Surgery for back pain?
Many people struggling with back pain have no doubt wondered if having back surgery would help their back pain, if not make it go away entirely. So does surgery help low back pain?
Well, while we all probably know people who have done well after having back surgery, and some who haven't, that's not a good way to decide if surgery is helpful or not - because it only tells us how a few people did. No, what one really needs to do is look at studies that have been done where researchers have carefully followed many, many people over a long period of time to see how helpful surgery REALLY was. Then and only then will you know how helpful (or not helpful) surgery is for the majority of people.
Now while there are literally HUNDREDS of studies out there on surgery and back pain, we're really interested in the highest quality ones, those being the type called randomized controlled trials. That's because these are the best done studies of all, and if you really want to prove that something in medicine works, well, you conduct a randomized controlled trial (RCT). New cancer treatments, new drugs, etc - they all are tested in RCT's - as surgical procedures should be too.
Interestingly though, there aren't really that many RCT's that have been done where back surgery has been compared to conservative treatment - conservative treatments being things like exercises or traction. However here's a few of the handful that have been recently conducted...
- one study (Osterman 2006)) published in Spine, took 56 patients with herniated discs and nerve compression, and randomized them to surgery (microdiscectomy) OR exercises. The results? There were no clinically significant differences between the patients who underwent microdiskectomy and those allocated to conservative treatment over a TWO year follow-up - no difference in leg or back pain intensity, subjective disability, or health related quality of life.
- another study (Peul 2007) published in the prestigious New England Journal of Medicine, took 283 patients who had severe sciatica and randomly assigned them to surgery (to remove the disc compressing the nerve) OR get pain meds, physical therapy, and advice to stay active. So what happened? Interestingly, after one year, both groups were doing the SAME.
Of course sometimes surgeons feel like removing discs aren't enough. Sometimes they take another approach and prefer to fuse vertebrae in the spine together...
- published in the journal Spine, this study (Brox 2003) took 64 patients with low back pain lasting longer than a year, and randomly assigned them to have vertebrae in their spine fused OR get exercises plus informational sessions designed to be reassuring and to encourage activities. So who did better after one year's time? The patients improved to the same degree and at the same rate whether they underwent fusion or exercises/advice to stay active.
- finally, a study published in the British Medical Journal (Fairbank 2005) took 349 people with low back pain for more than a year, and randomly assigned them to get either spinal fusion OR exercise. So how'd they end up doing? Both groups improved over the course of the next two years with no important differences in the rate or degree of improvement.
Apparently surgery is far from a home-run cure for low back pain. Of course this is not to say it is useless in all cases, it's just that with no less than four randomized controlled trials telling us that having back surgery is no better that conservative treatments like exercise, well, it should raise a few questions about its effectiveness - especially when surgery carries risks, as well as other problems such as scar tissue and adjacent segment breakdown.
Jim Johnson, PT
What's the best way to sit?
Now there's a question I get asked a lot. If you asked me this when I first graduated from physical therapy school, I would have told you to sit up straight and use a small pillow or towel to support your lower back curve. However after reading much orthopaedic back literature. I am far from convinced that sitting up straight is the best posture for the spine from a mechanical standpoint. Here's what the literature from peer-reviewed journals has uncovered about the sitting posture...
- an x-ray study by Fahrni and coworkers (1965) done on members of certain tribes that live in underdeveloped jungle environments and who habitually sit or squat in positions that greatly bend the back show that they have considerably LESS degenerative changes in their discs than more urban people. Now one would think that if a bent lower back position was so horrible for your back (the same position that these tribe members spend much of their time in) that they would have the worst looking spines on x-rays. Isn't it interesting that they actually had healthier discs that you or I?
- There is actually less stress placed on the facet joints, the tiny little joints of the spine, when one sits in a "slouched" position (Adams 1886). This is because sitting up straight actually pushes the two sides of the joint closer together - making them come into more contact with each other - and creates more compression at the joint surfaces.
- The flow of nutrients to your spine is actually better when you sit in a flexed or "slouched" posture (Adams 1985). And the better the supply of these vital nutrients you have, the better off your spine is. I can only speculate, but perhaps this is one reason why the tribe members mentioned above actually had better discs than most people.
- Creep, that is the continued deformation of tissues (like the discs) over time in response to a sustained load (as in sitting), is actually greater when one sits up straight - than when sitting slouched (Hedman 1995). In layman's terms, this means that sitting up straight makes the spine measure shorter after a period of time, than when one sits in a slouched position. This is because the tissues are deformed more while sitting up straight compared to sitting with the spine bent.
