With approximately 80% of Americans dealing with chronic back pain (i.e. pain lasting beyond three months), the convenience of using medication to manage symptoms is understandable. Acetaminophen and non-steroidal anti-inflammatory drugs are generally the first-line of defense, followed by opioids like tramadol and other adjunctive medications. Long term use of these medications can lead to vast side effects, making physicians and patients alike hesitant to pursue continuous use (especially when these medications end up masking the symptoms instead of addressing the underlying cause).
Some common back problems that lead people to investigating holistic treatment are…
- Muscle spasms
- Degenerative disc disease
- Herniated or bulging discs
- Facet disease
- Stenosis
- Pinched nerves
- Spondylolisthesis
- Spondylolysis
- Sciatica
- Sacroiliac joint dysfunction
If you are dealing with chronic back pain and feel like you have exhausted the use of various pharmaceuticals, you might be wondering “What else is there? Should I try physical therapy (PT), chiropractic, acupuncture, or massage? What therapy combinations are the best?” As a holistic PT, these are some of the most common questions I get. My response… It really depends.
In this blog I want to highlight six key interdisciplinary and conservative treatment modalities we have found to be effective in treating chronic back pain. Bear in mind that this should be seen as a general guide and not a ‘one-size-fits-all’ therapy recommendation. If you already have a practitioner or a healthcare team (that may not be mentioned in this blog), these recommendations might not apply to you. However, if you are just starting your healing journey (or stuck somewhere along the way), this may be helpful.
1. Manual Therapy based Physical Therapy
Like any other health care profession, PT’s offer various specialties. For example, our practice focuses primarily in John F. Barnes Myofascial Release (MFR), Craniosacral Therapy (CST) and Visceral Manipulation (VM). These are highly effective modalities in managing acute and chronic back pain.
What does it entail?
These techniques are all hands-on and focus on applying a gentle and sustained stretch into the fascial (i.e. connective tissue) system. This is a thick elastic system that surrounds and infuses with every single
structure in the body. In its healthy state, fascia is relaxed and able to stretch and move without restrictions. With inflammation, scarring, poor posture, and/ or trauma, the fascia loses its pliability and starts to shorten and solidify. This causes pressure on muscles, discs, and nerves resulting in pain, loss of range of motion, and decreased function.
2. Acupuncture
Acupuncture has been around for thousands of centuries making it one of the world’s oldest forms of healing. It stems from traditional Chinese medicine and it looks at chronic pain as a disruption in the flow of energy (or ‘qi’) in the body. It works by activating the body’s own physiological responses by increasing blood flow, invoking an analgesic (pain-relieving) effect, and stimulating the release of hormones and neurotransmitters that facilitate deep relaxation of the body.
What does it entail?
Imbalances in the flow of qi can be treated by inserting fine, sterile, metal needles along specific points located in channels (or meridians) throughout the body. The needles are about as thick as a strand of hair and insertion is typically painless. Acupuncturists can also include cupping which involves the use of a glass cup (inserted with fire) to create a vacuum. The cup is quickly placed onto areas of the body with a lot of ‘stagnant qi’ and its effect is an improvement in blood flow and relaxation of tight and bound myofascial tissue.
(Geeta Dsousza, L.Ac. Little Dragon Wellness)
3. Chiropractic care
Chiropractic care is a drug-free approach, focusing on the diagnosis and treatment of mechanical disorders of the musculoskeletal and nervous systems.
What does it entail?
Like PT’s, chiropractors specialize differently. While some primarily use high velocity manipulative techniques, others practice gentler forms like NUCCA chiropractic (an upper cervical chiropractic technique). Here the adjustment is as gentle as having your pulse taken. Even though the primary focus is the neck, the effects of the corrections influence the whole spine.
4. Strength-based therapy
Most people know that with chronic back pain, seeing a therapist to help build core strength is important. However, choosing the right practitioner to fine tune your core strengthening, with body alignment and flexibility work, is important. Working with a PT or a personal trainer that specializes in pilates, gyrotonics, and yoga can achieve this.
(Lauren Dodds, D.C. Upper Cervical Chiropractic Group)
What does it entail?
