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By Kyle J. Norton
Health article writer and researcher; Over 10.000 articles and research
papers have been written and published on line, including world wide
health, ezine articles, article base, healthblogs, selfgrowth, best
before it's news, the karate GB daily, etc.,.
Named TOP 50 MEDICAL ESSAYS FOR ARTISTS & AUTHORS TO READ by
Disilgold.com Named 50 of the best health Tweeters Canada - Huffington
Post
Nominated for shorty award over last 4 years
Some articles have been used as references in medical research, such as
international journal Pharma and Bio science, ISSN 0975-6299.
Chronic Lower Back Pain
Low back pain is a Musculoskeletal disorders
(MSDs) of degenerative disc disease, with pain persisted for longer
than 3 months, affecting over 80% of the population in US alone some
points in their life. Chronic LBP prevalence in older adults was
significantly higher than the 21-to-44-year age group and inflicted
more disabled, longer symptom duration, etc.(2). The unique impact of
CLBP is unknown(3).
I. Signs and symptoms
1. Movement-evoked discomfort(4)
2. Hypersensitivity to cold stimuli(4)
3. Morning stiffness, as a result of inflammation due to aging causes of degenerated discs(5)
4. Sleep interruptions due to pain
5. Higher compressive axial and tensile radial strains(6)
6. Depression, anxiety disorders and adjustment disorders
In the study of 127 patients suffering from chronic back pain in multimodal inpatient pain therapy who were assessed by a psychologist, showed that there was a high prevalence of depression, anxiety disorders and adjustment disorders in patients with chronic back pain(7).
7. Pain interfered with daily living, depressive, and quality of life(8).
8. Diabetic peripheral neuropathic pain, fibromyalgia, and chronic musculoskeletal pain
due to chronic osteoarthritis (OA) pain and chronic low back pain (LBP)(9).
9. Metabolic syndrome
The prevalence of metabolic syndrome among chronic lower back pain patients was 36.2% (30.2% male, 38.6% female), according to Seoul Medical Center(9a)
10. Etc.
II. Causes of chronic back pain
1. Trochanteric bursitis
Trochanteric
bursitisis a clinical condition simulated major hip diseases and low
back pain, it may also be mimic nerve root pressure syndrome(10).
2. Spinal stenosis
Aging population with spinal stenosis are at the higher risk of developing low back pain(11).
3. Chronic compression of the dorsal root ganglion (CCD) is associated with Chronic Low back pain(12).
4. Cauda equina syndrome (CES)
Although each type of CES has different typical signs and symptoms, low back pain may be the most significant one, accompanied by sciatica, lower extremities weakness, saddle or perianal hypoesthesia, sexual impotence, and sphincter dysfunction(13).
5. “Wear and tear” and “disc space loss” are associated with the development of Chronic Low back pain as a result of a progressive loss of structural integrity(14).
6. Osteoarthritis (OA), low back pain (LBP), and fibromyalgia (FM)
Although Osteoarthritis (OA), low back pain (LBP), and fibromyalgia (FM) are only poorly correlated with clinical pain, they all demonstrate abnormalities of muscles, ligaments, or joints(15).
7. Spondylitis
Spondylitis is associated with low back pain(16).
8. Extracellular matrix protein SPARC (Secreted Protein, Acidic, Rich in Cysteine)
SPARC-null
mice display behavioral signs consistent with chronic low back and
radicular pain that attribute to intervertebral disc degeneration(16b).
According to McGill University, human subjects with back pain exhibit
signs of disc degeneration and increased methylation of the SPARC
promoter, in transient transfection assays(16a).
8. Etc.
III. Risk factors
1. Aging
Elder is at higher risk of chronic back pain due to discs degeneration(17a).
2.
Repetitive bending and lifting can usually lead to severe back pain
and sciatica over a period of 30 years as a result of ‘Annulus-driven’
disc degeneration involved a radial fissure and/or a disc prolapse(17).
3. An increased risk for incident chronic LBP if exposed twice to awkward postures(18).
4. Sex, race and Lumbar symptoms
a. Back and spine impairments were more common in women than in men, and
b. Chronic LBP is more common among white people than black people (38·7).
c. Lumbar symptoms were 2·86 times more likely than thoracic symptoms to become chronic(19).
5. Smoking
The
prevalence of chronic LBP was 23.3% in daily smokers and only 15.7% in
non-smokers. Back pain treatment programs may benefit from integrating
smoking habit modification(20).
6. Psychiatric disorders are associated to the increased risk of transition to chronicity in men with first onset low back pain(21).
7. Alcohol dependency
Alcohol
consumption appears to be associated with complex and chronic LBP only
and in people with alcohol consumption dependence(22).
