Functional Medicine for Chronic Low Back Pain...Really?!

Updated: Sep 19, 2018

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Pain is one thing we can all relate to. After all, we have experienced it at some point. For some of us, it is temporary and short-lived. For others, it is much more persistent and chronic. It can affect our work, our interactions with loved ones and our overall quality of life. Based off a 2012 survey, it is estimated that 126 million adults in the United States experienced some pain in the previous three months. It’s also estimated that over 25 million adults experience daily chronic pain and another 23+ million experience severe pain. [1] This means that over 48 million adults in the United States are dealing with chronic and/or severe pain. This leads to worse health outcomes, increased disability and increased health care costs. [2]

https://nccih.nih.gov/research/statistics/NHIS/2012/pain/severity [3]

Our back is a common location for pain. In 1999, back pain was the second most common cause of disability. [4] The prevalence of chronic low back pain (LBP) has probably increased since that time. In North Carolina alone, the prevalence of chronic LBP increased from 3.9% in 1992 to 10.2% in 2006. [5] What is interesting is the fact that the prevalence of chronic LBP increases linearly from the age of 20 to 60. From the age of 60 on the prevalence decreases. [6]


Is Technology and Medicine the Answer?

The current treatment paradigm revolves around the use of medications like opioids or surgery. There has also been a large reliance on the use of special medical tests like MRIs, CT scans, myelograms, etc. After all, if there are structural issues seen on these tests, then that certainly is the cause of the problem. Correct? Maybe! Those structural abnormalities may be the cause but there is a caveat. A study found positive findings on myelograms but the patients studied were asymptomatic. This study also notes that sometimes the findings on the myelogram show no issue despite the patient being symptomatic. [7] This must be a new landmark study that will change the current treatment paradigm…right? Unfortunately, no. This study was published in 1968! Similar findings also occur with MRIs. [8] Also, the presence of spondylosis and spondylolisthesis are not associated with the presence of pain. [9]

Another treatment option is the use of opioid medication for pain. This is a hot topic right now. So much so, that the federal government is getting involved. There is a real and present risk of addiction to these types of medications. Is it possible to use something more natural to address chronic LBP? Something that has little to no risk of addiction or side effects?


Paradigm Shift

There are several options available to us all that are more natural and have little to no risk of addiction or side effects, but first we need to learn a little more. Research is showing that all pain comes from our brain. This does not mean that pain is made up or that it is not real. Pain is very real. Information is carried to the brain and it decides how to classify that information.

FIgure 1 from Pain and the Neuromatrix in the Brain, Ronald Melzack, Ph.D. [10]

The brain’s main focus is survival. This helps explain the stories we have all heard of people experiencing significant injuries during war or walking into the ER after horrific accidents, yet not feeling any pain. Basically, this means that input comes into the brain and the brain decides what the output will be.

The Neuromatrix Theory of Pain states that pain is a multidimensional experience that is produced by a characteristic “neurosignature” pattern of nerve impulses generated by a widely distibuted neural network — the body-self neuromatrix — in the brain. [10] This means that there is a pattern of nerve impulse firing, i.e. neurosignature, involved in the experience of pain. It is also interesting to note that chronic pain is often characterized by little or no discenrable injury/pathology and there is also a strong association with chronic psychological and physiological stress. [10]

https://en.wikipedia.org/wiki/Cortical_homunculus [11]

Our bodies are mapped on our brain. There is a sensory and motor homunculus. Areas that are more sensitive cover more area of our brain. There are artistic renditions of the way our brain sees our body. As you can see in these pictures, our brain has a funny view of us that is not very attractive. However, with chronic LBP, or any form of chronic pain, the brain’s view of the body gets distorted. This distortion actually leads to a decreased ability to determine if a model is rotated or laterally flexed to the right or to the left. [12]

3D models of sensory and motor homunculus from Natural History Museum in London. Photo taken from https://en.wikipedia.org/wiki/Cortical_homunculus [11]


How Do We Address Chronic Low Back Pain?

There are several ways to address chronic LBP without using medications or surgery. One important area is education regarding pain neuroscience. It is important to understand that pain is a strategy the brain uses to protect the body. It is not always something that needs to be avoided. It is possible that chronic LBP is an example of the brain “loving you too much.” [13] Understanding what pain is helps to change its threat level. This helps the brain to relax. In essence, this means that the input to the brain is less likely to excite the brain and since the brain is not excited, it is less likely to make the output a pain response.

