What to expect when you have low back pain: prognosis for the first year

A really interesting study was published recently in the Canadian Medical Association Journal.[i]  The study looked pooled data from a number of different studies reporting on the outcome of people presenting to a doctor’s office with back pain.

As a physician, we tell everyone that most injuries will get better within about 6 weeks.  This research confirmed “the broad finding of previous reviews that the typical course of acute low-back pain is initially favorable: there is a marked reduction in mean pain and disability in the first six weeks.” [ii]

However, there is more to the story here.

The researchers report, “Beyond six weeks, improvement slows and thereafter only small reductions in mean pain and disability are apparent up to one year. By one year, the average levels of pain and disability for acute low-back pain were low of suggesting that patients can expect to have minimal pain or disability at one year.” [iii]

A few of the specific studies in this meta-analysis are worth considering closer.

Gurcay et al. studied people present with back pain of less than 3 weeks duration.[iv]  They found:

• 27% recovered in the first week
• 31% recovered in the second week
• 23% recovered in the fourth week
• 10% recovered at the eighth week
• 1% recovered after 12 week
• 9% developed chronic low-back pain

If you looked at just this study and had back pain of more than 12 weeks duration, you might consider yourself screwed.  There is hope, though, and all is not so bleak.  Other studies within this same meta-analysis suggest that 95% of all people with back pain have complete resolution of symptoms by 3 months from the time of onset.[v] 

There a large body of research suggesting that chronic back pain can be improved or made to go away.  So there is always hope.  However, this study speaks to the importance of working to address symptoms before they settle into a more chronic state.  In chronicity the brain can develop patterns of being sensitized to the issue, making it harder to break free from the pain cycle.   

In a separate video post I have attempted to highlight a few exercises that can be used as “first aid” for the back: http://www.backexercisedoctor.com/journal/2011/7/30/video-of-mckenzie-press-up-exercise-first-aid-for-back-pain.html.

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[i] CMAJ. 2012 May 14. [Epub ahead of print]

[ii] CMAJ. 2012 May 14. [Epub ahead of print]

[iii] CMAJ. 2012 May 14. [Epub ahead of print]

[iv] Disabil Rehabil 2009;31:840-5.

[v] Arthritis Rheum 2004; 51: 168-76.

Relationship between pain and obesity

In the office I frequently get questions about what effect being overweight has on pain.  It is a complicated, weighty (no pun intended) issue.

A recent article in the Journal of Rehabilitation Research & Development considers this issue of this relationship between pain and obesity.[i]

The study reports “Prevalence rates of overweight/obesity among adults in the United States have increased markedly during the last decade, with current rates estimated as 66.3 percent for overweight and 32.2 percent for obesity.”

Wow!  Two-thirds of adults in the U.S. are overweight.  The figures are remarkable.

And what does weight have to do with pain?

Low back pain

Well-defined risk factors for low back pain include: age, smoking and physical conditioning. [ii]  We often assume that being overweight is a risk factor for developing low back pain but any association is tenuous.  Despite lots of looking, there is not any clear data to point to a causal association between back pain and obesity.  Rather, the more likely issues are “lifestyle changes associated with unhealthy behavior and poor overall health.” [iii]

Osteoarthritis

The issue of osteoarthritis and weight is a more clear-cut.  “Being overweight is a risk factor for development and progression of OA In the knee and hip and possibly development of OA in the hand.” [iv]

Weight loss is recommended for overweight persons with osteoarthritis.

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[i] JRRD. 2007. 44(2): 245-262.

[ii] JRRD. 2007. 44(2): 245-262.

[iii] JRRD. 2007. 44(2): 245-262.

[iv] JRRD. 2007. 44(2): 245-262.

Exercises for neck pain after surgery (ACDF)

I have been blessed my relative lack of neck pain during most of my life.  However, I have noted a few episodes of neck stiffness after sitting too long at the computer.  These episodes have made me more empathetic for the people I see in the office with complaints of neck pain.  It is miserable to not be able to turn your head or have constant neck pain and all that goes with it.

Studies have shown that neck pain is consistently associated with a decrease in endurance of the neck extensors muscles.[i]  This makes sense on several levels. 

I tell my patients that our head weighs about as much as a bowling ball (or if you are like that kid William in Mike Myers’ “So I Murdered an Axe Murderer” and have your own weather system for your head than maybe little more than a bowling ball). [If that reference here is a link to a youtube clip from this movie and the scene referenced]

If we slouch our head drops in front of the shoulders and this increases the strain on muscles and joints trying to keep the head upright.  That is why the extensor muscles of the neck are so important.  They do the heavy lifting of holding us upright and keeping the head in a neutral/ideal posture.

The correlation between a decrease in endurance of the neck extensors and pain holds true for people who have never had spine surgery and also for people with a history of prior neck surgery (ACDF). [ii]

So what can be done?  Exercise.