8. Others
Occupational
factors, including presence of multiple functional symptoms,
disease-related factors, onorganic disease, pain in the legs,
significant disability at onset, a protracted initial episode, multiple
recurrences, a history of low back pain, spinal condition, etc. are
all associated with higher risk to develop chronic back pain(23).
9. Etc.
IV. Diagnosis
1. Health and family history and physical exam
If
you are experience low back pain, a decrease in sensation, and
weakness of the extremities, the diagnosis may include a complete family
history including the prior and current illnesses and injuries and a
physical exam include pressure on (palpate) the spine, which may cause
tenderness over the affected area. The pain may radiate along the course
of a rib to the anterior chest or abdomen. Gait and posture can be
affected by disc herniation that causes spinal cord compression and are
usually evaluated during the physical exam(24).
2. Other tests may include
a. X ray
b. CT scan
c. MRI
d. Radiography of the spine
e. Etc.
Clinicians
should refrain from routine, immediate lumbar imaging as it does not
improve clinical outcomes, in primary care patients with nonspecific,
acute or subacute LBP and no indications of underlying serious
conditions, experts suggested (25)(26)(27).
V. Complications
1. Mental health
Adults
aged 65 years and above with chronic impairing LBP had higher mental
health scores, according to the study of a crosssectional, telephone
survey of 5,357 households(28).
2. Sleep disturbance, and interleukin-6
Inflammatory
processes may play a significant role in the cycles of pain and sleep
disturbance. In adults with CLBP, poorer sleep quality was associated
with higher pro inflammatory cytokine(IL-6) levels(29). The sleep of the
patients with CLBP was significantly altered compared with that of the
healthy population(30).
3. Maladaptive movement and motor control impairments
Chronic
low back pain (CLBP) disorders are more likely present with
mal-adaptive primary physical and secondary cognitive
compensations(31).
4. Somatic dysfunction (by the presence of any of 4 TART criteria: tissue texture abnormality, asymmetry, restriction of motion, or tenderness)
Somatic dysfunction in lumbar and sacrum/pelvis regions, is common in patients with chronic LBP, according to study(32).
5. Etc.
VI. Prevention
1. Weight loss
Weight loss is associated chronic low back pain and cardiovascular risk
factors, according to the study by Natural Wellness and Pain Relief
Centers of Michigan(33).
2. Tai Chi
Ancient
health art of Tai Chi may contribute to chronic pain management in 3
major areas: adaptive exercise, mind-body interaction, and meditation.
Tai Chi seems to be an effective intervention in osteoarthritis, low
back pain, and fibromyalgia(34).
3. Moderate alcohol consumption and quit smoking
Alcohol dependency and smoking are the risk factors of chronic low back pain.
4. Moderate exercise
Moderate
exercise are associated to reduced risk of chronic low back pain as it
increases oxygenation and blood circulation in the body(35).
5. Avoid recurrent Low back injure
Recurrent
Low back injure and injure which has been not treated well may come
back to haunt you when you get older, according to traditional Chinese
medicine.
6. Yoga
According to a
randomized control single blind active study in an residential Holistic
Health Centre in Bangalore, India, assigned 80 patients (37 female, 43
male) with CLBP, seven days intensive residential Yoga program showed
to reduce pain, anxiety, and depression, and improved spinal
mobility(36).
7. Healthy diet including calcium and vitamin D can prevent osteoporosis causes of chronic low back pain.
8. Etc.
VII. Treatments
A. In conventional medicine perspective
A.1. Non surgical treatment
1. Exercise therapy
Exercise
therapy is the most widely used type of conservative treatment for low
back pain as it improved post-treatment pain intensity and disability,
and long-term function(38). The therapy is effective for chronic but not
for acute low back pain, some study suggested(37). Impairment-based
manual therapy and exercise directed at the hip joints, showed
effectively in improvements in pain, function, and disability in
patients with CLBP(39).
2. Cognitive behavioral therapy
Cognitive
behavioral therapy (CBT) is a beneficial treatment for chronic
nonspecific back pain, as its improvements in a wide range of relevant
cognitive, behavioral and physical variables, according to the study by
Uni Health, Uni Research, Bergen, Norway(40).
3. Medication
The
range of regularly prescribed pharmacological agents to treat Chronic
Low back pain extends from nonopioids (paracetamol, NSAIDs, and COX-2
inhibitors) to opioids, antidepressants and anticonvulsants(42).
3.1. Non-steroidal anti-inflammatory drugs (NSAIDs)
Transdermal
fentanyl significantly improved visual analog scale scores and
Oswestry Disability Index scores in 73% of patients, especially those
with specific low back pain awaiting surgery(43).
