As an orthopedic and neurological physical therapist for 30 years, and as someone who had had a few minor episodes of back pain myself, I am familiar with this diagnosis. Low back pain and leg pain often termed “sciatica” due to the pain, weakness and paresthesias extending down into the hip, and as far as the toe. It can be terribly disconcerting. At least 80% of the population will experience some form of low back pain in their lifetime.
The initial response to having the low back pain generally entails something like, “Oh no not me, not this!” Then after it is clear that the pain and loss of function will not easily go away without help, the worry, confusion, and frustration really come into play. What should I do? Who do I see?
Like nearly everything in medicine, differential diagnosis is a process. Management is a process. Understanding the process is key to a faster recovery and to preserving your resources. So, let’s go with the statistics and then the best way to navigate through the process.
The etiology (the origin or cause) of low back pain breaks down into the following categories:
1. Mechanical or non-specific low back pain: This is estimated to be approximately 80% and up to 84% of the back pain population. This in layman's terms means the origin of the pain is due to spinal - pelvic or “core weakness” and usually tightness of muscles crossing the lower spine and hip. There is no specific injury, but pain sensitive structures in the region of the back are stimulated and the resultant pain can be quite severe and limiting.
The other ~ 16 - 20 % fall under a number of categories.
2. Stenosis: mild to moderate stenosis can be relieved with “core” or abdominal strengthening, stretching combined with some form of traction. In other words, it can be treated conservatively. Severe stenosis in which the peripheral nerves(intervertebral foramen) or the spinal cord (Central Stenosis) itself is being mechanically “pinched” or impinged does require surgery to relieve the pressure and to prevent damage. In mild or to moderate cases a home version of a traction unit for intervertebral foramen stenosis is effective in terms of health and cost.
3. A back muscle strain: Acutely painful but resolves steadily with rest and medication and lasts no longer than 8 to12 weeks. A healthy and strong back may be injured due to an obvious event and resolves fairly readily often with 2 – 4 weeks. Sometimes even sooner.
A strain and sprain though can be complicated because the strain or sprain may have occurred due to weakness of the thoraco-lumbar–pelvic muscles. That weakness or insufficiency along with the possible loss of flexibility of key muscles in those regions resulted in the strain or sprain. This “mix” of diagnoses means the management can initially be more challenging. People with this combination of problems often will readily sprain or strain their back with little physical activity. Because they so readily hurt their backs, they will
often say, “I have a bad back”. They avoid physical activity and self-limit twisting, bending, and lifting which over time aggravates the problem. This then further reinforces their perception that they have a “bad back”
4. A back ligament sprain: This type of injury can linger as the ligament, while very tough, is prone to re-injury until it is fully healed. If it is clear that the injury is a ligament (It is not always clear) a strong abdominal brace may be needed. The secondary problem then is the use of the brace weakens the “core” or abdominal pelvic musculature. Then another 4-6 weeks is needed to re-strengthen it to prevent recurrent injury and pain. Recovery from this injury is similar to the back sprain. Sprains and strain as a rule need to be treated in a comparable manner. The reason for this is pragmatic. Their presentation can be close to identical, so it is better to proceed as if both are injured, and if possible avoid the use of bracing.
5. A bulging or herniated disc: Can be difficult to manage and to do this properly is a 2-3 year process for exceptional outcome. The time with a provider will often require 3 weeks to 3 months then the rest of the treatment is self-directed. The motivation is an increasingly strong, functional and over the long term, a healthy back. This may include a home version of a traction unit but not always. Sometimes it is just positioning, posturing and activity modification. This is truly a case by case basis of just how the treatment plan will be put together and implemented.
6. Other: I am not going to include fractures, referred pain from other regions of the body or all the possible disease referral patterns of which there are many. The reason for this is the fact that there are many things to rule out with the diagnosis of low back pain. This is why a deliberate medical – orthopedic screening is essential. This is what is termed as differential diagnosis. It is important because other non-back pain related problems may first manifest as back pain. These other causes must be ruled out first. This is also termed a “systems review”. The review is performed more extensively by the medical doctor, physician assistance or the nurse practitioner and again during the physical therapist assessment. If there is a potential non-musculoskeletal etiology, the patient is referred back to the medical doctor for further testing. This is uncommon but is important in case something other than musculoskeletal or mechanical etiology is causing the low back pain.
