Low back pain due DJD is one of the most complicated case, from my experience, I found that, it is important to stay active, do exercise for Para-vertebral muscles strength, stretching back muscles and lower extremities muscles, and William flexion exercise , These activities may be achieved through swimming.

Hi,

As you noted, aetiology of back pain is very complex. Any meaningful answer is probably beyond scope of RG message box.

You best bet would be to check out recent reviews of the available evidence, e.g. Cochrane reviews.

http://www.cochranelibrary.com/topic/Rheumatology/Back%20disorders/Non-specific%20low%20back%20pain/

http://back.cochrane.org/our-reviews

Hope it helps.

Take care.

Thank you for the answers. In your experience, what is the role of medication in treating chronic LBP patients?

Before any recomendation we need to know why, when and how the pain and guide the person to understand what he or she should not do to exacerbate the pain. My 33 years practice the SI condition is much much prevalent than low back but treat like low back.

Degenerative joint conditions can be both due to injuries and age related conditions in addition to certain surgical procedures done at or near the joints. In my opinion, most of the chronic low back pain is due to either discogenic that may cause stenosis of the canal or foramen, or the deterioration of the facet joints. The SI joints are not very mobile and dynamic joints and are difficult to assess as a primary diagnosis or main source of pain. I realize there are school of thoughts out there especially among physical therapists who believe the hips and SI joints are fundamental in treating low back pain even though I haven't seen tremendous success in treating long term pain complaints no matter what the etiology. I have found the "extension" maneuvers that often used by physical therapist in their initial regimen work quite well in most cases other than spinal stenosis.

I like some comments or insight regarding McKenzie approach as the primary regimen to treat LBP. I'd like to hear other clinicians' experience in applying McKenzie in their treatment plan. Personally, I have seen very high success rate in treating lumbar radiculopathy due to protruding or ruptured disk using McKenzie. Recently, we were able to reverse a right sided nerve root impingement from a bulging disk causing neural foramen stenosis resulting in drop foot by doing intensive McKenzie principles.

You might want to review this 2014 paper which found that bracing with an inelastic corset style LSO, provided pain relief and clinically significant reductions in ODI for up to 65% of patients who were getting PT. Staying active is accepted as being beneficial and the study suggests that bracing can help.

https://www.ncbi.nlm.nih.gov/pubmed/?term=A+randomized+clinical+trial+comparing+extensible+and+inextensible+lumbosacral+orthoses+and+standard+care+alone+in+the+management+of+lower+back+pain

Thank you, Geoffrey Garth, for your response. I do give patients LSO to help them manage chronic low back pain especially during certain activities that require repetitive bending and lifting. The LSO does stiffen the trunk thus preventing it from excessive forward flexion which often "is" the cause of posterior disc herniation by opening the posterior disc space and putting anterior pressure when returning upright especially in a loaded position such as lifting. However, there are some thoughts that prolonged use of LSO may not be good for the core muscle strength even though there are studies that completely discredit the abdominal core muscle theory. In one study done by "Lederman", he dismissed the theory that abdominal muscles play a role in low back pain both in the cause and the treatment and debunked the popular exercises of strengthening core muscles for back pain.

Lederman_The_myth_of_core_stability

Thanks for your answer. Lederman, in the article above, debunks the validity of core muscle theory. It's explained that there's no relationship between core muscle strength and the cause or the improvement of low back pain. His argument is very strong and based on very compelling research data regarding the core muscles and back pain. I believe that general aerobic exercises are very beneficial in relieving day to day symptoms of chronic low back pain regardless of the cause. People can choose which aerobic exercise they prefer and that is easiest to adhere. My rationale behind the exercises is simply because aerobic exercises have multiple health benefit to different organs from bones and muscles to the cardiovascular system. Some "feel good" hormones are also being produced as byproduct of the exercise. People with back pain often complain of the their back being very stiff. The stiffness could often be due to the tightening of the para-spinal muscles that are guarding the spine from any sudden or further movement. The initial presentation of an acute injury to the back no matter what the etiology is usually accompanied by muscle spasm to the back, the para-spinal musculature, which cause even more pain due to the spasm. I've never seen of any "core muscle" involvement during the presentation. Aerobic exercises may help the para-spinal muscles to put the guard down and back into its relax and resting state effectively reducing or even eliminating the pain.

Weight loss is usually a good advice to most people that are extremely overweight or obese to ease the load not just to the spine but to the knees as well. However, to maintain a good posture throughout the day in all activities is also very crucial in managing chronic back pain.

