<>A large Cochrane review of 65 trials (11 237 patients) of nonsteroidal anti-inflammatory drugs (NSAIDs) and COX-2 inhibitors in the treatment of acute and chronic low back pain showed that NSAIDs had statistically better effects compared with placebo.51 The benefits included global improvement and less additional analgesia requirement. NSAIDs were associated with higher rate of side effects. There was no strong evidence that any one NSAID or COX-2-selective NSAID is clinically superior to the others. NSAIDs were not superior to acetaminophen, but NSAIDs had more side effects. NSAIDs were not more effective that physiotherapy or spinal manipulation for acute low back pain. COX-2-selective NSAIDs had fewer side effects than nonselective NSAIDs.51
<>I found the [Consumer Reports] articles on back pain very disappointing. I hope I can still trust Consumer Reports when shopping for a washing machine, but I have no confidence that I can trust them when looking for an effective medical treatment. They seem not to understand the difference between anecdotes and data, between a popularity contest and a controlled scientific study. These articles may do harm by encouraging readers to try treatments that don’t work and by suggesting that it is reasonable to prioritize testimonial evidence over scientific studies. On the other hand, these articles may do some good insofar as they may dissuade some patients from rushing to a doctor and demanding imaging studies or prescription drugs.
<>Dr. Richard Deyo, one of the great myth busters of low back pain research, believes that “low back pain is second to upper respiratory problems as a symptom-related reason for visits to a physician” — only the common cold causes more complaints. Hart et al puts low back pain in fifth place (lower because Hart oddly excludes chronic low back pain). Chronic low back pain is usually the kind that this book will examine. Andersson writes: “Although the literature is filled with information about the prevalence and incidence of back pain in general, there is less information about chronic back pain … .” Indeed, it is almost impossible to measure how much chronic low back pain there is: for every time that acute low back pain is the main reason for a visit to a physician, how many times does a patient mention low back pain as a secondary problem? Or sees an alternative health care professional about it instead? (Answer: pretty danged often.) So it’s actually possible that low back pain is the single most common reason that people seek help. BACK TO TEXT
<>Muscle relaxants: Muscle spasm is not universally accepted as a cause of back pain, and most relaxants have no effect on muscle spasm. Muscle relaxants may be more effective than a placebo (sugar pill) in treating back pain, but none has been shown to be superior to NSAIDs. No additional benefit is gained by using muscle relaxants in combination with NSAIDs over using NSAIDs alone. Muscle relaxants cause drowsiness in up to 30% of people taking them. Their use is not routinely recommended.
<>Whether or not research can prove that massage therapy helps, many people report that it relaxes them and eases chronic pain. In a 2009 research review published in Spine, researchers reviewed 13 clinical trials on the use of massage in the treatment of back pain. The study authors concluded that massage "might be beneficial for patients with subacute and chronic nonspecific low back pain, especially when combined with exercises and education." The authors called for further studies that might help determine whether massage is a cost-effective treatment for low back pain.
<>Stretch. Don't sit slumped in your desk chair all day. Get up every 20 minutes or so and stretch the other way. "Because most of us spend a lot of time bending forward in our jobs, it's important to stand up and stretch backward throughout the day," Reicherter says. Don't forget to also stretch your legs. Some people find relief from their back pain by doing a regular stretching routine, like yoga.
<>Lower back pain can be mild to very severe depending on its underlying causes, how long it’s been left untreated and the state of someone’s overall health. The University of Maryland Medical Center states that several important risk factors for lower back problems include family history of back pain, smoking or using tobacco, being overweight or obese, being female, being anxious or depressed, and either doing too much physical work or living a sedentary lifestyle.
<>Muscle relaxants: Muscle spasm is not universally accepted as a cause of back pain, and most relaxants have no effect on muscle spasm. Muscle relaxants may be more effective than a placebo (sugar pill) in treating back pain, but none has been shown to be superior to NSAIDs. No additional benefit is gained by using muscle relaxants in combination with NSAIDs over using NSAIDs alone. Muscle relaxants cause drowsiness in up to 30% of people taking them. Their use is not routinely recommended.