There is good evidence that exercises specifically intended to build endurance in the extensors muscles for the cervical spine can help to address these deficits and decrease pain.[iii]

Here is a simple exercise that I like to work on the spine extensors (not just the neck but helpful for the low back as well).

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[i] J Manipulative Physiol Ther. 2007 Jun;30(5):343-50.

[ii] J Manipulative Physiol Ther. 2007 Jun;30(5):343-50.

[iii] Clin Neurophysiology. 2006 Apr;117(4):828-37. Epub 2006 Feb 21.

2012 American Academy of Orthopedic Medicine

I am attending the AAOM annual conference on the topic of regenerative medicine for the spine in the 21st century. It is a great update on the latest in regenerative medicine and injection techniques for the spine. A gear conference.

Nutrition and Back Pain

I have started to put together some information for an eBook on the topic of nutrition and weight loss as they relate to back pain.

Following is an excerpt from this eBook.  I will be looking for feedback and comments on the project as I get a more formal draft together.

Researchers at Stanford University published an important research projected called the “A to Z Weight Loss Study.” This investigation compared four different weight loss diets representing a spectrum of low to high carbohydrate intake for effects on weight loss and metabolic variables. [i]

Three of the diets examined in this study are popular diets in the U.S. and one is based on “national guidelines” (i.e. the Food Pyramid): 

• Atkins: very low in carbohydrate
• Zone: 40%-30%-30% distribution of carbohydrate, protein, and fat
• LEARN (Lifestyle, Exercise, Attitudes, Relationships, and Nutrition): low in fat, high in carbohydrate, based on national guidelines)
• Ornish: very high in carbohydrate

The study followed about 300 women over the course of 2+ years.  The results of the study startled many observers. 

The participants assigned to the low carbohydrate (Atkins) diet had:

• Significantly more weight loss than all the other groups
• More improvement in HDL-C and triglycerides concentrations, both of which are major risk factors for heart disease
• A decrease in systolic blood pressure that was significantly greater than any other group 

These findings are nothing to sneeze at.  The winner was clear-cut – low carbohydrate intake.

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[i] JAMA, March 7, 2007—Vol 297, No. 9

How does acupuncture work?

Following is a letter I penned to a reporter on the issue of "how does acupuncture work in the healing of injuries?"  I get asked this question in the office all the time.  I thought the answer worth sharing because it certainly is a complicated issue and lots of people wonder how putting needles in the skin can help heal things.

I am a physician in the field of Physical Medicine & Rehabilitation.  I prescribe exercise as part of my treatments for most issues, including back and neck pain, athletic injuries and other musculoskeletal issues. 

In addition to my traditional medical training, I am also trained in medical acupuncture and integrate this into my practice of medicine.  

I get people in the office all the time that ask me "how does acupuncture work."

The answer is obviously a complicated one.  However, in a simplistic sense I tell people that acupuncture works on several different levels.  

1. Local effects: Inserting a needle into tissue helps to increase blood supply to that area which in turn can facilitate healing.  Needling may also help to "break-up" trigger points and encourage tissue repair;
2. Systemic effects: Studies have shown acupuncture and electroacupuncture to (a) stimulate the release of endogenous analgesic-like substances with the central nervous system[1], (b) modulate the transmission of pain pathways at the level of the spinal cord[2], and (c) suppresses or deactivates areas for pain processing in the brain.[3]
3. Energetic effects: encourage the flow and balancing of “qi” (loosely translated as “energy”) through the body.  This notion of flow of qi is obviously more metaphysical and harder to get your hands around.  The intention, though, to facilitate the balancing of forces that may be beyond our traditional notions of medicine is critical to the holistic healing influences of acupuncture.

 Hopefully this information is helpful.  Let me know if you need anything else.

Shane Mangrum, MD

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[1] Anesthesia & Analgesia. April 1999 vol. 88no. 4 841

[2] Neurochem Res. 2011 Nov;36(11):2104-10. Epub 2011 Jun 22.

[3] Mol. Pain. 2011 Jun 7;7:45.

Low back pain exercise: curl-up for low back pain

I just recently reworked some of the video on the exercises that I often recommend for patients.  Below is video on the curl-up, an exercise described by Stuart McGill.  This exercise is an essential exercise for most any back pain rehabilitation program.

Let me know if you have feedback or comments. More videos are forthcoming to fill out the exercises that I frequently recommend.

Kettlebell Exercises for Neck and Back Pain

The Kettlebell is a cast-iron weight used for centuries to train Russian soldiers and athletes.

Kettlebell exercises for back and neck painIn the context of Crossfit and dynamic exercise programs, Kettlebell exercise programs are being applied in many different forms.

An interesting study recently published a study evaluating the potential for Kettlebell exercises to be helpful with back and neck pain.

