What is Chronic Low Back Pain?
Chronic low back pain (LBP) refers to pain in the region of the body that lies between the ribs and the gluteal muscles. It includes the five vertebrae of the lumbar spine (L1-5), which supports the weight of the upper body. Between the vertebral bones are round, squishy intervertebral discs that behave like shock absorbers as the body moves. Ligaments are like mobile tape that keep the vertebrae in place and attach from one vertebra to another. Ligaments attach muscles to the vertebral bones. The spinal cord runs through the middle of each vertebra in the spine. Spinal nerves exit out the sides of the vertebral column through specific holes called intervertebral foramen. They run out to innervate all muscles in order to control movement of our body. They also transmit sensory signals from the body to the brain.
How Common is Chronic Low Back Pain?
Back pain is one of the most common reasons people see a doctor and are absent from work. Experts estimate that 50-80% of all people will at some point in their life have experienced LBP, including school-age children [2]. It accounts for more than 264 million days lost at work annually [3]. Approximately 20% of people who experience acute LBP develop chronic LBP [1].
What are the Early Signs of Chronic Low Back Pain?
Low back pain can range from dull, constant ache to a sharp, sudden pain that may even shoot to other regions of the body. Acute LBP is present from a few days to a few weeks, although complete resolution may take a few months. Most cases of acute low back will spontaneously resolve on their own. Recurrence rates are high, and acute pain can turn into chronic LBP over time for a significant percentage of the population. Chronic LBP is present for at least 12 weeks or longer [1].
What are the Later Symptoms of Chronic Low Back Pain?
Later signs of chronic LBP may include pain that has spread to other regions of the body or intensity and severity has become debilitating. There may also be nerve damage related to the LBP, resulting in numbness, tingling or altered sensations in the low back or more often in the legs and feet. With this altered sensation, stability and balance may become compromised or challenging. With chronic pain usually comes fear-avoidance behavior, as well as anxiety and depression around the pain. Fear of movement and excessive avoidance behavior can contribute to ongoing pain and prevent recovery [6].
What Causes Chronic Low Back Pain?
Most cases of LBP are mechanical and non-organic in nature, meaning they are not signs of inflammatory arthritis, infection, fracture or cancer [4]. Oftentimes, LBP is caused by sprained ligaments, strained muscles, ruptured intervertebral discs or irritated joints. These issues can be caused by sports injuries or accidents, repetitive movements with unsafe movement mechanics, or sometimes the simplest of movements can trigger an episode of LBP. Other factors that may increase LBP include obesity, arthritis, poor posture, inactivity, and psychological stress [5]. There are some disease processes that can be responsible for chronic LBP, including kidney stones, kidney infection, blood clots or bone loss.
What Happens in the Brain With Chronic Low Back Pain?
It is important to understand that pain is not a sensation, it is a perception and an experience. People tend to think of their pain system as a series of on-off switches, in that if they are not experiencing pain, their pain system must be shut off. Nothing can be further from the truth.
There are receptors called nociceptors that exist throughout your body. These receptors respond to heat, cold, chemical irritants, and mechanical compression. When these are stimulated, they come to threshold and fire nociceptive signals through small nerve fibers and into your spinal cord. These nociceptive neurons are just like any other neurons in your body; they are always firing at a baseline rate. Indeed, essentially only nociceptive neurons that are not firing at all times are the dead ones. So why are we not in 24/7, head to toe pain?
There are also several anti-nociceptive mechanisms in your nervous system, which exist in your spinal cord and brainstem. They function to filter and gate the nociceptive input, which prevents the signal from making it to the conscious parts of your brain. With enough input from the nociceptive systems, such as when there is tissue damage or inflammation, the anti-nociceptive systems are overwhelmed, and the signal is transmitted to areas in the parietal lobe of the brain where we map the body. Even once this occurs, we still don’t have pain, only localized nociception. The input does not become pain until we assign a negative emotional valence to it; we must decide “that sucks” for the signal to become a painful experience.