Pain neuroscience is complex but it is possible for it to be explained in a way that it can be understood by everyone. This requires time and interaction. In doing so, structural brain abnormalities associated with chronic pain can be reversed. [14] Let’s use two examples to help understand pain neuroscience. The first example involves a client with low back pain. The client was fearful of movement and focused exclusively on the pain. The client was instructed on pain being a form of protection and that their pain no longer related to any tissue damage or other form of danger. This education combined with other forms of treatment allowed the client to begin moving without fear, experience a significant decrease in pain and a major improvement in quality of life. The second involves a client who had to immobilize their knee for several months after a fracture. When the client was able to begin performing range of motion for that knee, they felt tightness and pain in their knee. This pain and tightness was a way for the brain to protect that knee that had not moved for so long. By educating the client that this is normal and nothing to fear, it avoids the development of a chronic pain state. Also, by continuing to perform range of motion for the knee, there will be input to the brain and activation of the sensory and motor homunculus. This will help to restore or normalize the brain’s view of the body. I like to call this “hormoncular refreshment.”

Depiction of General Adaptation Syndrome. Image copied from https://en.wikipedia.org/wiki/Stress_(biology) [16]

There are also hormonal and immune connections to our brain and therefore to pain. These hormonal influences include Cortisol and Adrenalinewhich are associated with the Sympathetic Nervous System and the body’s stress response. Meditation and Mindfulness can help address this area. A study found that the use of Mindfulness Based Stress Reduction or Cognitive Behavioral Therapy yielded better results regarding improvement in pain and decrease in functional limitations vs. the usual form of care. [15] How can this be? Cognitive Behavioral Therapy helps to address the fearful thoughts related to pain, etc. and mindfulness is a form of stress reduction. By addressing fear and stress, you decrease the stress response and activation of the HPA Axis. This can lead to a decrease in Cortisol and Adrenaline. This can have dramatic impacts on quality of life because the fear of pain is often more disabling than the pain itself. [17]

Diagram of the HPA Axis and negative feedback loops [18]
Schematic showing that when a cell membrane is injured the arachidonic acid pathway is activated to initiate the local inflammatory response. [19]

Inflammation can also play a role in acute and chronic pain. It has been a target in pain management via steroidal anti-inflammatory and non-steroidal anti-inflammatory drugs (NSAIDS). However, there are side effects associated with both types of medications. Some common side effects of steroidal medications include increased risk of infection, high blood pressure, osteoporosis, weight gain, depression and worsening of already present medical conditions. [19] There have also been several medications removed from the market due to serious life-threatening side effects. There are several natural compounds that can help to modulate these inflammatory pathways. These include omega 3 fatty acids, curcumin, green tea and frankincense among others. [19] These compounds can be taken in supplemental form or consumed via the diet. We have to remember that we want to address the root cause of the chronic LBP and not attempt to use the supplement as a medication and ultimate treatment for the problem.

Schematic showing that when a cell membrane is injured the arachidonic acid pathway is activated to initiate the local inflammatory response through the production of prostaglandins, thromboxanes, and leukotrienes. [19]

Inflammation is also associated with our Immune System. There is a connection between our gut and our brain. Also, most of our Immune System is located in our gut. Many now refer to the Nervous and Immune System as the Neuroimmune System. [20] When the Immune System is activated it communicates with the brain via pro-inflammatory cytokines. [21] These cytokines play a role in the creation and maintenance of pain states. [22] How do we address this? Again, supplements can play a part, especially initially, but diet and lifestyle modifications play the biggest role. By addressing diet, we can decrease the amount of pro-inflammatory foods we consume and we can decrease systemic inflammation. This could lead to decreased sensitization of the brain and therefore, decreased pain.

This diagram depicts the neuroimmune mechanisms that mediate methamphetamine-induced neurodegeneration in the human brain. Image from https://en.wikipedia.org/wiki/Neuroimmune_system [20]


Are You Dealing With Chronic Pain and in Need of a Helping Hand?

Pain is a complex phenomenon that we are still learning about. The brain and the Nervous System are not fully understood. Nor is how all the body systems interact/communicate with each other. This complexity does help to show the need for other people to be involved in the process. This is true if we are referring to chronic pain of any sort or another health issue. A Functional Medicine Practitioner is able to assist with addressing diet and lifestyle modifications that are needed for you to experience your optimal health. They can also work in conjunction with any health professional; MD, PA, NP, PT or otherwise, to address the issue and you as a whole person and not a diagnosis. If you have any questions or comments, please respond below or contact me via healthydesignfxmed.com.