<>Articles and information on this website may only be copied, reprinted, or redistributed with written permission (but please ask, we like to give written permission!) The purpose of this Blog is to encourage the free exchange of ideas. The entire contents of this website is based upon the opinions of Dave Asprey, unless otherwise noted. Individual articles are based upon the opinions of the respective authors, who may retain copyright as marked. The information on this website is not intended to replace a one-on-one relationship with a qualified health care professional and is not intended as medical advice. It is intended as a sharing of knowledge and information from the personal research and experience of Dave Asprey and the community. We will attempt to keep all objectionable messages off this site; however, it is impossible to review all messages immediately. All messages expressed on The Bulletproof Forum or the Blog, including comments posted to Blog entries, represent the views of the author exclusively and we are not responsible for the content of any message.
<>To relieve pain all over instead of just in one problem area, Dr. Mark Liponis, the chief medical officer at Canyon Ranch in Tucson, Arizona, recommended an inversion table that provides massage. While it may be expensive for some, he said it could be worth it for managing a chronic pain issue. "Over time can help relieve chronic neck and back pain,” Liponis added.
<>Model Zach Job is a New-York based artist and producer who is also an up-and-coming drag queen known as "Glow Job." Zach has aspirations to join a circus and thus has some training in gymnastics, silks/wall running, parkour, boxing, dance, and acro-yoga. He also swings kettlebells at New York's Mark Fisher Fitness, climbs rocks at Brooklyn Boulders, bicycles 10-20 miles every day, and plays competitive dodgeball.
<>Stay strong. Once your low back pain has receded, you can help avert future episodes of back pain by working the muscles that support your lower back, including the back extensor muscles. "They help you maintain the proper posture and alignment of your spine," Reicherter says. Having strong hip, pelvic, and abdominal muscles also gives you more back support. Avoid abdominal crunches, because they can actually put more strain on your back.
<>Pregnancy symptoms can vary from woman to woman, and not all women experience the same symptoms. When women do experience pregnancy symptoms they may include symptoms include missed menstrual period, mood changes, headaches, lower back pain, fatigue, nausea, breast tenderness, and heartburn. Signs and symptoms in late pregnancy include leg swelling and shortness of breath. Options for relief of pregnancy symptoms include exercise, diet, and other lifestyle changes.
<>Prolotherapy has been used to treat back pain for more than 50 years, according to a report by the Cochrane Database of Systematic Reviews. (6) Prolotherapy, including the specific type called PRP or dextrose/glucose prolotherapy treatments, use platelet-rich plasma and sometimes stem cells taken from your own body that contain growth factors that help heal damaged tissues.
<>To understand various causes of low back pain, it is important to appreciate the normal design (anatomy) of the tissues of this area of the body. Important structures of the low back that can be related to symptoms in this region include the bony lumbar spine (vertebrae, singular = vertebra), discs between the vertebrae, ligaments around the spine and discs, spinal cord and nerves, muscles of the low back, internal organs of the pelvis and abdomen, and the skin covering the lumbar area.
<>Acupuncture: Acupuncture may provide even more relief than painkillers, according to one 2013 review. In 11 studies of more than 1,100 people, this Chinese medicine staple improved symptoms of lower back pain better than simulated treatments and, yes, in some cases, NSAIDs. The needles appear to change the way your nerves react and may reduce inflammation around joints (which is only one of the therapy's benefits), says DeStefano.
<>If you have severe back pain, if your back pain has not improved after two weeks, or if you are experiencing any of the following symptoms, you should contact your doctor: numbness in your genital area; pins and needles or numbness/altered sensation down your legs; altered walking patterns, ie losing balance and falling over; unexplained weight loss or gain; or night pain.
<>Braces are not effective in preventing back pain.64 However, there is conflicting evidence to whether braces are effective supplements to other preventive interventions.64 Bracing, in combination with activity restriction, is effective in the treatment of spondylolysis in adolescents.33,42,46,53 A meta-analysis of 15 observational spondylolysis and grade 1 spondylolisthesis treatment studies did not find a significant improvement in rates of healing with bracing when compared with conservative treatment without bracing.37 Most experts recommend surgical consultation for spondylolisthesis with 50% slippage or more (grade 3 and higher).46
<>Exercise therapy appears to be slightly effective at decreasing pain and improving function in adults with chronic low back pain.30 In subacute low back pain, there is weak evidence that a graded activity program improves absenteeism.30 In acute low back pain, exercise therapy was no better than no treatment or conservative treatments. Exercise therapy using individualized regimens, supervision, stretching, and strengthening was associated with the best outcomes. The addition of exercise to other noninvasive therapies was associated with small improvements in pain and function.
