent of adults will experience low-back pain during their lifetimes. While medication is often used as treatment in conventional healthcare, integrative practitioners prefer to use complementary therapies and lifestyle changes for better overall care of the patient.

One of the most common work-related disabilities and among the most popular reasons for doctor visits and absences from work, low-back pain affects people of all different age groups and has a host of causes. Whether it is a little kid carrying a backpack that is too heavy, a high school athlete managing a sport injury, an adult sitting at their computer all day, or an elderly person suffering from a muscle pull, they all experience low-back pain, according to Lillie Rosenthal, DO, a board-certified physical medicine and rehabilitation physician in New York.

Rosenthal explained that because the human body is all connected, low-back pain can have manifestations far beyond the back. Sleep loss, headaches, fatigue, stress, lack of exercise, are all symptoms of low-back pain. In addition, pain in the lower back can cause patients to walk differently and alter their posture. The “real puzzle” for any pain syndrome, according to Rosenthal, is finding the reason why it’s happening.

“In order to treat back pain effectively, we have to identify the root cause,” said Rosenthal.

A diagnosis of the issue is essential before beginning treatment. Back pain is a “global term,” Rosenthal explained, and to treat it, a physician must determine what kind of pain it is. To do this, Rosenthal will ask patients for a detailed history, observe the patient’s posture, evaluate the way they walk and how they sit, as well as conduct detailed orthopedic and neurological exams.

“My best diagnostic tools are my eyes, my ears, and my hands,” said Rosenthal. “From that I can get 98 to 99 percent of what I need to know.”

According to Robert Silverman, DC, DACBN, DCBCN, MS, CCN, CNS, CSCS, CIISN, CKTP, CES, HKC, FAKTR, who maintains a private practice in Westchester, New York, there are three phases of low-back pain: acute, subacute, and chronic. Acute pain involves elevated levels of inflammation, and usually occurs three to five days after injury. Subacute pain usually lasts four to 12 weeks, and chronic pain is long-term pain which lasts past 12 weeks and involves scar tissue, chronic inflammation, and potential structural damage.

Silverman said most people suffering from low-back pain have “mechanical low-back pain,” which has to do with the structure of the lower back, its autonomy, and its discs. He explained that the key to ascertaining the cause of an individual’s low-back pain is to “work the patient up.” Patients often come into his practice and point to their lower back as the location of their pain however the structural issue is often elsewhere.

Causes and conventional approaches to treatment

According to Silverman, low-back pain is caused by a range of factors including ergonomics and biomechanical faults, age, nutritional deficits, and trauma.

Diagnosing a patient’s issue requires an in-depth history and thorough observations of the patient. However, conventional medicine often fails to take these details into account, explained Rosenthal.

“Unfortunately, I can’t tell you how many patients, if I’m not their first stop, tell me their doctor didn’t even examine them,” Rosenthal said.

Rosenthal said a lot of the low-back pain she sees is due to structural problems, muscular issues, trigger points, and mechanical dysfunction. She said while she can prescribe MRIs, X-rays, and drugs, it is often not necessary. Through osteopathic manipulation, Rosenthal can manually fix structural imbalances with techniques like myofascial release, paving the way for the body to begin healing itself. Some doctors begin prescribing medicine without any examination at all, including X-rays or MRIs, Rosenthal explained. Other times, when they do perform MRIs and X-rays, they end up “just giving a pill to quell the pain,” Rosenthal said.

Due to the opioid crisis, many physicians have turned to non-steroidal anti-inflammatories. While these medications decrease pain, evidence suggests, they may impair healing.

“The body is living tissue,” Rosenthal stated. “We have to make sure we give it the appropriate thing to take away the barriers that are preventing healing and give the body what it needs to heal.”

Movement as medicine

In terms of physical therapies, Silverman said he applies chiropractic adjustments like soft tissue release on patients struggling with back pain. He applies several other treatments including U.S. Food and Drug Administration (FDA) cleared low-level lasers, decompression and traction, shock wave therapy, and exercise rehab.