The brain’s anti-nociceptive circuits are normally very good at shutting off incoming nociception before it reaches conscious experience. These systems exist in the frontal and prefrontal cortex, the parietal lobe, the vestibular system, the brainstem, and the spinal cord. When functioning properly, the nociceptive input from an injury is maintained long enough to allow it to function as part of the healing process. Nociception allows us to automatically regulate blood flow and focus inflammation on injured tissues, which is crucial for tissue repair. Once this takes place, nociception needs to be shut back off.
There are also regions in the brain that are involved in the negative experience of pain. The amygdala is involved in threat detection and fear perception. The hypothalamus and pituitary gland are involved in the release of stress hormones that allow us to respond to threats. Some of these hormones can sensitize nociceptors, and thus make anything that hurts hurt more. The anterior cingulate cortex is involved in the perception of suffering. When this is excited, nociceptive input becomes a negative, painful experience.
Chronic pain is best seen as a loss of balance between the nociceptive and anti-nociceptive systems, coupled with a negative emotional consequence leading to ongoing painful experience. In acute pain, nociception tells your brain that tissue has been injured. In chronic pain, these signals persist and become amplified. They may even continue to exist long after the tissue has healed and returned essentially to normal.
When our bodies are stimulated by external sensations such as stubbing your toe or burning your hand, the sensory receptors in our skin relay that signal to the spinal cord. These signal travel in a pathway that delivers the message from the spinal cord to the brain. Under normal circumstances, this input is recognized as not very harmful, and no extreme signals of pain are ascribed to it. The body and brain sense and localize the external stimulus, deal with it by triggering inflammatory responses to heal the injured tissue, and move on.
In chronic pain, these pathways can produce an amplified response to the stimuli. The pain from the burn weeks ago maybe continue to be painful due to a process in the brain called central sensitization. An imbalance between the nociceptive and anti-nociceptive systems can lead to failure to properly shut off the nociceptive input once the tissue heals. This allows the nociceptive neurons to keep firing, become more sensitive, and more efficient. When these nerve cells wind up, they can become so sensitive and efficient that normal sensory input from light touch or gentle pressure, and the normal chemical environment can all become triggers. With enough central sensitization, just about any normal sensation can become painful [9].
Central pain states also involve changes in the areas of the brain where pain is perceived. Chronic pain leads to changes in sensory maps of the body, such that the brain’s ability to localize a sensory input to a body part can become impaired. As the brain’s map of the affected area is reorganized by the nociceptive signals, it loses the ability to properly regulate the anti-nociceptive system. In essence, when somatotopic reorganization takes place, the brain loses the ability to properly localize the affected body part. And if it doesn’t know where it is in space, it can’t properly send it signals to shut off the incoming pain [18].
Areas in the brain involved in negative sensory experiences also undergo changes in chronic pain. The anterior cingulate cortex, the area where we experience suffering, has been shown to become extremely sensitized in chronic pain states [9]. Most chronic pain patients note that they experience negative emotions at higher levels than before their injuries, their ability to regulate negative thoughts and negative self-talk is decreased. This is largely due to the excessive wind up of the anterior cingulate cortex seen in chronic pain. As a result, depression and anxiety are extremely common in cases of chronic pain [19].
The presence of these disorders leads to changes in stress systems, including upregulation of the hypothalamic-pituitary adrenal axis. The increase in circulating stress hormones can lead to further promotion of chronic pain (9). These changes also promote neuroinflammation, which is inflammation taking place within the spinal cord and brain, leading to further loss of the ability to shut off the experience of pain [20].
The ultimate consequence of all of these processes is that central pain responses can become exaggerated and long lasting. Worse, the perception of pain can become decoupled from the sensation of tissue damage, and the perception of pain can exist long after the tissue has fully healed, or exist in response to normal background stimulation. Worse still, the emotional changes seen with chronic pain can spill over into all domains of a person’s lived experience, creating the changes in mood, motivation, and cognition seen in chronic depression and anxiety [9].
Patients regularly struggle to find successful treatments for their chronic pain, bouncing from provider to provider chasing progressively more invasive structural interventions without success. This is usually because both the patients and their providers fail to understand that their pain is no longer about what is occurring in the tissue, but rather is about circumstances in the brain that must be addressed for their pain to improve.