<>Ongoing pain can wreak havoc on your life, affecting your cherished relationships, finances, and your ability to get stuff done at work and at home. It can also interrupt your sleep and affect your mood. Because many other problems commonly occur along with chronic lower back pain, anything you can do for yourself that is a natural anti-depressant will help.
<>Massage: There's an upside to your discomfort: It's a legit excuse to get a weekly massage. One study found that people who did had less lower back pain and disability after 10 weeks, compared with the control group—and general relaxation rubdowns worked just as well as structural massage targeted at specific parts of the body. Osteopathic and chiropractic therapies—in which joints and muscles get stretched and repositioned—have been shown to work, too. In a study published in the Annals of Family Medicine
<>Not Enough Activity: Sedentary people experience the same kind of pain for the opposite reasons. Muscles that go unused become stiff and inflexible. Sitting all day causes tight hip-flexors, poor posture and weak abdominals. When your muscles are limited to the same basic body position day in and day out they do not learn to move safely and freely through different ranges of motions and are injured more easily at sudden movements. In addition, the body is one long kinetic chain. Tight hamstrings or hip flexors turn into tight hips and glutes, which pull on the back and create pain.
<>That’s a huge topic, but here’s one simple example of an extremely common problem with back pain science: control groups that don’t control. Rather than comparing a treatment to a good, carefully selected placebo, most studies use a comparison to a treatment that is allegedly neutral, underwhelming, or placebo-ish. That makes the results hard to interpret: if each works about the same, it could mean that the treatments are equally effective … or equally ineffective! So much back pain science has this problem — or any one of a dozen other weak points — that you can effectively ignore at least 80% of all back pain research, because it’s so far from the last word on anything. Good science is essential to solving these problems, but really good studies are also difficult to design and rare. BACK TO TEXT
<>Stay strong. Once your low back pain has receded, you can help avert future episodes of back pain by working the muscles that support your lower back, including the back extensor muscles. "They help you maintain the proper posture and alignment of your spine," Reicherter says. Having strong hip, pelvic, and abdominal muscles also gives you more back support. Avoid abdominal crunches, because they can actually put more strain on your back.
<>For instance, there’s good evidence that educational tutorials are actually effective medicine for pain.?Dear BF, Gandy M, Karin E, et al. The Pain Course: A Randomised Controlled Trial Examining an Internet-Delivered Pain Management Program when Provided with Different Levels of Clinician Support. Pain. 2015 May. PubMed #26039902. Researchers tested a series of web-based pain management tutorials on a group of adults with chronic pain. They all experienced reductions in disability, anxiety, and average pain levels at the end of the eight week experiment as well as three months down the line. “While face-to-face pain management programs are important, many adults with chronic pain can benefit from programs delivered via the internet, and many of them do not need a lot of contact with a clinician in order to benefit.” Good information is good medicine!
<>Why so different? If you pay in United States dollars (USD), your credit card will convert the USD price to your card’s native currency, but the card companies often charge too much for conversion, well above the going exchange rate — it’s a way for them to make a little extra money. So I just offer my customers prices converted at slightly better than the current rate.
<>COX-2 inhibitors, such as celecoxib (Celebrex), are more selective members of NSAIDs. Although increased cost can be a negative factor, the incidence of costly and potentially fatal bleeding in the gastrointestinal tract is clearly less with COX-2 inhibitors than with traditional NSAIDs. Long-term safety (possible increased risk for heart attack or stroke) is currently being evaluated for COX-2 inhibitors and NSAIDs.
<>I accept Visa, Mastercard, and American Express. Discover and JCB are not supported for now, but I hope that will change in the not-too-distant future. Note that my small business does not handle your credit card info: it goes straight to the payment processor (Stripe). You can also pay with PayPal: for more information, click the PayPal button just below. CURRENCY ?