Many practitioners view movement as medicine for low-back pain. While some patients experiencing pain are hesitant to exercise and cause further damage to their injury, Rosenthal said it’s better to move the right way than to not move at all. She suggested talking to patients about what forms of exercise are realistic for them, even if it’s an hour walk.

A form of exercise that is often prescribed to those struggling with back pain is yoga. Kimberly Williams, PhD, former research assistant and professor for the School of Public Health at West Virginia University, explained that specific forms of yoga are more helpful to low-back pain than others.

Williams is a certified Iyengar yoga instructor and has conducted multiple studies on the effectiveness of Iyengar yoga as a low-back pain intervention. Derived from the teachings of B.K.S. Iyengar, Iyengar yoga focus on biomechanical poses that lengthen and restore the back. William’s most recent study in 2009 found a 24-week Iyengar yoga therapy program helped reduced pain intensity and functional disability as well as depression in participants suffering from chronic low-back pain.

Iyengar yoga addresses muscular imbalances and brings people into more symmetry using props such as wall ropes, blocks, plate weights, and benches, said Williams. These props assist people with certain positions, meeting people where they are with their yoga abilities while encouraging the back to remain straight.

Unlike other yoga certifications which only require a 200-hour teaching training, an Iyengar certification includes a mentoring period, written exams, a demonstrating practice exam, and finally, a teaching exam.

“A lot of yoga that is being taught these days, these vinyasa flows, it’s more like follow the leader,” said Williams. “Instructors are just guiding the class as opposed to looking at the muscular imbalances and giving people feedback.”

Williams explained that patients suffering from serious back pain require a teacher that is closely watching them and giving them corrections and feedback in person, which is best, or virtually, which requires the student’s camera to be turned on.

Regardless of the yoga style, Williams said that practitioners should be aware of yoga studios and instructors in their area, their qualifications, and level of experience before suggesting yoga for low-back pain to their patients.

“Yoga can be really helpful, but because you’re going to the end range of motion, you can also compress your back,” said Williams, “It can go either way depending on the skill of the teacher and the methods being used.”

Dietary adjustments and supplements

Another crucial part of treating low-back pain is changing patients’ diets. Processed food, gluten, sugar, dairy, artificial sweeteners, and vegetable oils all prevent healing.

“Foods that are inflammatory are going to be inflammatory to the lower back,” Silverman said.

To manage inflammation, practitioners should recommend their patients remove all inflammatory foods from their diet. In addition, Silverman said he often has his patients take food sensitivity tests. Identifying foods that patients are sensitive to, and removing them from their diet, prevents the delayed inflammatory reaction that is a result of their sensitivity.

Rosenthal explained that she rarely prescribes her patients medications. She primarily uses “food as medicine” and recommends an anti-inflammatory, whole food, plant-based diet.

“I use pain as a portal to optimize the health of my patient,” said Rosenthal. “I’m hoping to not just responsibly and effectively treat their back pain but get them healthier in other ways.”

Another natural way of providing additional nutrition for inflammation is through supplements. Silverman recommended supplements such as glucosamine chondroitin, omega-3 fatty acids, vitamin D3 taken with K2, as well as white willow bark, Boswellia, turmeric, and quercetin.

Rosenthal explained that the integrative approach is comprehensive and effective but acknowledged that there needs to be a “buy-in” for the patient. The practitioner and the patient must work as a team and in doing so, the patient must be willing to change their lifestyle.

Most Americans, according to Silverman, have the mindset of “let’s wait and see. I want to see if it goes away.”

While humans can forget an injury, the central nervous system does not, Silverman explained. Preventing pain in the first place, through anti-inflammatory diets, stress management, and exercise are all key to the integrative approach. However, when an injury does arise, Silverman said treating it the first time will always be more effective than waiting until the next injury, which is often more painful.

“The body is a beautiful functioning organism, and it has the ability to treat itself in many instances after a muscular skeletal injury,” Silverman said. “It often just needs some sort of input from a doctor whether it be nutrition, chiropractic, taking foods away, taping, whatever it may be.”