How is Chronic Low Back Pain Diagnosed?
Low back pain is diagnosed with a complete medical history and physical exam that can direct attention to any serious conditions that may be causing the pain. A neurological exam should also be performed to determine cause and create a treatment plan. Most of the time, imaging is not required, but may be ordered to rule out specific causes of pain, such as tumor or spinal stenosis. Other tests that may be ordered by an overseeing physician are [1]:
Laboratory tests, including tests of the blood and urine to diagnose an underlying issue in the organs or bones that may be responsible for the pain. Signs of inflammation, infection, cancer and arthritis may be seen with these tests, as well.
Bone scans, in order to detect and monitor infection, fracture or other disorder of the bones.
Discography, utilized to test specific intervertebral discs that are suspected to be the cause of the patient’s pain. The increase in fluid pressure of the disc will recreate the patient’s pain.
Electrodiagnostic studies can be performed to identify problems with the nerves in the back and legs.
Diagnostic imaging can allow specialists to see images of the body and its structures without having to perform surgery
Computerized topography (CT scan)
Magnetic resonance imaging (MRI)
X-ray imaging
Myelograms enhance the appearance of the spinal cord and nerves on x-rays or CT scans in order to look for signs of compression caused by herniated discs or fractures.
How is Chronic Low Back Pain Usually Treated?
Initial treatment of chronic LBP is usually medication for pain or inflammation management. This may include analgesics (like Aspirin), non-steroidal anti-inflammatory drugs (NSAIDS like Ibuprofen), muscle relaxants or topical pain relief that can be put on the skin directly over the site of pain. Opioid drugs prescribed by a physician are quite common, as well, but should be used for only a short period of time and under a physician’s supervision.
It is becoming more common now for patients to receive supervised exercises from a trained therapist such as a physical therapist, occupational therapist or chiropractor. Cognitive behavioral therapy and biofeedback can improve a patient’s cognition around their pain and help them develop healthy coping strategies to get through their pain. Patients may also utilize electrical therapies, such as a TENS unit, which blocks or modifies the perception of pain locally. Multidisciplinary approaches to chronic LBP are increasing and may include spinal manipulation, acupuncture, manual therapy or other physical therapy modalities [1].
More invasive procedures such as spinal injections for trigger points (tight knots or bands of muscle that may be causing pain), epidural steroid injections or radio frequency ablation to destroy nerves that are sending a pain signal to the brain may be used if patient does not respond to less invasive forms of care. Lastly, spinal surgery may be considered if all other treatments fail to relieve pain. Specific surgeries are selected depending on the condition or indication, with the possibility of these being unsuccessful, as well [1].
How Is the NeuroRescue Program Different?
It has long been understood that the brain has a powerful influence on our pain thresholds. It can alter and modulate (calm down or turn up) sensory information like pain at the level of the spinal cord. This is known as descending control of pain. This model explains why our pain thresholds change depending on mood, stress, sleep and expectation of pain. For example, chronic pain and anxiety facilitates more pain, whereas acute pain and expected pain relief can produce an analgesic effect or decrease pain.
While pain is uncomfortable, it may not be a sign that something is dangerously wrong. There are two types of pain that are important to understand. Nociceptive pain can be described as pain coming from actual or threatening damage to parts of the body such as muscles or ligaments. It can be stimulated by things that are uncomfortable, such as changes in temperature, mechanical changes like stretching or chemical changes like burning. Neuropathic pain is caused by direct damage to the nervous system. Most of the time, what is being experienced in chronic LBP is nociceptive pain fibers being stimulated, and not the actual nerves being damaged.
This unfortunately does not stop a person in pain from anticipating painful movements and choosing to avoid them altogether, out of fear of creating further damage or perpetuating the pain itself. The Fear-Avoidance model of chronic pain suggests that pain becomes chronic when a vicious cycle occurs that includes catastrophizing about pain leading to fear of movement and hypervigilance, which leads to hyper sensitization and exacerbation of pain, ultimately leading to more movement avoidance.
