Treatment of low back pain

Type in the internet: treatment of low back pain and you get hundreds of thousands of hits. If you read a number of sites, you will see how many types of treatments exist. And there are other practical solutions for the best treatment. It is certain that the treatment of back pain does not exist. But how to choose from the multitude of offerings, what is most suitable for you?

Examination

It will be clear that the 'diagnosis' of back pain requires further investigation: how did it originate, what is the course, what factors influence the back pain. Every back pain has its own face and character. And that strongly determines the therapy. No good diagnosis and no effective therapy without good examination. So first find a good doctor specialized in back problems, such as the doctor musculoskeletal medicine.

Causes

Elsewhere on the site, medically known causes of back pain are discussed:

• herniated disc: an intervertebral disc is damaged and painful
• narrowing (stenosis) of the spinal canal so that nervous tissue is clamped
• tumor: can be a metastasis of cancer elsewhere in the body
• infection: for example in people with weakened resistance
• breakage (fracture): due to a fall or osteoporosis
• inflammatory process: as in Bechterew's disease (ankylosing spondylarthritis)
• scoliosis: too much curvature of the spine
• slip of a vertebra (spondylolisthesis).

The problem is that 5-10% of the lower back complaints can be explained with the causes mentioned above: the so-called specific back complaints because there is demonstrable evidence in the body of a specific structure or process that explains the symptoms. The other low back complaints are called non-specific. Here the specific causes are virtually excluded.

Treatment of specific back complaints

For an overview, I can also refer you to the signpost for back complaints, in which you will find a step-by-step plan to get to a suitable practitioner. We now continue with a brief discussion of a number of specific causes of back pain.

Herniated disc
Most people with back and/or leg complaints due to a hernia will receive no special treatment. They will improve spontaneously within 3 months after the occurrence. For this the following applies: wait and see. Sometimes painkillers can be helpful in this. In former times surgery was performed. The doctors have come back from this because research shows that after a year there is no difference in improvement or residual complaints between people who have had surgery and who have not had surgery. Even a nerve damage, as can be felt by a dull piece of skin or a muscle that loses strength, is no reason to operate on the same reason. Is there no surgery at all at a hernia? It are the people who threaten to get incontinence symptoms. And it are the people who indicate suffering from excruciating pains and where there are no other options.

Narrowing (spinal canal stenosis)

The surgeons are also reluctant to operate with complaints due to narrowing of the spinal canal. And that is because some of the operated people get relapsed after a while, which means that they have to undergo surgery again. Some of the people with narrowing can be well helped with exercises and non-surgical treatments. It takes a few months of therapy to find out, but if it works, then you have something.

Tumor, infection, fracture, inflammatory process, scoliosis

In these specific causes, I can not 'treat' treatment in this specification. That is because it is very different per subject and per person. The people concerned will be referred to a specialist for further research and targeted treatment. Also a doctor of musculoskeletal medicine can not apply effective treatment here.

Slipping of a vertebra (spondylolisthesis)

Most people with a shear need no treatment, because they have no complaints. The people who do have to think about treatment are the younger people in particular, with the shear increasing in the course of time. Sometimes an exercise program is suitable, sometimes operation.

Treatment of non-specific back complaints

For the treatment of non-specific low back complaints various guidelines and protocols have been developed, both in the Netherlands and internationally. In general they have the following recommendations:

• become or stay active
• use temporary painkillers if necessary
• try to pick up or maintain the normal daily routine
• if necessary, refer to a suitable doctor for a deviating course (see the signpost again).

But ... what treatment is it going to be?

I assume my position again: without proper research, no proper diagnosis and no effective therapy. So look for a doctor with knowledge of the musculoskeletal system, for example a doctor with training in musculoskeletal medicine. Extra requirement when it comes to the choice of treatment: it must also be a doctor who is aware of the possibilities of the ins and outs of the different therapies. Some examples from practice.