PRP or platelet rich plasma injection has also been used to treat disc disease of the spine. I have very limited experience in using this treatment modality in treating chronic back pain. I only have one patient with disc disease of the cervical spine from sport injury that opted to take this type of treatment with satisfactory outcome. Most of the time, I reserve this type of alternative treatment to the injuries of the knees, shoulders, or the Achilles tendon which has poor blood supply. I'd like to hear experiences from others regarding PRP injection in the treatment of back pain.

Another consideration in treating chronic lower back pain due to DJD or mechanical injuries is the fact that the back joints have become unstable as a result. The various ligaments that support the spine have lost their ability to keep the spine in good alignment all the time especially during prolonged static postures such as in sleeping, prolonged sitting and standing. For example, people often experience back pain upon getting out of bed in the morning or getting up from a prolonged sitting. I believe the ligaments that connect and support our back bones are no longer working as they should to keep the spine in good alignment. Therefore upon rising, our spinal muscles will involuntarily tighten which causes pain in an effort to guard from further derangement or misalignment within the spinal joints that may occur from the sudden movement and change in postures. The thoracolumbar fascia and core muscles may have significant roles in helping the lumbar spine to regain its stability and correct alignment by noting that simple maneuvers such as side lying in fetal position or knee to chest flexion may ease the spinal muscle tightness by causing the fascia to tighten thus realign the spinal joints. The core muscle exercises such as the pelvic rocking or Kegel's exercise may serve as a brace to the lower back. My advice to patients is to learn what works and what doesn't work and try to learn and understand their condition as much as possible so the daily exercises become part of their lives.

Sorry!!! The "Enter" button on my computer got stuck and caused the duplicate answers above. Oops!

I have also observed that many people who suffer low back pain from various etiology with the exception of spinal stenosis find some relief from the muscle tightness by lying prone. Lying prone tends to restore the lumbar lordosis by virtue of gravity and restore the paraspinal muscles around the lumbar area to its resting state thus ease muscle tightness or spasm. I have noticed that patients often able to get up and move much better from a prone position than supine.

Anyone out there cares to comment or give a more in depth insight regarding chronic back pain management using injections such as injections into the epidural space or facet joints? I usually only use this method when all else has failed and patients are in terrible pain not relieved by any other noninvasive or nonsurgical interventions. I like to compare my finding from the result of my own patients to other clinicians who have tried and used the injection intervention. I have seen and am aware of studies regarding the subject but am more interested in the experience of regular practitioners who treat patients in their regular clinics outside any formal studies.

I would like to add one trivial finding that I have observed through the years treating patients with back pain. I sometimes ask patients to do toe walking to quickly assess the integrity of the motor strength and the nerve that innervates the ankle movements. I have observed that by raising the heels, the lumbar spine is inevitably made to extend itself. Extension of the lumbar spine may ease some of the problem caused by protruding disc disease. The question now becomes "can raised heels alleviate lower back pain due to certain cause such as herniated disc?" I haven't read or am not aware of any research regarding this matter. If any of you would give me your thoughts and comments regarding this issue, it'll add another arsenal to help people with low back pain.

While the radiating pain to the extremities can often be traced back to the nerve root irritation or central canal stenosis by looking at the MRI result and/or electrodiagnostic studies matching with the physical examination findings, the localized pain that often occurs across the lumbar spine may be largely due to the para-spinal muscle spasm to the area. Strain to the back muscles or sprain to the ligaments from repeated bending and lifting or a sudden awkward movement will usually result in the back muscle spasm which will undoubtedly contribute to the overall pain experience. Muscle spasm is usually one of the predominant complaints and findings in back pain no matter what the underlying etiology whether it's only a simple strain/sprain or a more complicated problem such as disc disease or degenerative joint disease. The body will somehow automatically "guard" the all important spine by producing muscle spasm to prevent the spine from further mobility which in turn causes increased pain to the area. It is a vicious cycle. Pain begets more pain. In my medical practice, reducing and eliminating muscle spasm by learning self muscle relaxation technique is often the best way and most lasting method to care for the achy back without pharmacologic.

Many people that experience back pain will often tell you that they can't move because of their back is so stiff, and any movement involving the back is very painful. The cause of the localized pain can often be traced to the muscles and soft issues surrounding the area. Some brace that corrects and supports the posture may relieve some tension and ease the pain by helping the muscles and soft tissue to relax. Physicians often prescribe muscle relaxant in conjunction with pain medication to deal with patients' back complaints. Muscle relaxant often works centrally which causes other unintended side effects such as drowsiness and dizziness. Warm compress that is applied directly to the area will dilate the blood vessels, thus effectively increase the circulation and deliver more oxygen and nutrients to the area. The muscles and soft tissues will naturally expand and relax because of the warmth effect. The increased local temperature will also increase sensory fibers to the skin, and in return will decrease the pain signal to the brain effectively reduce the overall pain experience.