ARE YOU TIRED OF LIVING WITH LOW BACK PAIN?

By Fred G. Arnold, DC, NMD

INTRODUCTION AND STATISTICS
Low back pain is also referred to as backache and lumbago and is one of the most common health conditions why people see a doctor. If you haven’t experience low back pain up to this point in your life, the odds are you will sometime in the future. The statistics involving low back pain are alarming with approximately, 70 to 85 percent of all people having back pain at some time in their life. Low back pain is the fifth most common reason for all physician visits in the United States.9,6 Approximately 2 percent of the U.S. work force is compensated for back injuries each year.6 Americans spend at least $50 Billion per year on back pain—and that’s just for the more easily identified costs. 18.

Low back pain (LBP) is defined as acute if it lasts less than 3 months and is considered chronic after 3 months. Approximately 2-8% of people with low back pain will develop a chronic pain condition. Of those individuals who remain disabled for more than 6 months, fewer than half return to work, and after 2 years of LBP disability, a return to work is even more unlikely. 2

LOW BACK ANATOMY
The anatomy of the low back refers to the lumbar spine and the sacro-iliac joints that are part of the pelvis. The lumbar spine is normally composed of 5 lumbar vertebrae with each vertebra separated by a disc. The disc is the space between the vertebrae and acts as a cushion to buffer and distribute weight in the low back. The lumbar vertebrae connect to each other by facet joints and there are 4 different facet joints for each lumbar vertebra. Running through the lumbar spinal vertebrae are extensions from the spinal cord and exiting between each vertebrae are spinal nerves. In the pelvis are located the two very critical sacroiliac joints, formed by the sacrum and ileum bones on each side. Both the lumbar vertebrae and the sacroiliac joints are held together by many connecting supportive tissues called ligaments. Ligaments connect bone to bone and are critical to the support, strength and integrity of each bone that they attach to. When these ligaments are overstretched as during overuse or an injury this is referred to as a sprain. Also connecting to the lumbar spine and the pelvis are a vast array of muscles. Our muscles also provide strength and stability to the low back and it is the contraction or shortening of our muscles that allow for our back to move in different directions. At the end of each muscle is a tendon that connects to a specific bone. Tendons connect muscles to bones and when a tendon attachment is injured or overused this is referred to as a strain.

CAUSES OF LOW BACK PAIN
Most cases of low back pain (98%) are mechanical or non-organic—meaning they are not caused by serious conditions, such as inflammatory arthritis, infection, fracture or cancer. 3 It should be understood that each ligament, muscle and tendon, facet joint, and disc are each supplied by a unique system of nerves and is capable of causing pain independently or in combination. While disc problems have gotten much of the credit for low back pain, ligament injury is a more important source of back pain. 15. In fact, it has been reported that only 4 percent of low back pain is due to a disc problem, such as a herniated disc. 10 Most low back pain is triggered by some combination of overuse and injury to the muscles and tendons, ligaments, and discs that support the spine. Dr. Hackett, who is considered the father of prolotherapy, injected salt solutions into various ligaments and discovered a particular pattern of referred pain from the ligaments in the low lumbar and sacroiliac regions. 8

The causes of pain in the low back pain in the lumbar and sacroiliac regions, tend to add on to one another. This leads to a constant tension on the muscles, ligaments, bones, and discs, making the back more prone to injury or re-injury For example, after straining muscles, you are likely to walk or move in different ways to avoid pain or to use muscles that aren't sore. That can cause you to strain other muscles that don't usually move that way and create stress on the facet joints, sacroiliac joints, discs and even cause nerve root compression. Compression of nerve roots that exit between the vertebrae can cause a condition called sciatica. A disc condition can be brought on by repeated vibration or motion (as during machine use or sport activity, or when lifting improperly), or by a sudden heavy strain or increased pressure to the lower back. Although osteoarthritis (joint degeneration), is a condition that develops as we age, it can be accelerated by imbalances in the musculo-skeletal system of the low back.

Another cause of low back pain is called Failed Back Surgery Syndrome (FBSS), which means that a person is still having significant painful symptoms after back surgery. Although, the prevalence of FBSS in the United States is not exactly known, it has been estimated to affect nearly 30-50 percent of spinal surgery patients, depending upon the study.12,4 There are a number of different reasons why a person will have experience Failed Back Surgery Syndrome, and the statistics show that the odds for success with repeated surgeries diminish with each subsequent surgery. 14.

TREATMENTS FOR LOW BACK PAIN
Treatments for low back pain and be both frustrating and very expensive. The more common medical treatments for low back pain includes muscle relaxants, pain medications, physical therapy, and surgery. Chiropractic and acupuncture are considered alternative methods of treatment by many members of the medical community.

