CHRONIC BACK PAIN
A COMBINATION OF BONY RESTRICTION, FASCIAL ADHESION, MUSCLE WEAKNESS, LOSS OF PROPRIOCEPTION, AND INFLAMMATION
If there’s one thing we know for sure about Chronic Low Back Pain it’s that the model we currently use for looking at it is outdated. What do I mean? First and foremost, you can tell very little from imaging the lower back (HERE and HERE). Secondly, and probably just as important, is the fact that in health-related matters, inflammation is everything (HERE) — especially chronic systemic inflammation. Not only is chronic inflammation going to lead to pain, but it is actually the very cause of the SCAR TISSUE that the medical community calls “FIBROSIS” (HERE). Unfortunately, the average physician does little (many would argue nothing) to educate their patients about inflammation or let them know that for the most part, they themselves have the power to control it without drugs. Let’s take a look at the way we think about chronic low back pain is changing.
Back in 2010, the journal Spine published a study (Increased Intramuscular Pressure in Lumbar Paraspinal Muscles and Low back Pain) which helped shed some light on this topic. For at least a couple of decades previous to this, researchers had realized that Increased Intramuscular Pressure (IIP) in the spinal errectors / para-spinal muscles (aka backstraps for you deer hunters) was related to pain, but did not understand the mechanism. Not surprisingly, it turned out to be inflammation. The thing was, once the process got going, it could feed itself, as IIP was not only caused by inflammation, but actually had the power to produce inflammation (see last link of previous paragraph for more info on this vicious cycle).
Last year, the European Journal of Pain (Inflammation of the Thoracolumbar Fascia Excites and Sensitizes Rat Dorsal Horn Neurons) went even deeper by looking at the relationship between a sensitized dosal horn (pain arising from an overstimulated portion of the spinal cord that carries pain messages) and inflammation. They discovered that not only does this inflammation cause pain, but it actually causes the pain to spread to adjacent nerve levels, almost like an unholy neuro-infection. What science is beginning to show us is that at least some of this pain is coming from the Thoracolumbar Fascia itself (anytime pain comes from the cord or brain, you run a greater risk of developing CENTRAL SENSITIZATION).
For instance, July’s issue of the Journal of Bodywork and Movement Therapies (Evidence for the Existence of Nociceptors in Rat Thoracolumbar Fascia) dealt with this issue of pain receptors in FASCIA. We’ll get to this momentarily, but let’s first talk about nociception. Nociceptors are the nerve endings that sense things that are “noxious” to the body (inflammation, extreme temperatures, mechanical issues such as crushing, pinching, or cutting, etc). The messages from these nerve endings end up in the dorsal horn of the spinal cord, where they make their way to the brain to be interpreted as pain.
“Recently, the existence of nociceptive fibers in fascia tissue has attracted much interest. Fascia can be a source of pain in several disorders such as fasciitis and non-specific low back pain. As a pathological state, inflammation of the TLF was induced with injection of complete Freund’s adjuvant. The density of CGRP- and SP-positive fibers was significantly increased in the inner and outer layer of the inflamed fascia. In additional experiments, a neurogenic inflammation was induced in the fascia by electrical stimulation of dorsal roots. In these experiments, plasma extravasation was visible in the TLF, which is clear functional evidence for the existence of fascia nociceptors. The presence of nociceptors in the TLF and the increased density of presumably nociceptive fibers under chronic painful circumstances may explain the pain from a pathologically altered fascia. The fascia nociceptors probably contribute also to the pain in non-specific low back pain.”
Although there are some technical terms here, what I want you to gather is that inflammation causes, “pathologicially altered fascia,” which “probably contributes to non-specific low back pain“. When you consider that the vast majority of low back pain is “non-specific” (not primarily related to the discs) you begin to get an idea of just how big a deal this is. Last August’s issue of Neuroscience (Innervation Changes Induced by Inflammation of the Rat Thoracolumbar Fascia) showed something almost identical. “The fascia innervation has become an important issue, particularly the existence of nociceptive fibers. Fascia can be a source of pain in disorders… such as non-specific low back pain. In conclusion, the inflamed Thoracolumbar Fascia showed an increase of presumably nociceptive fibers, which may explain the pain from a pathologically altered fascia.” All of this begs the question of how people are causing the inflammation that is stimulating nociception?
For one, we know beyond the shadow of a doubt that inflammation (a group of chemicals made by your immune system for the express purpose of helping heal damaged or injured tissues) can be driven to excess by crappy diets. It’s fairly common knowledge at this point that sugar and highly processed carbs are two of the more common drivers of inflammation (HERE). As for the inflammation that is induced mechanically, let’s take a look.
Between our national WEIGHT PROBLEMS and sedentary lifestyle, it is common to see muscles in the back actually turning to fat. Listen to the results of this study (Fat Infiltration of Paraspinal Muscles is Associated with Low Back Pain, Disability, and Structural Abnormalities in Community-Based Adults) published in last July’s issue of Spine. “Paraspinal fat infiltration was associated with high-intensity pain/disability and structural abnormalities in the lumbar spine.” It’s not like this is something new. 1983’s November issue of the American Journal of Neuroradiology (Fatty Replacement of Lower Paraspinal Muscles) likewise concluded that, “It is well known that muscles wasted due to aging, disuse, or disease are replaced by fatty tissue.” Allow me to paint you a typical American scenario.
