By Laurie Melrose-Doering, Osteopath & Applied Kinesiologist
Lower back pain is very common – it is estimated that up to 80% of us will develop lower back pain at some point in our lives. Things such as sitting for long periods of time or bending over to lift heavy loads can place stress on our lower back. And it is often an accumulation of these stresses that leads to lower back pain.
Lower back pain is bread and butter for osteopaths – for many people with lower back pain, one of the first things that will come to his or her mind is their osteopath.
Our lower back is also known as the lumbosacral area of the back. The lower back covers the area between the ribs and the buttock muscles.
The lower back is made up of five lumbar vertebrae, numbered L1 to L5. You may have come across L4 or L5 if you know anyone who has had a disc prolapse in the low back.
As well as the vertebrae, the low back is made up of muscles, ligaments, tendons, nerves, discs, and fascia.
The smaller of the low back muscles, the intrinsic muscles, have a primarily proprioceptive function, i.e. telling the spine where it is in space. Our larger low back muscles, meanwhile, are responsible for moving and stabilizing the low back. The fascia of the low back, most notably the thoracolumbar fascia, provides structural support and is a site for muscles to attach.
The discs provide shock absorption and allow movement, while the ligaments maintain stability. The ligaments, just like the intrinsic muscles of the low back, also play an important role in proprioception.
Low back nerves control the muscles and organs, and provide sensation to the pelvis, hips, thighs, legs, and feet.
The spinal cord – which runs from the top of the spine to the level of L1 or L2 – is housed within the vertebral column. The spinal cord connects the brain with the nerves that control the arms, legs, organs and other parts of the body.
If you look at the spine, you will notice that it tends to be curved. The lumbar spine is concave, meaning it has an inward curve. This inward curve is called a lordosis. The cervical spine also has a lordosis, while the thoracic spine has an outward curve, called a kyphosis.
The reason we have these spinal curves is to allow for shock absorption. Without these anterior-posterior curves, too much force would be transmitted from our feet to our head when we walk or run, potentially causing headaches.
For osteopaths, the most useful way to classify low back pain is through the underlying cause. Understanding the cause allows for best treatment:
Mechanical low back pain is the most common type of low back pain. It is usually due to injury of the muscles, ligaments, joints, or bones in the lumbosacral area. Mechanical low back pain tends to be localized to the low back, buttocks, and thighs.
Common examples of mechanical low back pain are muscle strains, ligament sprains, facet dysfunctions, minor injuries to the discs, spondylolisthesis, and sacroiliac joint dysfunctions. Then there are causes that are more age-related. These include osteoarthritic changes (spondylosis) and osteoporosis.
Mechanical low back pain is often aggravated by certain movements of the spine, such as bending forwards, sitting-to-standing, or during walking. Typically, it is easier to lay on the back with the knees and hips bent. It is usually best to avoid bending or lifting until the pain is treated by an osteopath – if this is possible.
This is pain that is caused by the impingement of a nerve root as it leaves the spine. Radicular pain will be felt along a dermatome, i.e. the area of the skin that is innervated by a specific nerve root. The pain will usually come with pins and needles, or even numbness. The nerve roots that are most commonly irritated are L4, L5, and S1 – you can see the location of the dermatomes here (((add dermatomes))). Symptoms along the back of the thigh and calf are often called sciatica.
The impingement of a nerve root that causes radicular pain is called radiculopathy. In addition to causing the dermatomal pain, a radiculopathy can cause specific muscle weakness and reduced reflexes. Osteopaths, test muscle strength and deep tendon reflexes to ascertain whether there is motor compromise associated with the radicular pain.
Radiculopathies are mostly caused by a disc prolapse (a ‘slipped disc’) or lateral stenosis, which is the result of arthritic changes to the spine. But radiculopathies can also be caused by trauma, tumours, or even infection.
Usually, radicular pain is on one side of the body. If a patient has bilateral pins and needles, or numbness, there could be impingement of the nerves called the cauda equina. This is called cauda equina syndrome and is a medical emergency.
The following symptoms should also raise suspicion of cauda equina syndrome and warrant immediate investigation at A&E:
Treated late, cauda equina syndrome can cause permanent damage to the nerves that control the bladder and anal sphincter.
