Low Back Pain

Low back pain is one of the most common sources of chronic pain that can lead to disability and can prevent patients from being able to enjoy their lives. Common approaches to treating low back pain include Physical Therapy, Manipulation, Acupuncture, Pain Medications, Anti-Inflammatory medications, Muscle Relaxants, Steroid injections and Surgery.

At the San Francisco Institute for Integrative and Regenerative Medicine our approach starts with a robust diagnosis. Understanding the specific cause of low back pain is essential to understanding what approach will be effective.

Evaluating the low back and supporting structures requires an intimate knowledge of the physical exam tests, palpatory skill to detect healthy and injured tissue and diagnostic imaging. An X-Ray can be helpful to detect degeneration of disc space, facet joint arthritis, changes in alignment and more serious issues like fractures. A MRI is often ordered when a herniation causing nerve impingement is suspected. This type of imaging is especially helpful for evaluating the discs, nerves, and spinal canal. These are the two most common tests ordered to evaluate an injured low back.

What is commonly missed on both an MRI and X-Ray is the connection between more subtle chronic soft tissue injuries of the ligaments in the low back, pelvis and hip joint. This is where a high resolution ultrasound is essential. Ultrasound is not as commonly ordered because it requires a physician skilled in physical exam and trained in musculoskeletal ultrasonography in order to obtain the appropriate images and be able to interpret them. As an Osteopath, I am able to palpate the areas that appear abnormal on ultrasound in a coordinated fashion to put together a larger picture of the chain of biomechanical stress into the low back as well as determine if the primary pain generator is a referred pain from an injured hip extensor, vertebra out of alignment, sprained ligament, strained muscle, or more serious pathology such as a herniated disc or fracture or, in some cases, a combination of all of these.

One of the most common causes of low back pain is a vertebra that has become stuck out of alignment. Other common sources of low back pain are sprained ligaments that stabilize the vertebra and strained muscles that protect the spine.

In the acute stage, a vertebra out of alignment can be simply adjusted by manipulation and moved back into alignment. If this is the only cause then often there is instant relief and return of full range of motion. If there is also a muscle strain or ligament sprain then it will be better but may require a few days to a few weeks to fully recover. During this period, Acupuncture, Biopuncture, Myofascial release or other soft tissue forms of manipulation can help support healing of the soft tissue. Medications can be prescribed to help provide relief in between these treatments and supplements can help support the innate healing capacity to accelerate the healing process. Physical therapy exercises such as stretching and light exercise can be helpful but over exercising the injured area may exacerbate the injury or elicit guarding from other muscles and compound the problem or cause further misalignment issues. If the injury is severe enough in the acute phase then Regenerative Injections such as Prolotherapy, Platelet Rich Plasma or Amniotic Membrane derived growth factors can be used to accelerate healing.

Chronic low back pain can also develop from recurrent episodes of acute sprains and strains. In this case, the area has failed to heal and the body is no longer responding with the growth factors necessary to heal the area. This is where Regenerative Injections can become essential to healing. Physical therapy is also essential to help strengthen the muscles to support the injured area.

If chronic low back pain or even recurrent acute sprains and strains are not properly rehabilitated then patients can develop more serious causes of low back pain such as herniated discs, spinal stenosis, and nerve impingement. Depending on the severity, surgery can be warranted but in my experience the majority of these patients can be treated using regenerative injection therapy to help address the underlying causes as well as the end effects of the spinal pathology. Physical therapy is essential to supporting and maintaining the health of the spine as well. Regenerative Medicine utilizes the body’s innate healing capacity to restart the healing process in areas that have stopped healing or have a poor blood supply to begin with. Applying regenerative agents correctly involves understanding the pain generator but more importantly it involves treating the system in which that pain generator has occurred. In the low back, often it is weak hip extensors that are not supporting the low back, causing the low back muscles, hip flexors and hamstrings to over work. This is often compounded by ligamentous laxity of the ligaments that stabilize the vertebra, facets, sacroiliac joint and hip joint.

Other less recognized factors that can contribute to chronic inflammation, soft tissue degeneration, and arthritis of the spine are poor nutrition, stress, imbalances of the microbiome of the digestive tract, food sensitivities, metabolic disorders like diabetes, hormonal imbalances and deficiencies and poor ergonomics at work or home. In any given case some or all of these factors may be the primary cause perpetuating chronic low back pain and accelerating the wear and tear to the area. The field of Functional Medicine is about addressing these types of systemic factors to help optimize the system of the patient so they are able to heal to their fullest potential.

At the San Francisco Institute for Integrative and Regenerative Medicine our approach is to obtain a robust understanding of the underlying causes of the symptoms that patients hope to address. Combining services such as Functional Medicine with Regenerative medicine, Acupuncture, Biopuncture, Osteopathic Manipulative Medicine, Physical Therapy, and medical management, including referral when appropriate, allows the treatment to be dictated by the underlying cause of the problem rather than being limited by the services offered.