Jolene has a desk job, but loves to work in the yard / garden (I could have just as easily picked on her overweight husband Joe whose favorite weekend pastime is to watch sports on TV while kicking back with a few beers). Despite the fact that Jo gets little exercise with her stressful job at the office, if the weather is good she likes to spend part of her weekends trimming, cutting, raking, digging, or landscaping her yard and flower beds. Let’s look at how this can damage her back. A study published in a 2012 issue of the Journal of Electromyography and Kinesiology (Neuromuscular Manifestations of Viscoelastic Tissue Degradation Following High and Low Risk Repetitive Lumbar Flexion) helps us understand why CORE STRENGTH is so critical, and must be addressed on a regular basis (all it takes is a few minutes but it must be done regularly).
“Cumulative lumbar disorder is common in individuals engaged in long term performance of repetitive and static occupational / sports activities with the spine. The hypothesis is that static and repetitive (cyclic) lumbar flexion-extension and the associated repeated stretch of the various viscoelastic tissues (ligaments, fascia, facet capsule, discs, etc.) causes micro-damage in their collagen fibers followed by an acute inflammation, triggering pain and reflexive muscle spasms/hyper-excitability. Continued exposure converts the acute inflammation into a chronic one, viscoelastic tissues remodeling / degeneration, modified motor control strategy and permanent disability. Changes in lumbar stability are expected during the development of the disorder. Prolonged cyclic lumbar flexion-extension at high loads, high velocities, many repetitions and short in between rest periods induced transient creep / laxity [CREPITUS] in the spine, muscle spasms and reduced stability followed, several hours later, by an acute inflammation/tissue degradation, muscular hyper-excitability and increased stability [spasm]. The major findings assert that viscoelastic tissues sub-failure damage is the source and inflammation is the process which governs the mechanical and neuromuscular characteristic symptoms of the disorder. “
On top of all this, we know that it is possible to actually ‘learn’ pain. Once the pain starts moving from the point where it is generated at the nociceptor to the point where it is being generated in the spinal cord or brain, we have a real problem on our hands. If you want to understand how this sort of pain can progress, I created a very short post for you called THE THREE KINDS OF PAIN.
Information like this is fantastic. The problem is, information in and of itself can’t solve your problem and help you get rid of your pain. While knowledge truly is power, you’ll have to put that knowledge to good use in order to have a chance at getting rid of (or at least diminishing) your pain.
SOLVING YOUR CHRONIC LOW BACK PAIN
Before we get into the list of what you should be doing for your low back in order to take care of the pain, let’s talk about what you want to avoid at all costs — SPINAL SURGERY. January’s issue of the Journal of Pain Research hit us with a study called Failed Back Surgery Syndrome: Review and New Hypotheses. In this study the authors stated, “The percentage of pain detected after spinal surgery varies ranging from a low of 5% to a high of 74.6%, and the percentage of need for re-operation ranging from 13.4% to 35%.” Talk about a variation! Everyone knows that the true numbers would fall on the high side of this spectrum. If back surgery was 95% effective as the “5%” statistic above would suggest, everyone would be doing it and everyone would be happy. Unfortunately, not everyone is happy with their back surgery — not by a long shot.
“The fascial system is richly innervated by proprioceptors, which can transform into nociceptors. The crural and connective tissue areas are populated by proprioceptors and it can be assumed that an alteration to the position and function of the respiratory muscle [diaphragm] creates a state of irritability of these proprioceptors and subsequent presence of pain. It can be assumed that if the position of the diaphragm is not physiological, the phrenic nerve is retracted or irritated in different ways, causing nociception, in the same way as for a peripheral nerve irritation from the surrounding tissues that it crosses.”
Did you catch that? The medical community is saying that mechanoreceptors / proprioceptors can turn into nociceptors. Furthermore, if you alter the position or function of the diaphragm (HERE are a few posts on the topic) you can foul not only the innervating nerves, but the tissues that said nerves cross. It’s why UNDERSTANDING PROPRIOCEPTION as well as understanding what it takes to RESTORE PROPRIOCEPTON is of critical importance for all of us — those hoping to recover from back surgery (failed or successful) or more importantly, trying to avoid it in the first place.
What about those of you struggling to get through the day and cope with the pain? Fortunately for you, I’ve created a post that describes in detail (complete with short videos) the difference between adhesed and healthy Thoracolumbar Fascia, as well as a generic protocol for helping you solve your chronic back issues (HERE). Does it work? As crazy as it sounds, I have seen this protocol work for many many people with crazy-severe problems, in some cases almost overnight. Not that you can expect to have such quick results, but when you address adhesed, restricted, or injured tissues, deal with underlying inflammation, and work to strengthen the core in ways that do not aggravate the back, good things tend to happen.
Chief Wellness Officer of the renowned Cleveland Clinic, Dr. Michael Roizen, made this shocking statement when answering a question on the site ShareCare —How many people suffer from back pain? “With about 65 million Americans suffering from back pain, it’s the second most common reason for medical visits.” Don’t become a statistic. And if you are already a statistic, create an exit strategy to change that (see previous link). If you’re liking what you’re seeing on our site, be sure to spread the wealth. The best way to reach those you love and care about most with the pertinent and interesting health-related information found on our site? FACEBOOK, of course (just be sure to like, share, or follow).