Modern pain neuroscience has advanced significantly and has a greater understanding of central nervous system (brain) mechanisms that increase our susceptibility to feeling pain, the longer we have pain. The term is called central sensitization or CS and it is defined as “increased responsiveness of nociceptive neurons in the central nervous system to their normal or sub threshold afferent input” [8]. What this means is that the longer the nerves sending the signal of “potential pain” are activated, the more sensitive they become to any stimulus, even a stimulus that is unharmful.
An analogy that could be made is someone in your home takes a liking for scaring you on a daily basis. Following these incidents, you have heightened perception of sound to avoid a repeat offense. You may even scream in fear and surprise at something as small and harmless as the sound of a door closing. The same thing happens to your central nervous system with pain perception. This dysfunctional system can now cause other systems to become dysfunctional, such as altered sensory processing in the brain, malfunction of pathways that should be able to inhibit how much pain we experience, increased activity of pathways that send pain signals to the brain, and enhanced perception of pain when potentially painful stimuli are presented at times that are close together.
In most of these cases there is hyperactivity in certain parts of the brain, and this can contribute to increased perception of pain over time. It is interesting to note that hypersensitivity of nerves to pain may also lead to hypersensitivity to other stimuli, such as light, sound, smell, hot or cold sensations [9].
Depending on the cause, we may be able to significantly reduce or resolve LBP by employing a host of advanced therapies and technologies that can help improve the function of your remaining systems. By doing so, we can often help restore your mobility, reduce your pain, improve your balance and gait, decrease your anxiety and/or depression and enhance your quality of life.
Much of what happens in chronic LBP is related to the inability to properly localize yourself in the environment. Your brain makes sense of where you are in the world through inputs from your muscles and joints, inputs from your inner ear, and inputs from your eyes. Your vestibular system is the main system that fires directly down into the small muscles that stabilize your spine and tell them how to stabilize you against the numerous small and large movements you perform during a day [17]. Loss of appropriate vestibular system output or alterations in its integration with other sensory systems can result in poor spinal muscle coordination and lead to deterioration of the spine over time [10].
The eyes are constantly scanning the world to provide the brain with a visual map of the surrounding space. It does this with saccades, which are fast eye movements from target to target. In order for you to move through and interact with the world, you first need to know where the world is. This requires that saccades are fast, accurate, stable, and have very quick reaction times. As the frontal lobes are involved in saccades, all of these functions break down with chronic pain. Saccades become slow, lose accuracy, and are easy to fatigue. Research shows that the breakdown in saccades leads to poor postural control [11], which means poor control of spinal stabilizing muscles. We find that by rehabilitating saccades in a very precise manner, we can often improve balance, postural stability and reduce pain.
Another more complicated eye movement is called an anti-saccade, where a target is presented, and a person needs to inhibit the reflex to look at the target and instead consciously choose to look in the other direction. Anti-saccades are involved in a number of executive functions, and these give rise to foundational cognitive processes. Research shows that anti-saccades break down in patients with chronic pain, leading to catastrophizing, attentional bias to pain, anxiety, depression, problems with emotional regulation and cognitive reasoning [12]. We find that by rehabilitating these eye movements we can often restore some of the cognitive flexibility and emotional regulation lost to this issue.
There are a host of other therapies that we engage in with our chronic LBP patients. All of these have different functions and allow us to rehabilitate specific capacities. These range from vestibular rehabilitation to improve balance, gait, and spinal control, to visual stimulation to improve motor control and postural stability [10,16]. They include a number of different types of electrical stimulation to improve cognition, eye movements, balance, gait and pain inhibition. They may include therapies such as transcranial magnetic stimulation (TMS) to not only decrease pain, but also to improve anxiety and depression associated with pain [14]. They may even include virtual reality exercises to improve the ability to function in the world and decrease perception of pain [15]. We also employ spinal manipulation and manual therapies with specificity to brain function in order to reduce fear-avoidant behavior and decrease pain [6]. We also focus on teaching you about chronic pain during your treatment, also known as pain neuroscience education, which alone has been demonstrated in the literature to reduce pain by enhancing patient expectations [7].
No two chronic back pain presentations are alike, and the same holds true for the NeuroRescue program. A cookie-cutter approach will be doomed to fail in a condition as complicated as chronic LBP. All of our therapy protocols are tailored to the unique needs of the individual, based on the data we obtain in your neurodiagnostic testing and neurological examination.
