Different types of conservative care treatments and injections for chronic low back pain
Ross Hauser, MD
People with low back pain may spend years or decades of their life in pursuit of something, or anything, that will help them with their low back pain. These people, perhaps like yourself, may find short-term relief with rest, pain medications, trigger point shots, manipulation, and massage, but these treatments are usually temporary in their benefits. One reason that long-term relief and improvement in function are not attained is that these remedies and treatments may be addressing the wrong problem. Maybe for some, or many people, this is not a problem of muscle or muscle spasm. If your low back pain was being caused by muscle problems and spasms then why not sit in a hot tub for two hours or get a long massage? Certainly if your problem with your back pain was a muscle problem these treatments, in addition to muscle relaxants, would cure your pain. But we know this does not occur. Those therapies only help temporarily. (See our article Why physical therapy and yoga did not help your low back pain for more on this subject). The underlying cause of low back pain in many people is not the muscles themselves but rather the familiar and painful muscle spasms brought on by lumbar ligament laxity. Since the majority of spinal ligament injury cannot be seen on conventional x-ray or MRI, doctors and patients look for other problems, degenerative disc disease, stenosis, SI joint pain, among others. Yet in many cases the common underlying cause of low back pain, and degenerative arthritis in the spine, facet joint osteoarthritis towards the development of stenosis, lumbar spondylosis, loss of spinal curve or development of excessive spinal curve, is in large part, due to facet joint capsular ligament injury and is the cause of almost every chronic spinal pain.
These observations are not based solely on opinion. In almost three decades of helping people with low back pain, we have heard and seen many people who are trying to manage their back pain with conservative care options. They tell us about their use of:
- My back is always giving out, I wear back braces because I have a feeling of instability. Older patients will often use the term “I threw my back out.”
Self-manipulation or frequent back cracking:
- I frequently crack my back, I feel that I am able to put myself back into alignment that way.
Physical Therapy, Chiropractors, Acupuncture
- I have lower back pain that my doctor says is being caused by a herniated disc. I went for a second and third opinion and the doctors are telling me I need a spinal fusion, L5-S1. I have had pain for about two years now, the pain medications and anti-inflammatories are not helping. I get some relief from physical therapy, chiropractic, and acupuncture but I have to keep going back a few times a week. I do not want the surgery unless it is the last report.
What are we seeing in this image? Back pain is a progressive disease, this may account for why you need more and more medications. As your back pain progresses, so does you need for medication.
The caption reads: The progression of degeneration of the lower back. An initial injury to the spinal ligaments causes the start of spinal instability. The process progresses to involve more spinal segments. The completely degenerated lumbar spine is the final consequence of not resolving spinal instability.
The problem of using acute back pain treatments in treating chronic low back pain cases
The use of Nonsteroidal anti-inflammatory drugs and antidepressants
There is some consensus in the medical community on how to treat acute low back pain, but treatment of chronic low back pain presents many challenges and little agreement on standard of care. Nonsteroidal anti-inflammatory drugs and antidepressants provide some short-term benefit, but no published data warrant their long-term use. This was pointed out recently in the journal Systematic reviews (1) February 2021. Here researchers described small benefits in anti-depressant use for people with back pain.
In this study, the researchers suggested:
- On average, patients with low back pain treated with antidepressant medicines will experience a small improvement in pain and function and no improvement in symptoms of depression, compared to placebo. The benefits of anti-depressants were not seen as clinically significant.
- Patients are at increased odds of experiencing an adverse or serious adverse effect to the anti-depressants and at increased odds of stopping (anti-depressant) treatment due to an adverse effect or another reason, compared to placebo.
- Taken together, these data indicate treatment of low back pain symptoms with antidepressants has no important benefit; is less acceptable, less safe and less tolerable; and may be harmful, compared to treatment with a placebo medicine.
Numerous recently published clinical care guidelines call for nonpharmacological approaches to pain management. However, little data (research) exists regarding the extent to which these guidelines have been adopted by patients and medical doctors. In other words, are the doctors and patients compliant in trying to avoid pharmacological pain management?
Patients went to see their doctor for low back pain – what types of treatments did they get?
Recommended medical treatments: acetaminophen, NSAIDs, opioids, benzodiazepines, Gabapentin, Neurontin, and cortisone injections.