Disclaimer:

This article is for educational use only. Nothing contained in this article should be considered, or used as a substitute for, medical advice, diagnosis or treatment. This article does not constitute the practice of any medical, nursing or other professional health care advice, diagnosis or treatment. Always seek the advice of a physician or other qualified health care provider with any questions regarding personal health or medical conditions. Never disregard, avoid or delay in obtaining medical advice from your doctor or other qualified health care provider because of something you have read in this article. If you have or suspect that you have a medical problem or condition, you should contact a qualified health care professional immediately. If you are in the United States and are experiencing a medical emergency, you should dial 911 or call for emergency medical help on the nearest telephone.


References/Citations:

  1. Nahin RL. Estimates of Pain Prevalence and Severity in Adults: United States, 2012. The journal of pain : official journal of the American Pain Society. 2015;16(8):769–780. doi:10.1016/j.jpain.2015.05.002.

  2. http://americanpainsociety.org/about-us/press-room/nih-study-shows-prevalence-of-chronic-or-severe-pain-in-u-s-adults

  3. https://nccih.nih.gov/research/statistics/NHIS/2012/pain/severity

  4. Prevalence of Disabilities and Associated Health Conditions Among Adults — United States, 1999. JAMA. 2001;285(12):1571–000. doi:10.1001/jama.285.12.1571-JWR0328–3–1

  5. Freburger JK, Holmes GM, Agans RP, et al. The Rising Prevalence of Chronic Low Back Pain. Archives of internal medicine. 2009;169(3):251–258. doi:10.1001/archinternmed.2008.543.

  6. Meucci RD, Fassa AG, Faria NMX. Prevalence of chronic low back pain: systematic review. Revista de Saúde Pública. 2015;49:1. doi:10.1590/S0034–8910.2015049005874.

  7. Hitselberger, WE and Witten, RM. Abnormal Myelograms in Asymptomatic Patients. Journal of Neurosurgery. March 1968; 28(3):204–206.

  8. Brinjikji W, Luetmer PH, Comstock B, et al. Systematic Literature Review of Imaging Features of Spinal Degeneration in Asymptomatic Populations. AJNR American journal of neuroradiology. 2015;36(4):811–816. doi:10.3174/ajnr.A4173.

  9. van Tulder MW, Assendelft WJ, Koes BW, Bouter LM. Spinal radiographic findings and nonspecific low back pain. A systematic review of observational studies. Spine (Phila Pa 1976). 1997 Feb 15;22(4):427–34.

  10. Melzack R. Pain and the neuromatrix in the brain. J Dent Educ. 2001 Dec;65(12):1378–82.

  11. https://en.wikipedia.org/wiki/Cortical_homunculus

  12. Bowering KJ, Butler DS, Fulton IJ, Moseley GL. Motor imagery in people with a history of back pain, current back pain, both, or neither. Clin J Pain.2014 Dec;30(12):1070–5. doi: 10.1097/AJP.0000000000000066.

  13. Johnson, Bob and NOI US team. “Explain Pain.” Explain Pain Seminar, Chicago, Il, Oct. 2014.

  14. Davis KD, Moayedi M. Central mechanisms of pain revealed through functional and structural MRI. J Neuroimmune Pharmacol. 2013 Jun;8(3):518–34. doi: 10.1007/s11481–012–9386–8. Epub 2012 Jul 24.

  15. Cherkin DC, Sherman KJ, Balderson BH, et al. Effect of Mindfulness-Based Stress Reduction vs Cognitive Behavioral Therapy or Usual Care on Back Pain and Functional Limitations in Adults With Chronic Low Back Pain: A Randomized Clinical Trial. JAMA. 2016;315(12):1240–1249. doi:10.1001/jama.2016.2323

  16. https://en.wikipedia.org/wiki/Stress_%28biology%29

  17. Crombez G, Vlaeyen JW, Heuts PH, Lysens R. Pain-related fear is more disabling than pain itself: evidence on the role of pain-related fear in chronic back pain disability. Pain. 1999 Mar;80(1–2):329–39.

  18. http://www.integrativepro.com/Resources/Integrative-Blog/2016/The-HPA-Axis

  19. Maroon JC, Bost JW, Maroon A. Natural anti-inflammatory agents for pain relief. Surgical Neurology International. 2010;1:80. doi:10.4103/2152–7806.73804.

  20. https://en.wikipedia.org/wiki/Neuroimmune_system

  21. Watkins LR, Maier SF, Goehler LE. Immune activation: the role of pro-inflammatory cytokines in inflammation, illness responses and pathological pain states. Pain. 1995 Dec;63(3):289–302.

  22. Watkins LR, Hutchinson MR, Milligan ED, Maier SF. “Listening” and “talking” to neurons: Implications of immune activation for pain control and increasing the efficacy of opioids. Brain research reviews. 2007;56(1):148–169. doi:10.1016/j.brainresrev.2007.06.006.

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