Low back pain can also be caused by systemic inflammatory conditions. The inflammatory conditions that are most likely to afflict the low back are ankylosing spondylitis and rheumatoid arthritis. Crohn’s disease and lupus can also cause inflammation that causes lower back pain.
Ankylosing spondylitis and rheumatoid arthritis are usually worse in the morning, with stiffness that lasts more than 45 minutes. Movement often helps, which is why I often prescribe swimming or walking.
Individuals with inflammatory conditions will typically find that certain foods exacerbate their symptoms. It is often advised to cut out sugar and other inflammatory foods.
Meanwhile, anti-inflammatory foods such as turmeric, or immune-modulating herbs prescribed by a herbalist can be very helpful. The health of the gut and microbiome plays an important role in the treatment of such inflammatory conditions.
This is pain originating from a problem in another area of the body. Common examples of pain referring to the low back are kidney stones, bladder infections, fibroids, or inflammation of the pelvis.
Certain cancers can lead to low back pain. This is because certain cancers – thyroid, breast, lung, kidney, prostate, and testicular – can spread to bone. Such pain is not technically referred pain, because the damage occurs in the low back itself. But late-stage cancer is an example where a medical practitioner must consider areas not directly related to the spine.
The severity of lower back pain bears no relation to the severity of the injury. So if you are suffering from acute pain, it does not necessarily mean that the cause is serious.
Symptoms can range from stiffness or dull ache to spasms or sharp pain, from pins and needles to numbness. Knowing the aggravating and relieving factors gives the practitioner a lot of insight into what the cause could be.
It is probably best to see a manual therapist, especially an osteopath or chiropractor. Osteopaths or chiropractors treat low back pain every day and enjoy the luxury of having more time than GPs.
During your consultation, the practitioner will ask questions to try to understand what is going on. This will include questions about the onset, progression, associated symptoms, and relieving/aggravating factors.
He or she will also ask about the past medical and family history. The answers will allow the practitioner to come up with a list of possible diagnoses and rule out more sinister causes.
A physical examination often includes a postural assessment, orthopaedic tests, muscle testing, and reflex taking.
If results suggest something more sinister or the practitioner wants to rule out a certain condition, further referral is indicated. This may include:
Treatment for low back pain depends on the cause.
For mechanical low back pain, osteopathy is the gold standard. In addition to osteopathy, hot and cold or acupuncture therapy can be beneficial.
Over-the-counter painkillers and anti-inflammatories such as ibuprofen or naproxen may take the edge off the pain. Such medication can be useful, however, masking the pain comes with a slight risk. You might think that you are better than you are and try movements that you should not yet be trying. It is better to have the underlying cause treated – which usually requires hands-on treatment.
For severe mechanical low back pain with muscle spasms, a GP might prescribe muscle relaxants such as diazepam. What is true for over-the-counter analgesics is also true for muscle relaxants.
In rare cases, surgery is performed. These invasive interventions include discectomy, laminectomy, or spinal fusion. Low back surgery should only be considered when all other avenues have been exhausted.
As an osteopath, I am often asked what can be done to prevent low back pain returning.
Although the risk of developing low back pain cannot be completely removed, it can be significantly reduced.
The best way to make your low back more resilient is by staying generally healthy and fit. And this includes a healthy body weight.
Also, if you haven’t already, adopting a good lifting technique is helpful. I see many patients who develop low back pain from bending over and picking things up – no matter the weight. Lifting should be from the hips and knees, not the low back. And twisting under load should be avoided.
In most patients that I see for low back pain, there are a number of things that I treat. And many of these dysfunctions are regularly older than the low back pain itself. These dysfunctions can be called predisposing factors. And it is an accumulation of these that make the low back susceptible – it is a bit like ‘the last straw that broke the camel’s back’.
These underlying problems help explain why a seemingly innocuous movement can sometimes lead to low back pain.
For this reason, it can be useful to see an osteopath for a check-up to see if there are certain imbalances that might to be addressed. Depending on what is found, an osteopath will also be able to give low back exercises.
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Aston Clinic London is a third-generation complementary health clinic located in New Malden, serving Kingston, Norbiton, Wimbledon, Raynes Park, Surbiton, Chessington, Worcester Park, Sutton, Richmond, and other areas of southwest London and Surrey.
By Laurie Melrose-Doering, Osteopath & Applied Kinesiologist