In a March 2021 paper lead by the Department of Orthopaedic Surgery, Duke University School of Medicine and published in The journal of alternative and complementary medicine (2) the researchers found that patients indeed were being prescribed many treatments for their low back pain. In this study patients went to see their doctor for low back pain. Following their visit the study researchers contacted these patients to ask about the types of treatment recommendations they were getting. “Participants were asked about medical doctor recommendations for both drug (acetaminophen, nonsteroidal anti-inflammatory drugs [NSAIDs], opioids, benzodiazepines, Gabapentin, Neurontin, and cortisone injections) and nondrug (self-care treatments, massage, acupuncture, spinal manipulation, and physical therapy) treatments.
This is what they got:
- Ninety-six percent (96%) of patients who visited a medical doctor for low back pain received a recommendation for one or more pain treatments, with 81% reporting that their medical doctor recommended both drug and nondrug therapies.
- Seventy-six percent (76%) of respondents were recommended acetaminophen or NSAIDs,
- Seventy-nine percent (79%) were recommended self-care treatments,
- Thirty-seven percent (37%) were recommended massage, acupuncture, or spinal manipulation, and
- Sixty percent (60%) were recommended physical therapy.
Nearly two-thirds of the patients reported that their doctor had recommended prescription medications, including opioids, benzodiazepines, Gabapentin, Neurontin, or cortisone injections. Reported adherence to treatment recommendations ranged from 68% for acupuncture to 94% for NSAIDs. In other words the patients were listening to their doctors and following through on treatment recommendations.
Further: A lot of people are still being prescribed opioids which the researchers found “surprising”
Research has shown that the majority of opioid users report back pain. The researchers of this study noted: The known risks of death and overdose resulting from opioids coupled with increasing pressure to avoid opioid prescribing, make the high number of our respondents (29%) who reported that their MD recommended the use of opioids in the past 12 months surprising.
More treatments considered surprising or questionable
The study also notes more than a third of respondents (38%) reported a recommendation of cortisone injections, a treatment that may offer short-term benefit, but it is also associated with a significant risk of contamination and infection. Cortisone injections are generally not recommended in clinical care guidelines due to weak evidence for pain and function benefits.
- The researchers also reported that patient reported use of over-the-counter medications was high in spite of questionable benefits and known risks.
- Nearly 80% of respondents reported that they received a recommendation from their MD to take either acetaminophen or NSAIDs. NSAIDs may result in a small-to-moderate effect on pain and function, however, the risks of gastrointestinal bleeding associated with NSAIDs are well established
Patients selected their own treatments with MD guidelines:
- Patients reported self-management treatments such as heat, yoga or other exercises, as well as therapies provided by complementary and integrative health practitioners such as spinal manipulation and massage, was relatively high in respondents who did not receive a recommendation by an MD to do so.
- Conclusions: “In the majority of patient cases, a combination of prescription medications and self-care were recommended, according to the researchers this illustrates the need for additional research on the effectiveness of multi-modal treatment strategies. (In other words what will work what does not work).”
When someone emails or contacts our center with questions about treatments for their back pain they usually have a long story.
One may go like this:
- I have been suffering from low back pain for a few years. It came on after my retirement. I am in my early 80’s now. At first, I had chiropractic treatment, then I was moved onto physical therapy. I had this on and off for two years. I was finally sent to a surgeon who said I had lumbar facet stenosis. I was first treated with epidural injections and then Radiofrequency neurotomy at L4-L5. This did provide me with some relief. But now the back pain is returning and I have a pinched nerve which is making it difficult to walk or stand for any length of time.
Spinal Stenosis and Spondylolisthesis.
I am taking a lot of medications. Taking Zanaflex (Tizanidine) for my very painful spasms. Hydrocodone which I do not think is helping me and Gralise for “nerve pain.” I had epidurals, they did not help long-term. am declining all surgery. So the only recommendation now is for a spinal stimulator.
Some people do very well with lumbar fusion surgeries. Their surgeries are complete successes. These, however, are not the people we see in our offices. We see the people whose lumbar spine continues to degenerate and has now become more painful and unstable and it appears only another segmental fusion will do.