These sessions include 1:1 sessions of identifying and correcting poor
movement patterns with different functional activities. The exercises can range with each specialty, but generally focus on activating deep core, pelvic, and scapular muscles (i.e the diaphragm, deep back muscles, the transverse abdominus, the pelvic floor, and scapular stabilizers), and deactivating compensatory muscles (e.g. hip flexors, back extensors, etc).
5. Osteopathic manipulation
This is most commonly administered by osteopathic physicians who believe that the body works as a unified whole. So mobilization of any of its parts, especially the musculoskeletal system, will facilitate a natural process of the body’s own self-healing.
What does it entail?
Osteopaths use their hands to examine and treat the back and other parts of the body (i.e. joints, tendons, ligaments, and muscles) that are experiencing pain, inflammation, or limited mobility. Various manipulative techniques used are counterstrain, cranio-sacral therapy, muscle energy, MFR and high velocity-low amplitude techniques.
6. Regenerative medicine
This is a branch of medicine that has gained a lot of popularity in recent years. It involves non-invasive protocols to facilitate replacement or regeneration of human cells or tissues, thus accelerating the body’s natural healing mechanisms.
What does it entail?
Regenerative medicine is applied not only in research but also in clinical care by physical medicine and rehabilitation doctors. In the treatment of acute and chronic back pain, there are various in-office procedures (i.e. prolotherapy, platelet rich plasma injections and botox injections) they perform that are relatively fast and ultrasound-guided. Sessions can be a one time occurrence or every few weeks for a cumulative effect.
What therapy combinations are best?
We are strong believers in an inter-disciplinary approach in treating chronic back pain. For some, one treatment modality is enough in gaining long term relief but, for others, a treatment combination (or even a streamlined transition from one approach to the other), can yield the best long-term results.
Again, bear in mind that each modality mentioned can act as an effective stand alone protocol. The following are considerations that can help you determine the combination that may be the best for you.
Consider manual based PT AND/OR chiropractic AND/OR osteopathic manipulation if you have…
- Sharp, stabbing or burning pain
- A dull back ache pain
- Muscle spasms/tightness
- Loss in range of motion
- A hard time moving due to the pain
- A postural component to your pain
- An emotional/stress component to your pain
Consider acupuncture AND/OR osteopathic medicine if you…
- Are aware of multi-system issues that accompany your back pain (e.g. painful periods, gastro-intestinal issues, hormonal issues, insomnia etc)
- Are hypersensitive to touch
- Have chronic inflammation
- Have constant, sharp or dull back pain
- Have muscle spasms/tightness
Consider strength based PT AND manual based PT if you…
- Have dull back pain in combination with a sense of spinal and pelvic instability
- Have a sense of deep core weakness
- Consistently and easily get re-injured with attempts to return to exercise
- Have a sense that part of your pain is partly due to feeling like your spine or pelvis is out of alignment
- Have a general ache that is worse with prolonged bad posture (e.g. sitting in front of a computer)
- Have a lot of joint hypermobility associated with pain
Consider regenerative medicine AND manual based PT AND strength based PT if you..
- Have exhausted PT alone and still dealing with persistent back pain
- Are looking to avoid surgery
Consider manual based PT AND/ OR osteopathic manipulation AND/ OR acupuncture
- If you know your pain is mediated by stress
Please note there are several permutations and combinations to all of these modalities; working with your provider to determine a multidisciplinary plan is always best. It’s also important to understand that chronic back pain can be accompanied by psycho-emotional symptoms like anxiety and/or depression. Despite the combination of therapies you choose, working with a mental health therapist can be invaluable in processing how your spine responds to pain.
Ann Udofia, PT, DPT
References
http://www.webmd.com/pain-management/tc/pain-management-side-effects-of-pain-medicines#1
http://www.aafp.org/afp/2009/0615/p1067.html
http://www.abidingspiritcenter.org/acupuncture.html?gclid=CPPV0qeL-NICFUUdaQodYK4Ngw
http://serendip.brynmawr.edu/bb/neuro/neuro01/web1/Walker.htm