Back Pain Part I- Alternatives
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Back Pain Part I- Alternatives

There are many non-pharmacological alternatives available for the various causes of chronic pain. Common causes of lower back pain (LBP) are:

  • degenerative disk disease (osteoarthritis, herniation, osteoporosis)
  • radiculopathy & sciatica
  • muscle spasm/strain (repetitive stress & poor ergonomics)

Less common is back pain from ligament tears, rheumatoid arthritis (RA), tumors & multiple myeloma. Back pain can also be a symptom of kidney stones, gastric ulcers, pelvic inflammatory disease etc. 

DEGENERATIVE DISK DISEASE
Simple acute back pain does not require imaging unless trauma has occurred. MRI imaging can diagnose more complex causes such as DDD. DDD is characterized by degeneration of vertebral bodies, narrowing of discs, hypertrophy of bones in joints with osteocyte formation. This causes a stiff dull ache that is worse in the a.m., and with exertion. DDD is often associated with osteoathritis (OA) and Osteoporosis, which both increase the risk for vertebral fractures. A DEXA scan and Bone Mass Density (BMD) imaging can detect the extent of osteoporosis and the need for primary care and prevention.

RADICULOPATHY & SCIATICA
Radiculopathy is a general term meaning spinal nerve compression. Any radiculopathy becomes a medical emergency when nerve compression in the lower back begins to impair motor, bowel and bladder function (e.g. RA and tumors).

Radicular pain caused by spinal stenosis improves with trunk flexion- as if pushing a shopping cart. Spinal stenosis is narrowing of the vertebral foramen where nerves emerge from the spinal canal. By contrast, radicular pain from disc herniation worsens with trunk flexion, which increases pressure inside the disk. Radicular pain from spondylosis is caused by the fusion of the zygo-apophyseal (synovial) joints between each vertebrae. 

True sciatica is a type of radiculopathy caused by compression and/ or impingement of the common peroneal & tibial branches of the sciatic nerve between the lumbar and sacral vertebrae (usually L5 and S1). Piriformas syndrome can mimic true sciatic pain, but it is caused by the piriformas muscle compressing the sciatic nerve tracts. 

NON PHARMACOLOGICAL SUGGESTIONS
Qigong
Advice against sedentary lifestyle is an evidence-based PQRS Quality Measure, established by the Center for Medicaid & Medicare Services. Langevin & Sherman (2007) propose that an increase in stress (e.g. overexertion) can lead to micro-injury and inflammation, whereas a consistent lack of stress (e.g. bedrest) leads to fibrosis, adhesions and contractures. Gentle exercise is important to maintain mobility and tissue integrity without causing exertion, and re-injury. These Qi gong exercises are gentle movements to help strengthen the lower back, as well as release tension & spasm from holding ones breathe and guarding against pain. 
              
Bodywork
There are many types of bodywork and massage such as Swedish & deep tissue, trigger point & myofascial release, shiatsu & acupressure, structural integration, and Hellwerwork & Rolfing etc.. And of course TuiNa, which is Chinese physical therapyDetermine which one is most appropriate based on age, history, type of pain, and/or results of diagnostic imaging.

Supplements
It can be hard to figure out what supplements address the different pathomechanisms of pain. The list goes on and on...

...enzymes, anti-oxidants (glutathione, SAMe, CoQ10, carnitine, green tea), cortisol stimulants (e.g. alfalfa). joint & cartilage lubricants/ protectants (hyaluronic/ MSM, shark cartilage, glucosamine-chondroitin, cetyl-mystoleate, omega 3 fatty acids & fish oils; vitamins & minerals (niacin, B5, pantothenic acid, D3, K2, calcium, boron, bromelain), avocado soy unsaponifiables (ASU), undernatured  type II chicken collagen, LitoZin (a proprietary source of vitamin C from rosehips), RiboCeine, Zyflamed, Fulivic acid, special diets (gluten-free, low pro-inflammatory, alkalininzing, anti-allergic/Elimination Diet... 

MSM & GlucosamineDr. Borten DOM says, " If you’re going to try supplements for your joint pain, MSM plus glucosamine (1500 mg daily) is a good safe place to start. He recommends starting MSM low at 500mg daily, gradually increasing to1000mg per 50lbs of body weight 2x day. He advices that it takes weeks to months to notice the full benefit of MSM; if no benefit during this interval it is not going to be beneficial. 