- sitting in a slouched or flexed posture dynamically widens and opens up the neural foramens (holes) where the spinal nerves pass through (Inufusa 1996). This can be especially beneficial in conditions such as spinal stenosis, where things like bone spurs are making the holes smaller and crowd out nerves. On the other hand, sitting up straight makes the holes where the nerves pass through smaller.
And now the evidence for sitting up straight...
- sitting up straight increases disc pressure. This is true, but it has never been shown that this is a bad thing for a normal back. Incidentally, every time you contract your muscles, the intramuscular pressure (the pressure inside the muscle) also shoots up as well. Increased pressure is just part of the way things work in our bodies as we move. Furthermore, in the sitting posture, the compressive force of the spine is about 1000 Newtons, or less than 1/10 of the force required to actually cause failure of the spine.
- your mother probably told you to
All jokes aside, my point is that there is really no conclusive evidence from peer-reviewed journals that pinpoints sitting up straight as being the best posture for your back. In fact, the evidence appears to point in the OPPOSITE direction - sitting in a flexed or slouched position having many benefits for the spine.
So now that you have the above information, I'll tell you my answer to the question "What's the best way to sit?" It is threefold...
- from a mechanical standpoint, the best way to sit appears to be with the back in a slightly flexed or "slouched" position. And let's face it, its a position we all seem to end up in anyway.
- of course there are always exceptions to every rule. An obvious example is a patient with a confirmed acute disc herniation. For instance, let's say you bent over to lift a heavy box, perhaps felt a "pop" , and an MRI showed a herniated disk that exactly matches your symptoms. In that case, I would advise sitting up straight with a support for your low back, at least until symptoms improve. We do know that sitting slumped and with the back in a flexed position does indeed increase disc pressure - something obviously not good for an acute disc herniation that's trying to heal. But then again, I have never met a patient with an acute disc herniation who was able to sit slouched anyway - it simply hurts too much. Mother Nature seems to know best...
- my bottom line answer: it's not good for your spine to sit in ANY one position for a long period of time, but when you must, sit in the position you are most comfortable in - and stop feeling guilty for it!
JIm Johnson, PT
Stretching hasn't helped your back pain?
Try doing it this way...
If you've never tried stretching to get rid of your back pain you should. Stretching is a good tool to use if done CORRECTLY. On the other hand, If have tried it, and it didn't help your back one bit, well, I'm not surprised - it has to be done CORRECTLY. You'll notice I keep emphasizing CORRECTLY...
USE THESE STRETCHING SECRETS TO SUCCEED
While there are many different techniques to choose from when it comes to stretching out tight back muscles, by far the easiest and least complicated way is known as the static stretch. A static (or stationary) stretch takes a tight muscle, puts it in a lengthened position, and keeps it there for a certain period of time. For instance, if you wanted to use the static stretch technique to make the hamstring muscle on the back of your thigh more flexible, you could simply bend over with your knees straight and try to touch your toes. Thus, as you are holding this position, the muscle is being statically stretched. There's no bouncing, just a gentle, sustained stretch.
It sounds easy, perhaps a bit too easy, so you may be wondering at this point just how effective static stretching really is when it comes to making one more flexible. Well, a quick review of the stretching research pretty much lays it out straight as there are multiple randomized controlled trials clearly in agreement that this is a winning method. Here are the highlights...
- a study published in the journal Physical Therapy took 57 subjects and randomly divided them up into four groups (Bandy 1994).
- the first group held their static stretch for a length of 15 seconds, the second group for 30 seconds, and the third for 60. The fourth group (the control group) did not stretch at all.
- all three groups performed one stretch a day, five days a week, for six weeks
- results showed that holding a stretch for a period of 30 seconds was just as effective at increasing flexibility as holding one for 60 seconds. Also, holding a stretch for a period of 30 seconds was much more effective than holding one for 15 seconds or (of course) not stretching at all.
Hmm. Looks like if you hold a stretch for 15 seconds, it doesn't do much to make you more flexible. On the other hand, holding a stretch for 30 full seconds does work-and just as well as 60 seconds.
Wow. So now that we know 30 seconds seems to be the magic number, makes you wonder if doing a bunch of 30-second stretches would be even better than doing it one time like they did in the study...