If you have spinal instability after spinal surgery please refer to these articles on our website:
- The evidence for an alternative to Spinal fusion surgery
- Failed back surgery syndrome treatment options – the new research
For some people, they tell us that they have reached the point where something has to be done beyond the chiropractic, beyond the physical therapy, beyond the painkillers, anti-inflammatories, sometimes cortisone or epidural injections, back braces, yoga, and anything else they can find and try. They well us they are tired of MRIs, having had many of them. They have given up sports, any degree of exercise, and continue in a spiral of poor health. Some of these people ask, “What else can there be for me except surgery? I have been dealing with this for years.”
Identifying spinal instability in nonspecific back pain
Spinal instability begins when the stabilizing structures of the spine, especially the ligaments can no longer hold adjacent bones together. When present, this is termed mechanical instability.
The term functional instability is used when mechanical instability causes symptoms with a certain function or activity.
- Many people are walking around with mechanical instability but are asymptomatic because the force required to perform current normal activities is not beyond the tissue strength.
- Problems arise when the mechanical instability worsens when patients overdo an activity or start a new exercise program.
- Thus the patient may have symptoms only when performing a certain activity, such as back pain with running.
- From the patient’s perspective, pain symptoms do not exist during any other activity.
- This is called functional spinal instability with running and mechanical instability of the entire low back.
- Functional instability, or symptomatic instability with movement, occurs with mechanical failure of the spinal ligaments and the subsequent excessive motion of adjacent bones. This can be caused by trauma, disease, surgery, or any combination thereof to one or more regions of the spine.
Chronic back pain is caused by difficulty in understanding what is causing it.
Researchers in Germany writing in the medical journal Clinical Rheumatology (3) discussed the problems of assessing the true cause of back pain. To summarize their findings, the researchers noted that:
- The most examined spinal problem is low back pain.
- Low back pain, for the most part, is caused by a nonspecific problem that is difficult to diagnose. (Note: This is not very reassuring to patients that the most chronic back pain problem is difficult to understand. This is also why the rush to lumbar surgery is so troubling.)
- Inflammation of the spine is not as widespread.
- Only a small amount of patients have axial (low back sacroiliac joint) inflammation as the major cause of their back complaints with chronic inflammatory back pain as the most prominent clinical feature of spondyloarthritis (inflammatory/rheumatoid arthritis). (Note: This is also troubling to patients as if inflammation is not the problem, as patients are being put on long-term anti-inflammatory treatment plans.)
- Numerous diseases such as:
- degenerative disc disease,
- degenerative changes in the intervertebral (facet) joints and the associated ligaments,
- spinal instability,
- herniation of the intervertebral disc,
- and spinal stenosis has to be differentiated in interpreting imaging of the spine.
- (Ross Hauser MD has written an article on this site on how the MRI is a risk factor for failed back surgery)
In our opinion, most health care providers rely too heavily on diagnostic tests, especially for low back problems. Consequently, many who suffer from low back pain do not find relief.
The typical scenario is as follows:
- A person complains to a physician about low back pain that radiates down the leg.
- The physician orders x-rays and an MRI.
- The scan reveals an abnormality in the disc—such as a herniated, bulging, or degenerated disc.
- Unfortunately for the patient, this finding usually has nothing to do with the pain.
When a patient comes into Caring Medical we look for the familiar characteristic features of a patient with spinal instability. This helps us determine the role of discs and ligaments in the patient’s complaint of spinal instability.
1. The patient reports their back cracks a lot
Typically, patients will report that they hear a crack every time they turn over in bed or stretch out their back. This can be a tell-tale sign of spinal instability. With regular movements such as these, it isn’t normal for vertebrae to shift enough to make a cracking sound, also known as crepitation.
2. Patient reports that they get frequent chiropractic adjustments
Needing frequent chiropractic treatments or therapy to relieve chronic pain is not typical. This means that the patient is suffering from constant dislocations of the vertebrae. It is likely that the reason the vertebrae continue to move out of position is ligament laxity, or the inability of ligaments to hold the spine in place. This is typical of any joint instability and degenerative joint disease caused by ligament laxity.
When capsular ligaments and other soft tissues along your spine stretch out, the vertebrae are able to shift out of alignment. Even if you have them put back in place through repeated care and adjustments, the ligaments still remain loose and can allow for repeated shifting.
3. Patient continuously self-manipulates
Self-manipulation of the spine is an abnormal finding, yet is a common thing that we see. Whenever a new patient comes to Caring Medical for neck or low back pain, it is highly likely that they will tell us they crack their back or neck habitually.