Side effects include nausea, vomiting, diarrhea, constipation, decreased appetite, rash, dizziness, headache, drowsiness, etc.
3.2. Opioids
Tapentadol’s
μ-opioid agonism shows a greater contribution to analgesia in acute
pain with fewer adverse events. Noradrenaline reuptake inhibition shows a
greater contribution in chronic neuropathic pain models, according to
the study by Johns Hopkins University School of Medicine(44)
Side effects include Nausea, dizziness, constipation, CNS sedation, etc.
3.3. Antidepressants
Selective
serotonin reuptake inhibitors (SSRIs) or serotonin-norepinephrine
reuptake inhibitors (SNRIs) are a class of medication used as
antidepressants in the treatment of depression, anxiety disorders, and
some other disorders. According to study, visual analog scale scores
were similar in patients taking versus those not taking SSRIs/SNRIs
throughout the study(45).
Side effects include nausea/vomiting, drowsiness, headache, bruxism, tinnitus, extremely vivid or strange dreams, dizziness, fatigue, etc.
3.4. Anticonvulsants
Anticonvulsants benzodiazepines,
the medication used in the treatment of epileptic seizures has been
used as adjunctive medications for acute low back pain, with high
incidence of sedation(46).
Side effects are not limited to
dependency, rebound anxiety, memory impairment, discontinuation
syndrome, muscle weakness, dizziness, mental confusion, depression, etc.
3.5. Antispasmodic drug
Eperisone had
an analgesic and muscle relaxant effect in patients with LBP. The
drug may represents a valuable alternative to traditional analgesics
and muscle relaxants for the treatment of LBP, according to the study
by Service of Rehabilitation and Functional Reeducation, S.
Orsola-Malpighi Hospital, Bologna(47).
Side effects are not
limited to redness, itching, urticaria, edema, rash, pruritus,
sleepiness, insomnia, headache, nausea and vomiting, anorexia,
abdominal pain, etc.
4. Injection
In the
comparison of the clinical effectiveness of FJ injections (FJI) and
denervation in patients with chronic low back pain, found that the FJ
injections (FJI) is usually the first choice should be for treatment of
Chronic LBP patients. If pain reoccurs after a period of time or
injection is not effective, FJ radiofrequency (FJRF) procedure should be
used for replaced treatment(47a).
5. Others
According to Avalon Health Solutions, beside conventional medicine, use of alternative treatments included: chiropractor, OA 11%, CLBP 34%; physical therapy, 20% in both groups; transcutaneous electrical nerve stimulations (TENS), OA 14%, CLBP 22%; acupuncture, hydrotherapy, massage therapy, and biofeedback, <3%(48).
Multidisciplinary
rehabilitation program and oral drug treatment and oral drug
treatment alone, improve most domains of quality of life in chronic low
back pain patients in the 6-month period(49).
Biopsychosocial
rehabilitation and intensive individual therapist-assisted back muscle
strengthening exercises, showed a long-term improvements in pain and
disability scores(50).
A.2. Surgical treatments
Most
patients with back pain will not be beneficiary from surgery as it is
only performed when conservative treatment is not effective in reducing
pain or if anatomic abnormalities consistent with the distribution of
pain are identified. The most common types of low back surgery include
1. Microdiscectomy
Many
patients may be symptomatic following LMD, significant disability and
dissatisfaction are uncommon. Female sex, young age, lack of exercise,
and chronic preoperative LBP may predict a worse outcome. Disc collapse
is a universal finding, particularly at L4-L5. Neither DSC nor Modic
changes seem to affect patient outcome, according to the retrospective
cohort study of patients who underwent LMD in 2004-2005(51).
2. Discectomy(SD)
Recurrent
or persistent low back pain (LBP) after surgical discectomy (SD) for
intervertebral disc herniation has been well documented(52).
3. Laminectomy is a
most minimally invasive surgical procedure removed a portion of the
vertebral bone called the lamina, through a small skin incisions(53).
4. Spinal fusion is
a surgical procedure to join two or more vertebrae, either from the
patient (autograft) or a donor (allograft), for stimulation of natural
bone growth.
According to study, no subset of patients with
chronic LBP could be identified for whom spinal fusion with a
predictable and effective treatment(54). The surgical procedure showed a
strong evidence in support the treatment of back pain
caused by fractures, infections, progressive deformity, or instability
with spondylolisthesis(57). Spinal fusion may be effective than standard rehabilitation for
improving pain in people with chronic non-radicular low back pain, but
it is no better than intensive rehabilitation with a cognitive
behavioural component(56) but associated with a 16% pooled rate of early complication(55)
5. Etc.
B. In herbal medicine perspective
Moderate evidences suggested the use of Salix alba (White willow bark) for short-term improvements in pain acomparable to medication for daily doses standardized to 120 mg or 240 mg salicin with an additional trial demonstrating relative equivalence to 12.5 mg per day of rofecoxib(58).