Sometimes people have surgical fusion performed to their low backs not realizing that prolotherapy is an alternative to this type of surgery. A study by Dr. Merriman, a general and industrial surgeon, evaluated 15,000 patients comparing prolotherapy with fusion for sciatic pain. He found that prolotherapy to be a highly successful conservative therapy in 80 to 90 percent of patients with fewer side effects compared to fusion.13

PROLOTHERAPY: THE MISSING LINK
As I have mentioned in other articles, Prolotherapy is the “missing Link” when it comes to the treatment of musculoskeletal conditions. Prolotherapy (aka Regenerative Injection Therapy – RIT), also known as ligament reconstructive therapy or sclerotherapy, is a recognized orthopedic procedure that stimulates the body's natural healing processes to strengthen joints weakened by trauma or arthritis. Joints weakened when ligaments and tendons are stretched, torn, or fragmented, become hypermobile and painful.

The research supports the benefits of prolotherapy even though most doctors never recommend prolotherapy to their patients:

• A 2004 study in The Journal of Alternative and Complimentary Medicine reviewed one hundred and seventy-seven (177) patients with a history of chronic spinal pain. This study showed a ninety-one percent (91%) reduction in the patient’s level of pain; an 84.8% reported improvement in activities of daily living (walking, sitting, bending, etc) and an 84.3% reported improvement in the ability to work. No complications from treatment were noted. 11
• A 2010 article in the British Journal of Sports Medicine involved 25 patients who received treatments to the sacroiliac joint. As reported in the conclusion, “prolotherapy in private practice has shown positive clinical outcomes for the 76% of patients who attended the 3 month follow-up visit…”5
• In a 1987 study published in the Lancet medical journal, 81 patients with chronic low back pain were treated in 2 groups. One group of 41 patients were injected with anesthetic and saline solution and another group of 40 patients were treated with anesthetic and a prolotherapy solution. Follow-up was made at one, three and six months. At six months, the prolotherapy group had a 50% improvement compared to the non-prolotherapy (saline) group and almost 400% increased improvement in disability. 16

CASE REPORTS
Case #1: a 69-year-old lady reported to the office with a chronic four (4) month history of low back pain and associated left leg pain (sciatica). Her pain started in her low back and then began to travel or radiate to her left leg. She had increased pain when sitting and could only walk for short distances. An MRI was performed that indicated a 6 mm herniated disc. She had been taking 2 different pain medications that provided mild, temporary relief of her condition. The patient received a total of 5 prolotherapy treatments at 2-4 week intervals and reported a significant reduction in her pain pattern After her first treatment, she reported a significant reduction in her pain pattern and reported an overall 85% improvement in her condition after 5 treatments.

Case#2: a 52-year-old female reported low back pain and radiating left leg pain for the last 10 years as a result of overexerting herself during yoga. Her condition affected her ability to walk and even sleep at night. She had tried different conservative therapies, such as acupuncture, chiropractic, pilates, and stretching exercises, with only mild, temporary relief. Due to the nature of her pain, she was treated with prolotherapy to her lumbar spine, sacro-iliac joints, and left hip region at 2-4 week intervals. The patient has received a total of 7 treatments with a 90% resolution in her pain pattern.

Case#3: a 52-year-old male reported with chronic low back pain and occasional right leg pain. He had experienced periodic low back pain for the past 20 years that would cause him to be bedridden for days at a time and make it extremely difficult to sit. Previous treatments had included prescription medications, physical therapy, massage, chiropractic and acupuncture that would provide mild, temporary relief at best. The patient was treated in both the lumbar and sacro-iliac joints and experienced relief after his first prolotherapy treatment. He received treatment over a 4 month period and reported no low back pain after 5 treatments.

OTHER CONDITIONS THAT RESPOND WELL TO PROLOTHERAPY
Other conditions responsive to prolotherapy include neck pain, shoulder pain, elbow problems, wrist and hand conditions, hip pain, tail bone pain, knee pain, ankle and foot problems.

WHAT TO EXPECT
The average number of treatments needed is usually between 4-6, with some people needing more and some people needing less. As an injection therapy, a small amount of specialized solution is applied to the affected ligament or tendon attachment. The solution most commonly used for the low back includes a mixture of dextrose (a sugar solution) with anesthetics such as lidocaine and marcaine. These therapeutic injections have been shown to result in enlargement and strengthening of damaged ligamentous, tendon, and intra-articular structures.17 Although the treatment may take a little longer, prolotherapy can also be successfully used for people who have failed back surgery. The surgical scar may also require specific treatment and is called neural therapy. Neural therapy is a highly effective injection therapy used by over 40% of doctors in Germany; however, very few doctors in this country have even heard of it.7

Before prolotherapy therapy, each patient should be thoroughly evaluated with a personal history that includes an orthopedic physical examination, including neurologic assessment and careful palpation of the low back. Palpation of a painful joint is usually associated with weakened tissues and can at times be more beneficial in identifying the problem areas than diagnostic testing. On an individual basis further evaluation may include X-rays and/or MRI before receiving prolotherapy. In cases involving chronic pain, a comprehensive treatment approach should be considered that includes rehabilitative exercises, nutrition, and specific supplements to maximize your health and ability to heal.

