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Low back pain usually due to body mechanics

Many health issues have received front page attention over the years, with a few recent winners including the ebola virus, the AIDS epidemic, and, of course, cancer, which is always high on the list. But when it comes to actual number of people afflicted, nothing comes close to chronic low back pain (cLBP). It may not receive the media attention of CTE (chronic traumatic encephalopathy), for example, but it’s one of the most common maladies experienced by a huge number of individuals.

Over 80 percent of the population will experience an episode of low back pain over their lifetime. For many, the course is benign, with recovery attained after a few months of pain, but some develop a chronic problem. This is defined as pain that lasts for more than 3 months. LBP is the second most common cause of disability in American adults and an extremely common reason for lost work days. An estimated 149 million days of work per year are lost due to cLBP. The condition is also costly, with total amounts estimated to be between $100-200 billion annually, much of which is decreased wages and productivity.

Why is this such a common problem? What is it about the human body, and our lifestyle, which results in such a widespread and debilitating condition? Although extremely common, the cause of low back pain remains ‘obscure’, according to the World Health Organization. Although 85 percent of the time there is no clear etiology, it is believed 97 percent are due to musculoskeletal issues. Low back problems often develop without the occurrence of a single traumatic event, but simply from the extra stress placed on the back from upright walking. Thus, any discussion on back pain must include some mention of body mechanics and the hazards of being bipedal, meaning there are consequences to standing on two legs.

A discussion of the mechanics of bipedalism is especially relevant since low back pain is typically mechanical. Mechanical low back pain arises intrinsically from the spine, intervertebral disks or surrounding soft tissues. The spine is a column, composed of a series of bones, the vertebrae, with the infamous disks between each vertebral bone. These disks are especially susceptible to the recurrent trauma and physical stress of being upright. These stresses also can lead to fracturing of the vertebral bones when osteoporosis has weakened them.

What conditions will encourage the development of abnormal mechanical stresses on the low back? Regular readers will be well acquainted with the concept that foot function directly effects the structures, especially the joints, that rest on the feet. Abundant evidence supports this concept, that foot posture, particularly excessive pronation, is associated with mechanical low back pain.

Six weeks of prescription shoe orthotics significantly improved back pain and dysfunction in one particularly recent research study. Interventions that modify foot function, such as customized foot orthoses, may therefore have a role in the prevention and treatment of low back pain. Mechanisms to account for these findings are based on either mechanical postural changes or alterations in muscular activity in the lumbar and pelvic muscles.

Many treatments are utilized for mechanical low back pain, but strong evidence of the benefits from large-scale clinical trials is often lacking. Physical therapy remains the most commonly prescribed, reimbursable, evidence-based, non-pharmacologic therapy prescribed by doctors. There is moderate evidence for the use of non-steroidal anti-inflammatory drugs, as well as opioid medications in the short term, but little evidence has been found for the use of acetaminophen, antidepressants, muscle relaxants, or lidocaine patches in the treatment of cLBP. And yet, these methods are frequently prescribed by health care providers.

Surprisingly (to many), there is strong evidence for the short-term effectiveness of yoga and moderate evidence for its long-term effectiveness. It has been the subject of many critical reviews and medical trials over the past decade. A study recently published found that yoga was just as good as physical therapy for reducing pain and increasing mobility. Although not well-studied, the use of both physical therapy, concurrently with yoga, may work to restore and improve joint mobility, providing more effective, long-term relief. The utility of yoga is that it seems to help sufferers get used to moving again, to relax. It may have an additive effect, building on the gains of physical therapy, reducing back pain further. Thus, yoga should be considered by those suffering from cLBP because of its ability to alleviate chronic pain.

More research is needed to accurately quantify the effects of foot orthoses on chronic low back pain, especially their effects on lumbopelvic muscle function and posture. This is at least partially due to the difficulty in studying this relationship. It is quite challenging to construct a study which can accurately evaluate how well a pair of orthotics can affect low back pain when the supports themselves are going to vary so significantly.

There is tremendous variability in what constitutes an arch support and how well it functions. How is it constructed and what materials are used? Is it a custom device or a generic one? The former is made from a copy of an individual’s feet, but many differing techniques exist for creating such a positive, three-dimensional re-creation. Some are more exacting, more precise, than others. Unfortunately, for some prescribers, the primary consideration in casting a patient’s feet is how fast and convenient the method is, and not how accurate the copy. Different practitioners will prefer different materials for construction of the device, and prescribe the supports using different concepts and philosophies. Thus, different foot supports will vary in how well they alter foot motion during the complex act of walking, and, consequently, how they affect spine mechanics. The result will be supports that provide varying levels of comfort, as well as different degrees of therapeutic benefit.

This only touches on the complexity of a fascinating topic, the biomechanics of the human body. For many, this subject results in serious pain. Typically, the standard treatments for cLBP provide some measure of relief, although the benefits are often transient. Anti-inflammatory medications are sometimes followed by steroid injections. Surgical options can be successful at treating the consequences of mechanical low back pain, such as nerve compression syndromes. But numerous studies reveal foot orthoses represent a simple and potentially effective therapeutic measure for this common clinical condition, one that carries such a high personal and social burden to society.

Seeking the opinion of a medical specialist to rule out other causes is certainly appropriate. But this may be one of those conditions in which pursuing your own adjunctive treatments, like enrolling in a yoga class, can provide significant benefits. Finding a physician specializing in prescription arch supports can also be helpful in obtaining relief. Be proactive with your spine health, and thus your well-being. Be your own health advocate. No one knows how your body feels like you do!

Editor’s note: Dr. Conway McLean is a physician practicing foot and ankle medicine in the Upper Peninsula, with a move of his Marquette office to the downtown area. McLean has lectured internationally on wound care and surgery, being double board certified in surgery, and also in wound care. He has a sub-specialty in foot-ankle orthotics. Dr. McLean welcomes questions or comments atdrcmclean@outlook.com.

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