- another randomized controlled trial done several years later (Bandy 1997) set out to research not only the optimal length of time to hold a static stretch, but also the optimal number of times to do it
- 93 subjects were recruited and randomly placed into one of five groups: 1) perform three 1-minute stretches; 2) perform three 30-second stretches; 3) perform a 1-minute stretch; 4) perform a 30-second stretch; or 5) do no stretching at all (the control group)
- the results? Not so surprising was the fact that all groups that stretched became more flexible than the control group that didn't stretch.
- however what was surprising was the finding that among the groups that did stretch, no one group became more flexible than the other!
- in other words, the researchers found that as far as trying to become more flexible, it made no difference whether the stretching time was increased from 30 to 60 seconds, OR when the frequency was changed from doing one stretch a day to doing three stretches a day
So here we have yet another randomized controlled trial (the kind of study that provides the highest form of proof in medicine) which is showing us once again that holding a stretch for 30-seconds is just as effective as holding it for 60 seconds. And to top it all off, doing the 30-second stretch once is just as good as if you did it three times!
Interestingly, other randomized controlled trials have also supported the effectiveness of the 30-second stretch done one time a day, five days a week, to make one more flexible (Bandy 1998). Fantastic!
So as the randomized controlled trials clearly point out, it really doesn't take a lot of time to stretch out tight muscles IF you know how. Based on the current published stretching research, the following guidelines are recommended for the average person needing to stretch out a tight muscle with the static stretch technique:
1) get into the starting position
2) next, begin moving into the stretch position until a gentle stretch is felt
3) once this position is achieved, hold for a full 30 seconds
4) when the 30 seconds is up, slowly release the stretch
5) do this one time a day, five days a week
Now that you know the correct way to stretch, use the above guidelines to make your stretching more effective.
Jim Johnson, PT
Does losing weight help low back pain?
In my opinion, blaming someone's low back pain primarily on their weight is usually just a scapegoat. I admit it is tempting, and even logical. Patients also bring this to my attention at times, saying something like, "Do you think my weight has anything to do with it?". My reply used to be, "Well, it's possible. Certainly losing some weight couldn't hurt." Well, that's what I used to say.
In 2000, an article by Leboeuf-Yde came out in the peer-reviewed journal Spine that looked at all the literature on the link between back pain and body weight. This is by far the most comprehensive review I have ever read on this subject and still haven't found another analysis to date that has done a good a job. Here's a brief summary...
- the study reviewed some 65 articles on weight and back pain
- 68% of the 65 studies included in the review showed NO association between obesity and back pain
- the researchers concluded, that after 30 years of research on this topic, there was not enough evidence to determine that body weight is a true cause of low back pain
So contrary to popular belief, the majority of studies actually show NO link at all between being overweight and having low back pain. Furthermore, I do not know of any evidence showing that losing weight is effective for treating low back pain.
Now don't get me wrong, I am very much in favor of a person losing their excess pounds, but for general health reasons - not as a specific treatment for back pain. So if you are overweight and suffer with low back pain, I would investigate reasons other than your weight as the primary cause of your problem.
Jim Johnson, PT
True or False:
There are lots of people with abnormal discs that have NO pain.
For those who have back pain and have been told that they have a herniated disc, disc bulge, or "slipped disc", know that it may or may not be the cause of your back pain...
- a study in the New England Journal of Medicine took 98 people with NO back pain, and took MRI's of their low backs to see what kind of shape their discs were in (Jensen 1994)
- only 36% of subjects had normal discs. The other 64% had abnormalities such as bulges and protrusions.
So it appears that there are MANY people walking around with abnormal discs. but have NO back pain. At this point, some may be thinking, "Well, they may not have pain now, but with a herniated disc in their back, they're bound to have back pain sooner or later."
Well, maybe not...
- in 1989, a group of 67 people with no history of back pain underwent MRI scans of their low back (Borenstein 2001)
- 31% were found to have an abnormality of a disc or of the spinal canal
- 50 of these patients were re-scanned SEVEN years later
- seven years later, 42% had developed back pain, however most of those had no specific disc problems that could be seen on the MRI scans back in 1989
- therefore, the MRI scans were not predictive of the development or duration of low-back pain, and those people who ended up with the worst low-back pain were not the ones with the big disc problems seen on the original 1989 scans.
Apparently, according to published studies, it's quite possible to have a herniated disc in your low back and have NO pain. And furthermore, if you do have an asymptomatic herniated disc, it doesn't mean that you're going to have any more pain in the future than anyone else.