How Does the NeuroRescue Program Work?
We design your unique NeuroRescue Program to be among the most comprehensive diagnostic and therapeutic protocols available today. We create individual NeuroRescue Programs based on a comprehensive analysis of every relevant neurological system and pathway, using gold-standard, cutting edge neurodiagnostic technologies and examination procedures and state-of-the-art therapies.
We begin with your Discovery Day, wherein we perform a comprehensive history of not only your condition, but your life on a timeline. This allows us to dive deeply into your case and see all of the factors that led to where you are now. It helps us uncover hidden problems and associated conditions that may be making it difficult for you to move your recovery forward.
In the case of chronic LBP, this requires a deep dive into personal history including activities of daily living and job requirements, history of prior accidents and procedures, and family medical history.
Our examination allows us to identify the areas and pathways of your brain that have been impacted to produce your chronic LBP. We begin by precisely quantifying the function of your visual, vestibular, and proprioceptive systems through computerized analysis of your eye movements, your inner ear reflexes, and your balance in a host of different sensory conditions.
We employ technologies including Videooculography and Saccadometry to measure several classes of eye movements. We use Video Head Impulse Testing to measure the function of your inner ear, and Computerized Dynamic Posturography to assess your balance in different sensory conditions.
We use NeuroSensoryMotor Integration testing to evaluate hand-eye coordination and cognition, and Virtualis testing to assess dynamic eye tracking and perception of vertical in a virtual reality environment.
We combine all of this with a comprehensive physical and neurological examination of your sensory, motor, autonomic, and cognitive systems. We review any relevant laboratory testing, radiological imaging, and prior neurodiagnostic testing, and integrate that information with our findings.
We use this information to identify which parts of your brain are working properly, which systems are struggling, and the precise point at which your systems fatigue.
We can then design a NeuroRescue Program that is unique and specific to your brain, and yours alone. Your NeuroRescue Program works to rejuvenate and reintegrate the damaged neurons and pathways in your brain. It works to improve energy, endurance, and functional capacity within your fragile systems.
We use our technologies and procedures to not only see what we need to address, but also when it is time to stop and let you rest. We address your impaired neurological function from multiple angles of therapy, and provide metabolic support to improve neurological recovery.
Your NeuroRescue Program allows us to take the pathways that are inefficient and maximize their efficiency and endurance. And by focusing on the integration of systems, we can do more than just get pathways working better, we can get them working together again. This gives us our best opportunity to help you get your pain under control, restore your physicality, and return you to living a healthy, vibrant, and fulfilling life.
Your Next Best Step:
Living with chronic low back pain is challenging. While we may not always be able to offer a cure for your condition, in many cases we can markedly improve or even completely resolve chronic pain. In other cases, many of the symptoms can become manageable, function can be enhanced, and quality can often be significantly improved.
To see if the NeuroRescue Program is right for you, contact one of our patient care coordinators to schedule your Discovery Day.
And remember, it’s never too late to start getting better.
References:
2. https://pubmed.ncbi.nlm.nih.gov/17445733/
3. https://pubmed.ncbi.nlm.nih.gov/3161177/
4. https://pubmed.ncbi.nlm.nih.gov/29573870/
5. https://www.acatoday.org/Patients/What-is-Chiropractic/Back-Pain-Facts-and-Statistics
6. https://pubmed.ncbi.nlm.nih.gov/30392530/
7. https://pubmed.ncbi.nlm.nih.gov/27362980/
8. https://www.painphysicianjournal.com/linkout?issn=&vol=18&page=E333
9. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3843878/
10. https://pubmed.ncbi.nlm.nih.gov/32607076/
11. https://pubmed.ncbi.nlm.nih.gov/16482980/
12. https://pubmed.ncbi.nlm.nih.gov/32732895/
13. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7354674/
14. https://pubmed.ncbi.nlm.nih.gov/31824787/
15. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6914277/
16. https://www.sciencedirect.com/science/article/abs/pii/S0306452216305723
17. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5366978/
18. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6855684/
