Editor's Memo: Chronic Low Back Pain: Bringing Back A Forgotten Treatment
I have had a great concern for some time regarding low back pain patients. Like every pain specialist, I’m referred a preponderance of chronic back (cervical and lumbar) pain patients. As one who accepts and likes to treat intractable pain patients, every case sent to me is already on multiple pharmacologic agents including anti-inflammatory, antidepressant, neuropathic, and opioid medications. I recently counted the number of pharmacologic agents that my referred patients were taking, and the average was 11. All of the patients who were referred for back pain had also been the recipients of a plethora of the usual back pain treatments, including epidural and local corticoid injections, acupuncture, electromagnetic measures, and formal physical therapy, including massage and chiropractic care. I’ve made two disturbing observations that I relate here in the hopes of reviving an old back treatment:
- Essentially every back patient referred to me has paraspinal muscle contractions, which aren’t noted in the patient’s medical records
- Not a single patient has been taught the basic prevention and treatment of paraspinal contractures—ie, at-home “stretch and hold” or “range of motion” exercises.
Chronic low back pain always starts with some painful event. When this occurs the patient naturally leans or lists to one side to find some relief. The problem is that chronic listing and spasm may cause contractures of muscle, fascia, tendons, and ligaments in a relatively short time period. When this occurs, just normal walking and movement, in the face of contractures, may cause more spine injury and degeneration. Before long, these contractures become disabling. In other words, a vicious cycle is established: pain, muscle contracture, misalignment, more pain, and more spine degeneration.
Paraspinal muscle contractures can easily be detected on physical examination. As noted, over time the patient will lean or list to one side to find pain relief and there will be indentations or creases in the soft tissue of that side. The paraspinal muscles on either the splinted or compensated side will hypertrophy. Overall there will be significant asymmetry of the back and shoulder musculature. The patient will likely not be able to raise or extend his/her arms and legs to their maximum range. I like to examine low back pain patients while they stand up straight and are in the leaning forward position. Contractures, misalignments, and asymmetry are evident if muscle contractures have developed. The muscle groups on the contralateral side of the pain site may also hypertrophy, in an attempt to protect and relieve pain.
Once I find evidence of paraspinal contractures, I teach the patient, in less than 5 minutes, an at-home exercise program I call “stretch and hold” (Figures 1-4). Call it “range of motion” if you will. Just keep it simple and hold off the prescription pad and referral form for 5 minutes. First, teach the patient the “reach for the sky” exercise. The patient simply reaches upward, with their arms straight up, until it becomes slightly painful. Don’t be surprised if they can’t reach very high. I also teach them to bend forward with arms stretched and go down only to the point where pain begins. They hold this position for a count of 10. Feel free to teach other arm or leg stretches, but at least teach them to “stretch and hold” their arms and back muscles a few times each day. I’ve been amazed how much pain relief and mobility a patient can get during a 30-day, at-home regimen of muscle stretching.
To me, the most basic prevention and treatment measure for soft-tissue contractures, including those involving the paraspinal muscles, is regular, at-home stretching. It doesn’t do much good to refer to a physical therapist or anyone else unless he/she is taught that paraspinal muscle contractures can only be effectively prevented and treated if the patient stretches the affected muscle groups every day at home.
Editor in Chief