A boy of 10 years
He came into practice with his mother. For a while he had pain in his low back. He did little to move, but computer games. No, then he had no problems (but he did according to his mother). If he had to sit at school for a while and in the evening the complaints were coming. I saw in the waiting room that he was slumped, as well as in the consulting room. On the examination bench he could only just sit up with difficulty. Further research produced a healthy boy. The preliminary conclusion was: non-specific low back complaints where posture played an important role. I explained how the complaints had probably arisen and what was needed to get improvement. He accepted this, and was offered a program with exercises and assignments aimed at changing his attitude. At the second check a month later, he had his complaints under control.

A student of 20 years
After a hockey game she got pain in the right low back with some radiation in the right buttock and thigh. The days after there was improvement, but the following games repeated this pattern. Meanwhile, about half a year later, her complaints even got worse. Characteristic was that she got more complaints when bending and bowing, and there was improvement when walking. The preliminary conclusion was: chronic aspecific low back pain in which damage from one or more intervertebral discs in the lower back based on the hockey load (bending, lifting and turning at the same time) and the many sitting to study. She was treated with MDT (mechanical diagnosis and therapy) exercises, posture exercises for sitting, and a temporary stop of hockey. After 3 treatments and the homework exercises she was without complaints.

A skater of 30 years
This man had made a big fall in skating during the last winter. He could continue after that, but once he left the skating palace he could no longer get up: stiff and a painful area on the right side of the low back and pelvis area. There was radiance to his right groin. Physiotherapy, exercises and massage did help, but within a few days the symptoms returned. A particular twisting in his pelvic belt was noticed during examination. His back had adjusted accordingly. This complex is known in musculoskeletal medicine under the name: twisting pelvis. This was also the preliminary conclusion. He was treated 3 times and was then free of complaints.

A family father of 35 years
When he lifted a child it was like a shot in the back a few days ago. He had trouble getting up, coughing gave extra trouble, in the morning when he got up he had extra trouble, and his back felt stiff and painful. Nevertheless, some improvement was already noticeable. In examination I noticed some sensitivity and stiffness low in the back, but otherwise everything seemed good. The probability diagnosis was: acute non-specific low back pain. He received advice in the sense of: regular exercise, not staying in the same position for long, using painkillers and ... waiting for further spontaneous improvement. He could come back with about 2-3 weeks for persistent symptoms, but that was no longer necessary.

A woman of 40 years
During one of her car rides for work, she was regional manager of a business chain, she suffered from her low back left. Later, pain in her left leg, as if there was a kind of toothache in it. She could not find an attitude that brought relief, even at night she had a lot of trouble. On examination, there appeared to be loss of strength of her left foot. No trial treatment helped. She was referred to the neurologist with a probability diagnosis: herniated disc. It was decided to operate because of the severe pain. She had no complaints right after the operation.

A man of 50 years
This man had been in practice a few months earlier with a similar pattern of symptoms as the woman of 40 years, mentioned above. Then the diagnosis of 'hernia' was also made. This man was well helped with exercises and musculoskeletal medicine and did not need to be referred for any surgery. Yet the complaints returned after a few months. There was a difference: the complaints were not always present, he was not standing crooked, and the complaints could be called up when bending backwards instead of bending over. The probability diagnosis was: non-specific low back complaints based on scarring in the lower back. He was treated with exercises and musculoskeletal medicine. The recovery went well, and so far he did not return to practice.

A farmer of 60 years
In fact, he had been suffering from his low back for a long time. From an early age, he had done physically heavy work on the farm. Based on his story and findings in physical examination (problems with walking, no trouble sitting), I suggested the probability diagnosis: stenosis. I explained to him the possibilities: continue to the hospital, or try to achieve control over the complaints in 2-3 months with a combination of exercises, instructions and treatments. He chose the latter. After 3 months, his complaints were acceptable to him, although he could not walk long distances. Instead he cycled.

References
Schaafstra A et al. NHG-Standaard Lumbosacraal radiculair syndroom (Tweede herziening). Huisarts Wet 2015;58(6):308-20.
Weinstein JN et al. Surgical versus Nonsurgical Therapy for Lumbar Spinal Stenosis. N Engl J Med 2008;358:794-810.
NHG-Standaard Aspecifieke lagerugpijn (Tweede herziening). Huisarts Wet 2017.
Keller A et al. Effect sizes of non-surgical treatments of non-specific low-back pain. Eur Spine J (2007) 16:1776–1788.