The Diagnostic Process:
Step 1. Consult your primary doctor. This consultation in today's world though can be a waste of time as you may then be referred to a spinal - orthopedic doctor. So, if you go via the primary doctor first, it will be because you have confidence in their ability to help you out. Ideally, they should perform a systems clearing exam and rudimentary physical exam, X-rays or other radiological or diagnostic studies as indicated. A systems review exam rules out non-back related back pain such as a UTI, diverticulitis, kidney problems, liver problems, etcetera.
Step 2 ( or Step 1 alternative): You just may elect to go straight to the spinal specialist and get your screening and assessment. This just might save time and money. In some states you can go to a physical therapist first. If they have any suspicion that there is a medical reason for your pain, or if they need an X-ray or other radiological study to be sure of a clinical diagnosis, you will be sent to the medical physician or orthopedic specialist anyway.
The consultation and assessment is everything. The spinal physician (or primary physician) is doing two things:
1. Making sure your low back pain has no other medical origin. This is called a systems review. If the pain is from some other disease process you may go to a physician specializing in that area. For example, if the pain is referred from the kidney, intestines, or some other region you would then go to the appropriate medical specialist such as a nephrologist or gastro-intestinal specialist.
2. If the system review indicates the low back pain is a result of the musculoskeletal system: bones, joints, muscle as well as other soft tissues, then a more precise diagnosis is needed. The x-ray gives a great deal of useful information. Often folks get hung up on arthritis or disc flattening or some other aging and normal process. What you need from this second part of the exam is to know what the specific diagnosis is, such as a bulging disc, mechanical origin, strain, stenosis, etc. This is often where things “go sideways” in a manner of speaking. An example of this might be that you have arthritis in your spine. That is the diagnosis. Everyone has some degree of arthritis in their back over the age of 25 years. It advances with age. Also, age related arthritis of the spine may be a finding, but it is unlikely to be the origin of pain.
Step 3: Get an accurate diagnosis. If the physician cannot give you one, then it is highly likely “mechanical” in nature. This is also referred to as non-specific low back pain or back pain. That nearly always means “core” or thoraco-abdominal-pelvic musculature is weak. This weakness results in a drop of intra-abdominal pressure and support to the lower spine and irritability of the underlying tissues. This combination is manifested as low back pain and can even cause leg pain referred from the back.
Effective treatment can be implemented with a good quality differential diagnosis. When you get one, then seek out treatment from an appropriate provider. Most of the time (statistically) your diagnosis will be “Non-specific low back pain”, “Mechanical low back pain”. “Low back pain”, “back pain”, “Back pain with sciatica”, “Sciatica”. Back sprain and/or strain” may also be a non-specific low back pain diagnosis, the specific sprain/strain diagnosis, or a mix as stated above.
The steps for successful resolution of low back pain may seem like a lot of effort, but if followed as a rule, it is the best and fastest way to prevent a great deal of delay, expense, and frustration. Often folks will delay treatment due to fear it will not work, fear of the costs and so forth. They may try to take short cuts and circumvent this “system” only to find they cannot. Proper assessment needs to be done before treating low back pain precisely because so many injuries, dysfunction and disease mechanisms can cause back pain. Once the cause is known with a degree of certainty, the resolution with commitment is generally a smooth, timely and effective process.
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References:
1. Statistics and incidence of low back pain: CDC, National Center for Health Statistics
2. Lancet. 2012 Feb 4;379(9814):482-91. doi: 10.1016/S0140-6736(11)60610- 7. Epub 2011 Oct 6.Non-specific low back pain. Federico Balagué 1, Anne F Mannion, Ferran Pellisé, Christine Cedraschi
3. Mayo clinic
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Warm Regards
Dr Michael J. Malawey, PT
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