SUMMARY
If you, a family member, or friend are experiencing low back pain, prolotherapy should be considered, practically if the back pain is not responding to pain medications and especially if surgery has been recommended. Patients who report at least temporary improvement with chiropractic and spinal manipulation usually benefit from prolotherapy.8 Prolotherapy is a safe, reasonable, and proven orthopedic procedure that has provided significant relief to thousands of patients when other methods of treatment have failed. Strengthening weakened ligaments and tendons is proven to provide support to joints and muscles injured by overuse and trauma and improve the associated painful condition. Osteoarthritis and disc herniations are consequences of weakened ligaments and tendons and respond well to prolotherapy. 1 Prolotherapy is a treatment modality that provides long term relief for low back conditions without the negative consequences of medications and surgery.

References:

1. Alderman, Donna, DO, Prolotherapy For Low Back Pain, Practical Pain Management, May 2007, pp. 58-63.
2. Anderssen GBJ. Epidemiologic features of chronic low back pain. Lancet. 1999;354:581-5.
3. Argoff CE, Wheeler AH. Backonja MM, ed. Spinal and radicular pain syndromes. Philadelphia, WB Saunders: Neurologic Clinics; 1998:833-45
4. Chrobok, Vrba, Stetkarvoa. Selection of surgical procedures for treatment of failed back surgery syndrome (FBSS). Chir Narzadow Ruchu Ortop Pol. 2005
5. Cusi, M., Saunders, J., Hungerford, B., Wisbey-Roth, T., Lucas, P, Wilson, S, The Use of Prolotherapy in the Sacroiliac Joint, Br J Sports Med, 2010, 44:100-104
6. Deyo RA, Mirza SK, Martin BI. Back pain prevalence and visit rates: estimates from U.S. national surveys, 2002. Spine. 2006;31:2724-7.
7. Dosch, Peter M.D., Manual of Neural Therapy according to Huneke, Haug Publishers, 1984.
8. Hacket, George Stuart, M.D., Hemwell, Gustav A., M.D., and Montgonery, Gerald A., M.D., Ligament and Tendon Relaxation, Beulah Land Press, Oak Park, IL, 2002..
9. Hart LG, Deyo RA, Cherkin DC. Physician office visits for low back pain. Frequency, clinical evaluation, and treatment patterns from a U.S. national survey. Spine. 1995;20:11-9.
10. Hills, EC, Wieting JM et al. (eds). Mechanical low back pain, Updated 21 November 2004. Available at http://www.emedicine.com/pmr/topic73.htm
11. Hooper, RA, Ding, M., The Journal of Alternative and Complementary Medicine, Volume 10, Number 4, 2004, pp. 670–674
12. Javid MJ, Hadar EJ. Long term follow-up review of patients who underwent laminectomy for lumbar stenosis: a prospective study. J Neurosurg. 1998;89(1):1-7.
13. Merriman J., Prolotherapy versus operative fusion in the treatment of joint instability of the spine and pelvis. J of Intl Coll of Surgeons. August 1964. 42(2):150-159.
14. North RB, Kidd DH, Farrokhi F, Piantadosi SA. Spinal cord stimulation versus repeated lumbosacral spine surgery for chronic pain: a randomized, controlled trial. Neurosurgery. Jan 2005;56(4):98
15. Ombregt L., Bisschop P. and ter Veer HJ., A System of Orthopaedic Medicine, Second Edition, Churchill Livingstone, 2003, p 775
16. Ongley, Klein, Dorman, Eek & Hubert, A New Approach to the Treatment of Chronic Low Back Pain, The Lancet, July 18, 1987, pp. 143-146.
17. Rabago D, Best TM, Zgierska A, et al. A systematic review of four injection therapies for lateral epicondylosis: prolotherapy, polidocanol, whole blood and platelet rich plasma. Br J Sports Med 2009. DOI: 10.1136/bjsm.2008.052761
18. Vallfors B., Acute, Subacute and Chronic Low Back Pain: Clinical Symptoms, Absenteeism and Working Environment. Scan J Rehab Med Suppl 1985; 11: 1-98.

With over 20 years of clinical experience, Dr. Fred G. Arnold D.C., N.M.D specializes in Prolotherapy/Pain Rehabilitation services. He is a Diplomate of the American Academy Health Care Providers and he is one of the few physicians in the nation with both a naturopathic medical degree and chiropractic degree. 602-292-2978. www.prolotherapyphoenix.com.