<>Patient Education. Patient education involves a discussion of the often benign nature of acute back pain and reassurance that most patients need little intervention for significant improvement. Patients should be advised to stay as active as possible, within pain limits; to avoid twisting and bending, particularly when lifting; and to return to normal activities as soon as possible. The goal is to reduce worry about back pain and to teach ways to avoid worsening of pain or pain recurrence.
<>Regular updates are a key feature of PainScience.com tutorials. As new science and information becomes available, I upgrade them, and the most recent version is always automatically available to customers. Unlike regular books, and even e-books (which can be obsolete by the time they are published, and can go years between editions) this document is updated at least once every three months and often much more. I also log updates, making it easy for readers to see what’s changed. This tutorial has gotten 134 major and minor updates since I started logging carefully in late 2009 (plus countless minor tweaks and touch-ups).
<>Your core muscles—not just your abdominals, but the muscles that wrap around your midsection—support your spine and lower back. And your core, hips, glutes, and hamstrings together form one big stability machine, so weakness in any one of those muscles forces the others to take up the slack. If you have weak hip and gluteal muscles, for example, as they become fatigued during a run, your lower back is forced to work harder to keep you upright and stable, and you become vulnerable to injury.
<>Learning to keep your cool is as good for your back as it is for your mental health. When you're anxious, your body sets off the "fight or flight" response, which involves tensing your muscles so you're ready to spring into action. One European study revealed that people prone to negative thoughts and anxiety are more likely to suffer from back pain. Get calm now with these stress-busting solutions.
<>Surgery for nonspecific back pain is a last resort as spinal problems are unlikely to be the cause of chronic non-specific back pain in the absence of loss of movement and sensation or other findings such as loss of muscle bulk and reflexes. In cases where the pain spreads into the extremities and imaging studies reveal compression or damage to nerve tissue in the spine, surgery remains a consideration if loss of function as well as pain continues after a trial of conservative treatment with medications and activity modification including a home exercise program and physical therapy.
<>But how do you kow if you’re the exception? Can you recognize the early warning sign of cancer, infection, autoimmune disease, or spinal cord injury? These things often cause other distinctive signs and symptoms, and so they are usually diagnosed promptly. If you are aware of these red flags, you can get checked out when the time is right — but please avoid excessive worry before that.
<>Soft tissue therapies help treat the underlying causes of back pain, such as poor posture, muscular compensations, and weakness through manipulative, hands-on adjustments. These natural therapies can help “turn on” muscles that have been “turned off” due to past injuries and therefore eliminate added stress on painful parts of the back or legs. I recommend finding a practitioner who offers one of the following:
<>I’m writing to congratulate and thank you for your impressive ongoing review of musculoskeletal research. I teach a course, Medicine in Society, at St. Leonards Hospital in Hoxton. I originally stumbled across your website whilst looking for information about pain for my medical students, and have recommended your tutorials to them. Your work deserves special mention for its transparency, evidence base, clear presentation, educational content, regular documented updates, and lack of any commercial promotional material.
<>Opioid analgesics: These drugs are considered an option for pain control in acute back pain. The use of these medications is associated with serious side effects, including dependence, sedation, decreased reaction time, nausea, and clouded judgment. One of the most troublesome side effects is constipation. This occurs in a large percentage of people taking this type of medication for more than a few days. A few studies support their short-term use for temporary pain relief. Their use, however, does not speed recovery.
<>Bleeding in the pelvis is rare without significant trauma and is usually seen in patients who are taking blood-thinning medications, such as warfarin (Coumadin). In these patients, a rapid-onset sciatica pain can be a sign of bleeding in the back of the pelvis and abdomen that is compressing the spinal nerves as they exit to the lower extremities. Infection of the pelvis is infrequent but can be a complication of conditions such as diverticulosis, Crohn's disease, ulcerative colitis, pelvic inflammatory disease with infection of the Fallopian tubes or uterus, and even appendicitis. Pelvic infection is a serious complication of these conditions and is often associated with fever, lowering of blood pressure, and a life-threatening state.
