The New Science of Back Pain

The problem

For many people the problem becomes chronic and they will have severe back problems that limit their function at work and home many times each year. These problems most often get worse with each subsequent episode and can often become debilitating.

What to do?

There are an infinite number of opinions and a wide variety of treatment options available to someone suffering from back pain. The problem is opinions won't necessarily help you heal and just because a particular treatment worked for one person doesn't mean it will work for you. The truth is most of the so called “treatments” promoted today are the modern day equivalents of the Wild West Snake Oil Salesman. Many treatments may look effective but in reality time is a great healer. Hundreds of scientific studies known as randomized controlled trials (RCT's) have demonstrated that the pain symptoms with a back injury will simply go away in about 5 weeks. The true measurement of a back treatment's effectiveness is not just if your pain goes away but if your back pain comes back a few weeks or months later. For many people their pain symptoms clear up in about 5 weeks but that doesn't mean the problem is gone.

Randomized controlled trials (RCT's)

So what is a back pain sufferer to do? Dealing with back pain is bad enough without having to get a degree in research to figure out what's really going to help and what isn't. This is where RCT's come in. These are the gold standard used in medicine to determine what works and what doesn't. The RCT offers the highest proof of effectiveness that a treatment really works. The information presented here is supported by this type of research.  RCT's are at the heart of almost all medical research especially in the use of medications.  You probably wouldn't want to use a medication unless it had been properly tested first.  This brings up another interesting point with RCT's. There should be multiple RCT's done by different groups to give a treatment validity. Some examples of poor science are some of the recent weight loss drugs that have been discovered to have a number of bad side effects. These drugs had only a small number of RCT's supporting their use. They had not been studied thoroughly enough and the results were disastrous.

Unfortunately the same problem plagues people with back pain.  For some reason, medical professionals will often promote a treatment for back pain without first properly demonstrating that it actually works. As a matter of fact there are hundreds of RCT's demonstrating that many common treatment methods DON'T WORK for the majority of people. You can review many of these under the category “Fallacies of back care.”

Muscles and back pain, the heart of the matter

The focus on muscles in the treatment of back pain is nothing new. Hundreds of treatments such as massage, stretching, acupuncture and strengthening have all been used. Many times these do feel good and for many people will provide temporary relief but the key word is temporary. The main problem is most of these treatments are focused on the wrong muscles. To better explain this let's look at some anatomy.

Three layers of the back

Outer Layer:  Erector spinae

Middle Layer:  multifidus, transverse abdominus, quadratus lumborum.

Inner Layer:  spine, discs, ligaments, joints

Many of the treatments people have tried for back pain have focused on the outer layer of muscles. Although these may be sore and there is often moderate to severe guarding or spasm this is often just a symptom of a bigger underlying problem. The focus on outer layer muscles for rehabilitation is why traditional back exercise programs have failed.

Surgeons have often focused their attention on the inner layers of the back. There are many surgical techniques to address problems in the inner layer discs, joints and the spine itself. Common procedures include discectomy, in which a portion of the disc is actually removed, spinal fusion in which the disc is removed and the two vertebrae are fused together forming one bone. Currently there is significant controversy over new studies questioning the effectiveness of spinal fusion in terms of cost and relief of symptoms. There are also numerous studies looking at the long term effectiveness of spinal fusion vs. intense focused spinal exercises and they are finding both give similar long term results, although the specific exercise group cost is only a fraction of a spinal fusion. 

In the past few years more and more research is demonstrating that the middle layer of muscles plays a significant role in low back pain. Numerous studies have demonstrated that the multifidus muscle goes into a state of "shock" immediately after a back injury. This muscle is of particular importance as it is one of the main stabilizers of the vertebrae in the spine. It is a highly active muscle used during almost every movement of the back. The outer layer muscles are the "movers." These are the powerful muscles that actually move the spine and trunk. There are multiple multifidus muscles in many layers (as shown in picture) and they have two functions. One is to support the spine during all of the movements we do on a daily basis. The second is to detect movement and subtle changes in the spinal joints. This "position sense" which we call proprioception, is of utmost importance as it allows the nervous system to make ongoing adjustments in muscle tension which are necessary to stabilize and protect our spinal joints, discs and ligaments. This position sense is happening subconsciously in all of the joints of the body and is what allows us to have balance and move in a coordinated fashion.