The study, published in the Scandinavian Journal of Work and Health, looked at a group of 40 adults from occupations with a high prevalence of musculoskeletal pain symptoms.[i] 

The study participants were assigned to either a (1) Kettlebell training group where they did “full-body” kettlebell exercises 3 times per week for 8 weeks or (2) a control group.

The researchers found improvements in the Kettlebell training group in terms of: 

• Increased strength of trunk extensors
• Decreased pain intensity of the neck/shoulders
• Decreased low back pain intensity

These findings are important in several respects.

1. The spine extensors are critically important to stabilization.  Studies have demonstrated a clear connection between decreased endurance in the spine extensors and back pain (The Importance of Endurance in Spine Extensors for Runners)
2. Endurance of the spine extensors for the neck and upper back similarly have demonstrated importance in the treatment of neck pain (More Evidence for the Importance of Endurance of Spine Extensors for Neck and Back Pain)

I will post some additional video soon on the topic of which exercises with Kettlebells make the most sense for people with back and neck pain.

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[i] Scand J Work Environ Health. 2011 May;37(3):196-203. doi: 10.5271/sjweh.3136. Epub 2010 Nov 25.

Low back pain exercise: the curl-up

Here is an updated video on the curl-up exericse, one of Stuart McGill's "big three" exercises for lumbar stabilization.

Watch the video here and leave comments below.

Mattresses and Back Pain

As is often the case, I had a few patients this week ask me, “What kind of mattress is best for back pain?”

Then I received an email from a patient about this same issue.  I have included portions of the email below and will try to communicate where the data stands (or sleeps in this case) on the issue.

Hello Dr. Mangrum:

I was your patient two years ago this spring for upper back and neck pain.  You treated me fairly successfully…

Here’s the reason for me bothering you.  My wife and I need to buy a new mattress.  I’d really appreciate your thoughts on what type might be best for me.  Specifically memory foam, vs latex vs a traditional innerspring mattress…

Any thoughts, caveats or wisdom you could share would be most appreciated.

This question is more complicated than it may seem at first blush.  One reason for this is that back pain is often worse first thing in the morning, regardless of what type of bed you sleep on.

The discs in our spine tend to lose around 20–25% of their water content “due to high loads imposed by muscle tensions during the day's activity; this water is regained during the decrease in load under rest at night.”[i]  So first thing when you wake up in the morning the disc is superhydrated and more stiff.   

Similarly, joints with inflammation or arthritis often are more stiff first thing in the morning.  One of the defining factors, in fact, for osteoarthritis is stiffness that lasts for less than 30 minutes after waking up.[ii]

With that in mind, I hate to recommend someone with back pain go out and spend hundreds (or thousands for that matter) on a new mattress when the mattress may not be the source of the trouble in the morning.

Recognizing that a mattress is not the only thing that can cause pain or stiffness first thing in the morning there is some evidence that updating your mattress or certain types of mattresses can be helpful for someone with back pain.

A study published in the journal Applied Ergonomics studied a group of people with chronic low back pain.[iii]  They had these study participants report sleep quality and rate back pain/stiffness for 21 days in their own beds.  Then the participants beds were replaced with medium firm mattresses layered with foam and latex.  The study found significant improvements in sleep variables and back pain at 4 and 12 weeks after changing mattresses. 

A related study published in Spine compared the effects of sleeping on:  (1) waterbed (Akva), (2) body-conforming foam mattress (Tempur), and (3) a hard mattress (Innovation Futon) for one month.[iv]  The researchers found that “Both the waterbed and the foam mattress seemed superior to the hard mattress” in terms of decrease in back symptoms, improved function and sleep.[v] 

So if nonthing else I know that my dad was off base when he told me it would be better for my back to sleep on the floor.

These studies, though, are complicated.  There is not an easy way to do a placebo controlled trial for mattresses.  As a result there are no great head-to-head studies for innerspring mattresses versus latex foam mattresses.  If one mattress maker touts their product as being scientifically proven to be superior to other mattresses you may want to take pause.  The range of sleep position preferences and varied anthropomorphic characteristics of the human body likely make a one fix for everyone impossible.

All this being said, there actually is pretty good evidence that getting a new mattress (especially if your mattress is older than 9 years old) can improve back pain.[vi]  This effect of new bedding improving symptoms plays out in a number of different studies (each with different “new” bedding systems).  This could be a placebo effect of sorts. 

Hopefully this information is useful for those of you considering buying a new mattress.  Let me know if you have comments or a preference for one specific type of mattress.  Leave comments below.  I am sure others are interested in a range of opinions and experience with this issue.

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[i] August 1993 Radiology, 188,351-354.

[ii] http://www.spine-health.com/conditions/arthritis/osteoarthritis-symptoms

[iii] Appl Ergon.  2010 Dec;42(1):91-7. Epub 2010 Jun 26.

[iv] Spine.  2008 Apr 1;33(7):703-8.

[v] Spine.  2008 Apr 1;33(7):703-8.

[vi] J Chiropr Med. 2009 March; 8(1): 1–8