Self or chiropractic manipulation has the potential to further loosen the spinal ligaments and cause more instability.
4. Intermittent pain down the arm or leg
Spinal subluxations (slipped/herniated disc) can pinch on nerves as they exit the spinal cord. The pain of the pinched nerve is not constant but instead only occurs when the vertebrae shift and pinch on the nerve. This is usually a good prognostic indicator for ligament damage as the cause of spinal instability.
5. Tightness or spasm in the neck and back muscles, even at rest
What causes muscle spasms in the back? It isn’t normal to get knots, trigger points, or tender points in muscles. Neck, upper back, or lower back muscle spasms are a sign of spinal instability. The reason these painful spasms do not go away is that they are trying to stabilize the spine. The tightness and spasms are a clue that the ligaments have become weakened and injured. When there is ligament instability there is spinal instability the surrounding muscles contract as a way to help keep stability.
In this video, Ross Hauser, MD explains the use of Platelet Rich Plasma in treating this patient with problems of the sacroiliac arthropathy and sacroiliac instability caused by sacroiliac ligament damage.
The actual treatment begins at 3:15 of the video
What are the treatment options for patients with back pain?
A paper from doctors at the University of Georgia and McGill University in Montreal published in the American family physician (4) examined the top 20 research studies of 2015 that had the most impact on family practice doctors. Among the top 20:
- avoiding early imaging (MRIs et al)
- Do not add cyclobenzaprine or oxycodone to naproxen for patients with acute low back pain
- encourage patients with chronic or recurrent low back pain to walk.”
At Caring Medical we have to agree that concerns about treatment plans including back surgery based on MRIs, painkillers, and lack of movement in patients would back pain is something that needs to be looked into and corrected.
In a study from Vanderbilt University Medical Center published in the Journal of Neurosurgery, researchers followed:
- Fifty patients with lumbar spondylolisthesis,
- Fifty patients with stenosis, and
- Fifty patients with disc herniation who had symptoms persisting after 6 weeks of medical management and who were eligible for surgical treatment were followed after deciding on nonsurgical treatment.
The non-surgical treatment was:
- Spinal steroid injections,
- physical therapy,
- muscle relaxants,
- anti-inflammatory medication,
- and narcotic oral agents.
The maximum health gain in back pain, leg pain, disability, quality of life, depression, and general health state did not achieve statistical significance by 2 years of medical management, except for pain and disability in patients with disc herniation and back pain in patients with lumbar stenosis.
- Eighteen patients (36%) with spondylolisthesis,
- 11 (22%) with stenosis, and
- 17 (34%) with disc herniation eventually required surgical management due to a lack of improvement.
The Vanderbilt researchers concluded that: In all cases, comprehensive medical management included spinal steroid injections, physical therapy, muscle relaxants, anti-inflammatory medication, and narcotic oral agents was not cost-effective and the patients went on to surgery.3
Sometimes a patient will come in with a list of muscle relaxers they have been prescribed. The more common names and types they come in with are Diazepam (Valium) and Carisoprodol (Soma). These and other drugs given for muscle spasms/relaxation are part of a class of drugs known as Benzodiazepines – anxiety medication/tranquilizers.
In research led by doctors at the University of Sydney in Australia, the doctors found that muscle relaxants do provide temporary benefit for acute back pain. But for long-term chronic low back pain problems – there is no evidence for the efficacy of benzodiazepines.4
In their review of the pharmacological treatment of back pain, Oregon Health & Science University researchers also noted muscle relaxants are effective for short-term pain relief in acute low back pain but caused sedation.5 There is an old adage in medicine that is, fortunately, being erased, it goes something like this: “I can’t fix your problem so let me put you to sleep.”
Physical therapy for low back pain
Physical therapy is the major component of the conservative approach to low back pain. The Caring Medical experience is that the results are often disappointing.
Doctors at the University of Warwick in the United Kingdom came to a similar conclusion when they could not find clinical research evidence that physical therapy (therapist-delivered interventions) provided more than little to moderate benefits.6
Many acute back injuries get better by themselves. Many of these patients do take some PT, whether formally at a Physical therapy facility, or more haphazardly at a chiropractor’s office, but it’s difficult to tell whether the results are any better or faster than they would be without the PT. Cases in which there is muscle weakness should have a prescribed regular program of strengthening exercises.