The multifidus muscles allow for fine control of the spine which keeps the joints and bones moving properly. About two-thirds of the total stiffness that all the back muscles can provide for support through muscle contraction comes from the multifidus muscles. For many years the spine by itself was thought to be incredibly stable and strong but recent studies have demonstrated that the spine, although very mobile, is actually very weak. It can only support about 20 pounds before it collapses. Muscular support is of utmost importance. One can now see how a multifidus muscle not functioning properly can have great potential to cause back problems. 

Studies have shown that the multifidus muscle will atrophy, or waste away, 25% within the first 24 hours of back pain. To make matters worse the multifidus does not recover on its own in most people. This has been difficult to explain until recently. Researchers discovered that the multifidus muscles have only 1 level of nerves (think of nerves like an electrical cord) coming from the spine. Most muscles in the body have multiple layers of nerve supply so if one is damaged another can compensate. This makes the multifidus more susceptible to injury because it has no backup. 

The transverse abdominus also undergoes a similar "shock." Its purpose is to brace the trunk during movement.  Everyone has heard the old adage "Strengthen your stomach to help your back." Although the advice had good intentions it is not entirely accurate. Most people are not exercising the correct stomach muscle.  The universal stomach strengthening exercise that most people think of is the "sit up" or "crunch." This works the rectus abdominus muscle, which may look good at the beach, but does not help support your back. As a matter of fact many people with back pain have tried this exercise only to find their back pain worsens. This is most likely due to having weak multifidus muscles which are not properly stabilizing the spine during the sit up exercise. This means the discs and joints of the spine are not supported properly and are undergoing excessive strain and stress.

Clinical Spinal Instability

Now that we've discussed these particular muscles what does it all mean? The bottom line is this, research has shown with almost any back injury, regardless of how it happened, these muscles atrophy and do not work properly. This has been proven with herniated or bulging discs, during pregnancy, after back surgery, car accidents and any other way you can think of to hurt your back. This deterioration caused by loss of nerve control (neurological problem) combined with inability to keep the spine stable (mechanical problem) leads to what we term Clinical Spinal Instability. In summary nearly all back pain leads to three interrelated problems:

1. Increased motion will develop at the spinal joints leading to increased wear and tear.

2. At the same time, protective stabilizing muscles of the trunk's middle layer will fail to work correctly as the nervous system cannot properly activate them.

3. Outer layer muscles are then substituted for the middle layer muscles in an attempt by the nervous system to provide some support at the injured area, this is commonly referred to as spasm.

The solution to your back pain

At this point you may be thinking exactly what hundreds of our patients have wondered before: "Great, I've learned a lot but what do I do now?" Let's start by telling you more about what doesn't work. Unfortunately we've discovered that the muscles we have been discussing, multifidus and transverse abdominus, do not get better on their own. As a matter of fact, once they've been injured they tend to get worse. We've also discovered that most traditional exercise routines, even those taught by physical therapists, doctors and chiropractors are not specific enough to isolate and properly rehabilitate these muscles. The good news is they can be strengthened but it requires very specific techniques and equipment (MedX) to do the job properly. Some people have suggested that retraining these muscles is easy and can be done on your own. Simply put, it doesn't work. The reality of the situation is these exercises are difficult to do correctly on your own and require the guidance and supervision of a properly trained physical therapist. It will be worth the time and effort spent as it is so much more effective then other treatment methods. The techniques and equipment to permanently rehabilitate your back is available exclusively at RehabAuthority Physical Therapy.