C. In traditional Chinese medicine perspective
1. Acupuncture
Acupuncture
needling showed effectively in treatment for patients of chronic low
back pain, according to the study of a total of 640 participants (160
in each of four arms) between
the ages of 18 and 70 years of age who have low back pain lasting at
least 3 months recruited from integrated health care delivery systems in
Seattle and Oakland(59). Patients with chronic low back pain with
severe baseline dysfunction had mau be also beneficary in most
short-term benefit from acupuncture, according to the study of
Characteristics of patients with chronic back pain who benefit from
acupuncture(60).
2. Herbs
2.1. Traditional Chinese medicine interprets chronic lower back pain as of results of
(1) “Qi and/or Blood StagnationÈ with symptoms of piercing
pain; activity limited by feeling of local heaviness, lumbar and flank
stiffness with bending limitation and purple tongue, etc.;
(2) “Cold/Damp,” with symptoms of Cold/Damp pain, pallid face and greasy coating, etc.
(3) Kidney Deficiency,” with symptoms of dull pain and recurrent vague pain.
(4) “Warmth/Heat,” with symptoms of purple tongue, yellow tongue coating, and burning pain(61).
2.2. Herbal formulas (Please consult with your traditional Chinese medicine practitioner before applying)
a. Shen Tong Zhu Yu Wan (Shen Tong Zhu Yu Pian),
a Chinese herbal formula, used to treat shoulder pain, pain in the arm,
lumbago, pain in the leg or pain in the
entire body due to obstruction of the flow of Qi and blood in
channels. promotes blood circulation and Qi, removes blood stasis and
obstruction in the channels, alleviates blood-arthralgia and pain.
b. Ingredients
Radix
Gentianae Macrophyllae (Qin Jiao), Rhizoma Chuanxiong (Chuan Xiong),
Semen Persicae (Tao Ren), Flos Carthami (Hong Hua), Radix Glycyrrhizae
(Gan Cao), Rhizoma Et Radix Notopterygii (Qiang Huo), Resina
Commiphorae (Mei Yao), Radix Angelica Sinensis (Dang Gui), Rhizoma
Cyperi (Xiang Fu), Radix Achyranthis Bidentatae (Niu Xi), Phertima (Di
Long), Rhizoma Wenyujin Concisa (Jiang Huang), Rhizoma Corydalis (Yan Hu
Suo)(61a).
2. Liu Wei Di Huang Wan (Kidney Yin deficiency)
a. Liu Wei Di Huang Wan
can replenish Yin due to the Yin insufficiency of the kidney, the
innate foundation of all organs with respect to the Yin-Yang
principles, Qi essence etc.
b. Ingredients
Radix
Rehmanniae Preparata (Shu Di Huang), Fructus Corni Officinalis (Shan
Zhu Yu), Cortex Moutan Radicis (Mu Dan Pi), Rhizoma Dioscoreae
Oppositae (Shan Yao), Sclerotium Poriae Cocos (Fu Ling), Rhizoma
Alismatis Orientalis (Ze Xie)(61b).
3. Jin Kui Shen Qi Wan (Kidney Yang deficiency)
a. Jin Kui Shen Qi Wan can
replenish Yang due to the Yang insufficiency of the kidney, the innate
foundation of all organs with respect to the Yin-Yang principles, Qi
essence etc.
b. Ingredients
Radix Rehmanniae
Preparata (Shu Di Huang), Fructus Corni officinalis (Shan Zhu Yu),
Rhizoma Dioscoreae Oppositae ((Shan Yao), Cortex Moutan Radicis (Mu Dan
Pi), Sclerotium Poriae Cocos (Fu Ling), Rhizoma Alismatis Orientalis
(Ze Xie), Cortex Cinnamomi Cassiae (Rou Gui), Radix Aconiti Lateralis
Preparata (Zhi Fu Zi), Radix Achyranthis Bidentatae (Niu Xi), Radix
Polygoni Multiflori (He Shou Wu), Fructus Lycii Chinensis (Gou Qi Zi),
Fructus Schisandrae Chinensis (Wu Wei Zi(61c).
D. TCM and conventional medicine baclofen
Acupuncture and acupuncture + baclofen which is used as a muscle relaxer ufor treatment tof muscle symptoms , showed a significantly higher reduction and improvement in a Visual Analogue Scale (VAS) and Roland Disability Questionnaire (medical questionnaire, RDQ) score in patient with chronic lower back pain, according to a randomised controlled clinical trial(62)
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