So if things like disc herniations aren't necessarily associated with one having back pain, what is?
Well, if you put aside STRUCTURAL back abnormalities for a moment, and take a look at research on FUNCTIONAL back abnormalities, you get a little different view on things.
For instance, there's a critical muscle in your back known as the multifidus, and when researchers take low back pain patients and examine it, they find that it's SMALLER, WEAKER, and simply not contracting like it should!
But perhaps the most interesting thing about multifidus problems, is that unlike herniated discs, you do NOT find multifidus muscle problems in pain-free individuals to any large degree. For instance...
- a study was published in Spine where researchers, using EMG, examined 35 individuals with NO back pain (Haig 1995). They concluded that pain-free backs have few, if any EMG abnormalities in their multifidus muscles.
- Stein (1993) also found the same to be true in his subjects that had NO back pain
And that's just when researchers look at the multifidus muscle of people with no back pain using EMG's. In studies where tissue samples from people with no back pain are examined under a microscope, only around 1 to 5 percent at most are found to be abnormal.
So what's this all mean for the person with low back pain?
Well, while we can find plenty of abnormal discs in people with back pain, we can also find plenty of abnormal discs in people WITHOUT back pain (up to 64%).
However this is not the case with multifidus abnormalities. Problems with the multifidus muscles are plentiful in people with back pain, but hardly ever seen in pain-free individuals (1 to 5%). The moral of the story? If you have back pain, make sure your multifidus muscles are in good shape.
Jim Johnson, PT
Maybe a weak multifidus muscle
is contributing to your back pain?
Not many people have heard of the multifidus muscles, but everyone has them, and if you have low back pain that won't seem to go away, it's time you found out more.
Why? Simply because the research has literally been piling up showing that this back muscle is abnormal in many people with back pain. For instance, if you have a herniated disc, have had back surgery, have an unstable vertebrae, or just plain chronic (long-term) back pain, well, there's a GOOD chance you have a problem with your multifidus muscle.
But what kind of problem? Well, in most cases, its smaller on one side of the back, and if you stick it with an EMG needle, it's clearly not contracting like it should!
Sounds horrible, but don't worry too much yet, because with the proper exercises, its entirely possible to get it bigger and working again. Much research has shown this, for instance...
- one randomized controlled trial involved 44 patients that had unstable vertebrae in their lumbar spine (O'Sullivan 1997). At the end of the study, only those patients that did specific exercises for their multifidus muscles showed huge reductions in their back pain.
- another randomized controlled trial studied 54 chronic back pain sufferers (Risch 1993). One group sat on a waiting list, while the other group exercised their multifidus muscles. At the end of the study, only the group that exercised their multiifidus showed marked decreases in back pain.
As you can see, not only has the published research found a big connection between back pain and abnormal multifidus muscles, but the problem can be fixed with the right exercises.
Jim Johnson, PT
The multifidus and spinal stenosis
Anyone struggling with back pain should be aware of a condition known as spinal stenosis. What is it? Well, simply put, spinal stenosis is arthritis of the back. And why is it so important to know about? Because many of the well-known spinal problems people have are often involved in the process of spinal stenosis. In fact, if you have any of the following, spinal stenosis could be causing your back and leg pain...
- a bulging or heniated disc
- bone spurs
- one vertebrae slipping on top the other
- compressed nerves
- unstable vertebrae
But while spinal stenosis usually brings to mind images of bone spurs, pinched nerves, a wornout spine and pain, few people know that scientific studies have shown up to 69% of people over the age of 55 to have spinal stenosis on an MRI exam, but no pain! Clearly radiographic pictures of one's spine do not tell the whole tale, as there are many people that are able to live pain-free with spinal stenosis...
But if having a horrible looking spine on an MRI doesn't necessarily mean you'll have pain, then what does?
Well, consider the study that checked out the back muscles of spinal stenosis patients with an EMG - and found that 17 out of 22 of them had abnormalities! Apparently there are OTHER factors involved that might determine if one will have painful spinal stenosis or not.
Interestingly, much published spinal research is now identifying specific problems that people with painful spinal stenosis have, problems such as decreased back proprioception, or multifidus back muscles that simply don't contract like they should. And this is why it is sometimes wise to pay less attention to how your back looks on an MRI or X-ray, and more on how it is functioning.
Jim Johnson, PT