by Dr. Eric Winder
The Real Causes of Low Back Pain M
y patient, “John,” had daily low back pain for many years. Sitting in my office, he related a story of x-rays and MRIs, spinal arthritis and disc bulges, therapy with stretches and exercises and treatment with spinal manipulation and massage. He had even tried steroid injections and a nerve-killing procedure called RFA. Some things had helped for a while, some not at all. In the end, he was still in pain after years of seeking help. This is the story of how he finally got some lasting relief. To understand John’s lack of success, and why he finally got relief, we’ll need to take a deeper look at the causes of low back pain. First, however, it is important to clear up a common misunderstanding. At least two large studies have shown that there is not much correlation between severity of low back pain and how much spinal degeneration (arthritis, spurs, disc bulges or misalignments) a person has. In other words, your spine can be painful but look great on an MRI or feel
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pretty good while having advanced arthritis. It should be no surprise then that MRI imaging has not really improved outcomes for treating low back pain, except in some very specific cases. If arthritis and degeneration are not the main factors in low back pain, then where can we look? In my clinical experience, there are three main factors in chronic low back pain. Most cases have some combination of muscular imbalance, joint instability and stiffening of the connective tissue called fascia. Let’s take a look now at how these three factors can cause pain. Three Little Problems The first main factor, muscular balance, means the muscles that move or support a joint have the right amount of strength and tension to protect a joint in motion. Muscles can be imbalanced if they are either “too tight,” possibly to the point of spasm, or “too loose,” but a painful joint often has both tight and slack muscles. Such imbalances are almost always present with low back pain.
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The second factor in chronic low back pain is joint stability, meaning that a joint should move only in the directions that it is supposed to, not a little bit to one side or the other. If a joint has even a tiny bit of excess motion, this means that the tissues which hold it in place are repeatedly going to be overstressed, which can result in pain. Not surprisingly, one of the most common reasons for joint instability is muscular imbalance. The third common factor which I see in almost all cases of low back pain is stiffening of the fascia. This sheet-like connective tissue covers muscles, bones, joints and other tissues and serves as the structural fabric of our bodies. Fascia also holds the nerve endings that give us position sense, by sensing pressure and stretch in our tissues. Position sense, or proprioception, is what gives us the ability to have coordinated movement and upright posture. Stiffening of the fascia, which is typically caused by prior injury or trauma, can cause problems. This restricted fascia doesn’t stretch and flex the way it should, and that interferes with its ability to send correct signals to the nervous system for position sense. The Perception of Injury A glitch in position sense can cause several different problems. A disruption of position sense is one of the ways that our nervous system recognizes an injury, such as a broken bone or a torn ligament. Stiffened fascia can cause distorted perception, which makes our nervous system think that there is an injury, even though there isn’t one. Thus, a person with perfect looking spinal health on an MRI may still have intense low back pain from that ‘invisible’ misperception. Position sense from fascia is also what makes proper muscular balance and joint stability possible. When muscle imbalance and joint instability are involved in low back pain, it is typically due to restricted or stiff fascia. The nerve endings in fascia that give us our