<>The Agency for Healthcare Research and Quality has identified 11 red flags that doctors look for when evaluating a person with back pain. The focus of these red flags is to detect fractures (broken bones), infections, or tumors of the spine. Presence of any of the following red flags associated with low back pain should prompt a visit to your doctor as soon as possible for complete evaluation.
<>Joint Replacement Surgery Bursitis Fibromyalgia Fibrous Dysplasia Growth Plate Injuries Marfan Syndrome Osteogenesis Imperfecta Osteonecrosis Osteopetrosis Osteoporosis Paget’s Disease of Bone Scoliosis Spinal Stenosis Tendinitis Sports Injuries Sports Injuries in Youth: A Guide for Parents Sprains and Strains Back Pain Shoulder Problems Knee Problems Hip Replacement Surgery
<>The presence of any acute nerve dysfunction should also prompt an immediate visit. These would include the inability to walk or inability to raise or lower your foot at the ankle. Also included would be the inability to raise the big toe upward or walk on your heels or stand on your toes. These might indicate an acute nerve injury or compression. Under certain circumstances, this may be an acute neurosurgical emergency.
<>Three systemic reviews3,6,13 analyzed spinal manipulation therapy (SMT) for low back pain, including (1) high-velocity, low-amplitude manipulation of the spinal joints slightly beyond their passive range of motion; (2) high-velocity, low-amplitude technique rotating the thigh and leg; (3) mobilization within passive range of motion; and (4) instrument-based manipulations. There is moderate evidence of short-term pain relief with acute low back pain treated with SMT.6 Chronic low back pain showed moderate improvement with SMT, which is as effective as NSAIDs and more effective than physical therapy in the long term.6 Patients with mixed acute and chronic low back pain had better pain outcomes in the short and long terms compared with McKenzie therapy, medical care, management by physical therapists, soft tissue treatment, and back school.6 SMT was more effective in reducing pain and improving daily activities when compared with sham therapy.3 Dagenais13 found SMT effective in pain reduction in the short-, intermediate-, and long-term management of acute low back pain. However, a Cochrane review in 2004 on SMT in acute and chronic low back pain concluded that there was no difference in pain reduction or ability to perform daily activities with SMT or standard treatments (medications, physical therapy, exercises, back school, or the care of a general practitioner).3
<>I’m writing to congratulate and thank you for your impressive ongoing review of musculoskeletal research. I teach a course, Medicine in Society, at St. Leonards Hospital in Hoxton. I originally stumbled across your website whilst looking for information about pain for my medical students, and have recommended your tutorials to them. Your work deserves special mention for its transparency, evidence base, clear presentation, educational content, regular documented updates, and lack of any commercial promotional material.
<>Try an over-the-counter pain reliever. Anti-inflammatory drugs such as aspirin, ibuprofen (Advil, Motrin, Nuprin), and naproxen sodium (Aleve, Anaprox, Naprosyn) can help reduce back pain. Acetaminophen (Actamin, Panadol, Tylenol) is another over-the-counter option for pain management. Be sure to check with your doctor or pharmacist about any interactions over-the-counter pain relievers may have with other medications you are taking. People with a history of certain medical conditions (such as ulcers, kidney disease, and liver disease) should avoid some medicines.
<>Hyperlordosis (lordotic low back pain) is the second most common cause of adolescent low back pain.18,47 This condition is related to adolescent growth spurts when the axial skeleton grows faster than the surrounding soft tissue, resulting in muscular pain.55 Other causes of low back pain unique to children are vertebral endplate fractures and bacterial infection of the vertebral disk. Adolescents have weaker cartilage in the endplate of the outer annulus fibrosis, allowing avulsion and resulting in symptoms similar to a herniated vertebral disk.58 Additionally, the pediatric lumbar spine has blood vessels that traverse the vertebral bodies and supply the vertebral disk, increasing the chance of developing diskitis.51
<>When you have back pain, sleeping can be hard. It can be a vicious cycle because when you don't get enough sleep, your back pain may feel worse. A poor sleep position can also aggravate back pain. Try lying on your side. Place a pillow between your knees to keep your spine in a neutral position and relieve strain on your back. If you need to sleep on your back, slide a pillow under your knees. Be sure to sleep on a comfortably firm mattress.

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