How does your spine work?

The spine is made up of 26 vertebral bones that stack on top of one another. The lumbar spine is the lowest five vertebrae before the pelvis begins. Between each of the vertebrae are squishy fluid-filled discs that act as shock absorbers. To prevent the bones from slipping and sliding on the discs, we have lots of ligaments holding the bones in place, acting like supportive tape. The vertebrae are also surrounded by muscles that, when activated, create coordinated movements of the spine. The spinal cord runs down the middle of the vertebrae and nerves run off of the spinal cord to send signals between the body’s muscles, sensory systems, organs and the brain.

How common is chronic low back pain?

LBP is the greatest contributor to disability worldwide. It’s most commonly brought on for unknown reasons, meaning we often can’t trace the issue back to a specific action or moment in time. Approximately 20% of people who experience acute LBP will go on to develop chronic LBP.

What causes chronic low back pain?

Causes of LBP are numerous. Often it’s caused by injury to ligaments, muscles, discs or joints through sporting injuries, accidents, repetitive movements or sometimes from a spontaneous moment of instability doing a simple task. Some factors that may increase the likelihood of LBP are obesity, arthritis, poor posture, inactivity, concussion or whiplash injuries, repetitive tasks and psychological stress. Non-spinal reasons like kidney stones, kidney infection, endometriosis, pregnancy, osteoporosis, tumours or fibromyalgia can also result in chronic LBP.

 What’s going on in the brain with chronic low back pain?

The brain is constantly receiving sensory information, including sight, sound, touch, temperature, taste, vestibular information, vibration, muscle activation, etc. We all have receptors in our brain called nociceptors that respond to heat, cold, chemical irritants and mechanical compression. If the signals are strong enough, they are sent to the conscious level of your brain and are processed and perceived as pain after we have attached a negative emotional experience to the sensation. Therefore, pain is an experience.

These receptors are firing all the time at a baseline rate. So why are we not all in pain all of the time? We also have anti-nociceptive mechanisms that work to keep much of the incoming information from reaching your conscious level of awareness. It’s only when the important and overwhelming information — like an injury to your body or inflammation — comes in and makes it past this filter to your brain that you register the information as nociception. The final step in this processing is you deciding that you don’t like that information, which adds negative emotion to the experience, and then it becomes pain. Nociception is important because it helps to turn the attention of your immune system toward the site of injury or inflammation to promote healing. As soon as the healing has taken place, nociception should shut off and pain should go away.

When there is an imbalance in the nociceptive and anti-nociceptive systems, the pain signal stay turned up. This imbalance is called central sensitization and can lead to chronic pain, which can explain why pain persists well after the injury has healed. When nociceptive neurons are allowed to continue firing without any inhibition, they become extremely efficient at their job. This can cause hyperalgesia, where something that normally hurts a little suddenly hurts a lot, like bumping your elbow feels like a stabbing pain in your elbow. It may also cause allodynia, when something that should not hurt, like resting your elbow on a table, suddenly causes pain. Both are abnormal responses to normal sensory stimuli.

Changes in the brain take place when the nociceptive neurons are allowed to become efficient, including the areas associated with pain, fear and threat detection. The amygdala focuses on fear and threats, altering our perception of normal things and making them scary when they cause us pain. The hypothalamus and pituitary gland are involved in creating a stress response to a threat. While this was originally a lifesaving mechanism, it can become debilitating to be living in constant fear and stress. Stress hormones also further sensitize nociceptive neurons, which makes our pain hurt more. The anterior cingulate cortex is responsible for our perception of suffering. When it is chronically activated, it can have a huge impact on our lives. Everything can feel like a challenge, small aches and pains can hurt like a serious injury, negative thoughts and emotions become more frequent and difficult to ignore. Chronic pain patients frequently experience anxiety and depression which is a sign of dysfunctional dorsolateral prefrontal cortex. Anxiety can lead to an increase in stress hormone production, causing the nociceptive neurons to increase in activity, enhancing the cycle of chronic pain.

There are many pieces to examine when working with a patient with chronic pain. This is often what gets missed by the patient and practitioners. By the time the patient is into the experience of chronic pain, the injury has probably healed; it no longer needs to be the focus of the therapies. Instead, we need to focus on the changes that are being made to the various neurological systems that contribute to the chronic pain cycle.

How is chronic low back pain diagnosed?

Low back pain is diagnosed with a medical history and physical exam by a qualified medical professional. Based on what we have discussed in this blog post, a neurological exam should also be performed. Typically, imaging is not required, unless the practitioner wants to rule out specific structural causes of pain. Unfortunately, most cases of LBP do not show any markers that doctors can see on imaging.

How is chronic low back pain usually treated?

The focus of most practitioners is to break the pain cycle with medication, either targeted to manage the pain or inflammation. These treatments include analgesics (Aspirin), NSAIDs (Ibuprofen), muscle relaxants or topical pain relief creams and gels. Many physicians prescribe opioid drugs which should only be used for a short period of time due to their highly addictive nature. Multi-disciplinary approaches to managing chronic pain often incorporate a combination of acupuncture, chiropractic, massage therapy, physiotherapy and behavioural therapy. Further to medication for pain, chronic pain patients are often prescribed anti-depressants or anti-anxiety medications.

Living with chronic LBP is challenging. At Anew, we use a powerful combination of modalities including spinal manipulation to ensure every relevant aspect that is contributing to your chronic low back pain is addressed. We focus on getting your life back on track. And remember, we are with you every step of the way.