Physical therapists may suggest the balance ball, yoga, and pilates which placing stress on healing low back ligaments. Prolotherapy doctors usually recommend exercises such as side plank, supine plank, and regular planks. In these, as in holding yoga poses, there is no movement that stresses the spinal ligaments.
Prolotherapy for back pain
There is plenty of research to support the use of Prolotherapy for back pain (especially lumbar pain), here are some of the research summaries.
- University of Manitoba, Winnipeg, Manitoba, Canada. The Journal of Alternative and Complementary Medicine
- One hundred and ninety (190) patients were treated between, June 1999-May 2006.
- Both pain and Quality of Life scores were significantly improved at least 1 year after the last treatment.
- This study suggests that prolotherapy using a variety of proliferants can be an effective treatment for low back pain from presumed ligamentous dysfunction for some patients when performed by a skilled practitioner.7
- Harold Wilkinson MD, in the journal The Pain Physician
- Prolotherapy can provide significant relief of axial pain (soft tissue damage) and tenderness combined with functional improvement, even in “failed back syndrome” patients.8
Citing our own Caring Medical published research in which we followed 145 patients who had suffered from back pain on average of nearly five years, we examined not only the physical aspect of Prolotherapy but the mental aspect of treatment as well.
- In our study, 55 patients were told by their medical doctor(s) that there were no other treatment options for their pain, and a subset of 26 patients were told by their doctor(s) that surgery was their only option.
- In these 145 low backs,
- pain levels decreased from 5.6 to 2.7 after Prolotherapy;
- 89% experienced more than 50% pain relief with Prolotherapy;
- more than 80% showed improvements in walking and exercise ability, anxiety, depression, and overall disability
- 75% percent were able to completely stop taking pain medications.9
If our study, mentioned above, was solely based on getting 75% of patients off their pain medications, that would be wildly successful in itself. But the fact that Prolotherapy was able to strengthen the patient’s spines and decrease overall disability and return these people to a normal lifestyle. That is not pain management, that is a pain cure.
An April 2021 review article (1) published in the British Medical Bulletin examined found: “Prolotherapy is an effective management modality for chronic low back pain in patients in whom conservative therapies failed.”
1 Giordano L, Murrell WD, Maffulli N. Prolotherapy for chronic low back pain: a review of literature. Br Med Bull. 2021 Apr 21:ldab004. doi: 10.1093/bmb/ldab004. Epub ahead of print. PMID: 33884404.
The first step in determining whether Prolotherapy will be an effective treatment for you
The first step is to determine the extent of ligament laxity or instability in the lower back by physical examination. The examination involves maneuvering the patient into various stretched positions. If weak ligaments exist, the stressor maneuver will cause pain. Pain here is an indicator that Prolotherapy can be very effective for the patient.
When identified as a problem of ligament weakness causing instability, low back pain is one of the easiest conditions to treat with Prolotherapy. Ninety-five percent of low back pain is located in a 6-by-4 inch area, the weakest link in the vertebral-pelvis complex.
At the end of the spine, four structures connect in a very small space which happens to be the 6-by-4 inch area. The fifth lumbar vertebra connects with the base of the sacrum This is held together by the lumbosacral ligaments. The sacrum is connected on its sides to the ilium and iliac crest. This is held together by the sacroiliac ligaments. The lumbar vertebrae are held to the iliac crest and ilium by the iliolumbar ligaments. This is typically the area treated with Prolotherapy for chronic low back pain.
The diagnosis of ligament laxity in the lower back can be made relatively easily.
Typical referral pain patterns are elicited when gently pressed, for instance:
- the sacroiliac ligaments refer pain down the back of the thigh and the outside of the foot
- the sacrotuberous and sacrospinous ligaments refer pain to the heel.
- the iliolumbar ligament refers pain into the groin or vagina.
- Iliolumbar ligament sprain should be considered for any unexplained vaginal, testicular, or groin pain. Please see our companion article which talks about the non-surgical treatment of lumbar radiculopathy.
The most common cause of unresolved chronic low back pain is an injury to the sacroiliac ligaments which typically occurs from bending over and twisting with the knees in a locked, extended position. This maneuver stretches the sacroiliac ligaments, placing them in a vulnerable position.
If you have questions about back pain, Get help and information from our Caring Medical staff
References for this article.
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