Calcium Asparate Anhydrous. According to a proprietary brand study, it breaks the "chronic pain neuromatrix", which is the vicious cycle of pain, depression & sleep disturbance etc. It has a longer metabolic half-life and higher bioavailability compared to calcium citrate. Thus there is less risk of calcium deposits in joints & vessels. These deposits cause the bone spurs that contribute to the pain and muscle spams of OA & RA. Enhanced bioavailability also improved bone matrix and bone mass density in a one-year, multi-center, double placebo, double-blind study.

Cell Salts. Hyland’s Bioplasma homeopathic cell salts enhance absorption and utilization of vitamins and minerals by the elderly or chronically debilitated. Cell salts like calcium & phosphorous are important for the formation and integrity of bone. 

Vitamin  is necessary for the absorption of calcium. The body makes vitamin D when the skin is exposed to sunlight. However, the body does this most efficiently when the skin is moist- as in sweating. So, a vitamin D deficiency may require supplementation to bring serum levels up to par (>50 ng/ml). The amount needed is proportional to the degree of deficiency, with  9,000 to 10,000 IU  of D3 (cholecalciferol) once per week the median according to studies. Less than this dose may be ineffective, but consult with a provider before supplementing with such large doses. Find the food sources of D3 at Worlds Healthiest Foods.com.

Western Herbals
Mullein Root & Solomon Seal. Jim McDonald (herbalist) values mullein root to increase the volume & density of disk synovial fluid (relief of radiculopathy pain). If mullein herbal tinctures cause GI upset the flower essence   or homeopathic can be tried. Solomon Seal is legendary for miraculous healing of bones, joints, muscles, connective tissue! Jim McDonald recommends combining it with:

  • SAINT JOHN'S WORT for nerve numbness, tingling, shooting pains. 
  • MULLEIN ROOT for spinal curvature & subluxations.
  • HORSETAIL for healing of bones & cartilage, and other tissues 
  • BLACK COHOSH for dull, achy, inflammatory pain. 
  • GOLDENSEAL (a tiny bit) for injured discs. 
  • ARNICA for pain from injury. 
  • TEASEL for muscle injuries and tears. 
  • YARROW for bruising/ bleeding. 
  • LOBELIA for severe muscle spasms. 
  • NETTLES (fresh) applied externally for tendonitis.

Forrest McDowell, PhD adds:
  • GRAVEL ROOT to remove bone spur deposits in arthritic joints. 
  • PLEURISY ROOT for acute inflammation, and clicking of dry joints.

Frankincense
There are many studies on the use of Frankincense (Boswellia ssp.) for pain relief. The results are mixed. Boswellia serrata, a unique species of Frankincense, contains a high concentration of boswellic acid (acetyl-11-keto-beta-boswellic acid, 5-LOXIN) which is analgesic & anti-inflammatory. In studies where this species was given orally for OA of the knee, the experimental groups demonstrated good pain relief and/or less NSAIDs use. I have not found studies on the use of this species of frankincense for LBP. 

Another study showed improvement after 3 to 8 weeks of use for arthritis pain, swelling, and inflammation. Other studies show that oral Boswellia supplements can suppress pain and immobility associated with OA in as little as a week on a Western herbal dose of 400mg boswellic acids 3 x day. and up to 1,200–1,500 mg 2 to 3 times a day of a standardized (60–65 % boswellic acid) product. 

Anecdotally, I have seen patients self-treating with commercial Frankincense topical creams for various types of musculoskeletal pain. The responses were mixed, The pain-relieving effect of Frankincense may be species specific; specific to OA (of the knee), or acute traumatic injury (vs. chronic pain). Or specific to oral vs. topical use. Also the carrier may effect penetration.

However, in Chinese medicine Ru Xiang (frankincense) is classically used both topically and orally for both chronic stiff & painful  joints and during the acute phase of traumatic musculoskeletal injury. Borten cites that the boswellic acids in Ru Xiang have several anti-arthritic action, including inhibition of a pro-inflammatory enzyme (5-Lipoxygenase), prevention of decreased glycosaminoglycan synthesis, and improved blood supply to joints. The Chinese herbal dose is 3 to 9 gms of the raw herb (resin) in a formula (not as a single herb).

Chinese Herbs & Formulas
Certain individual herbs are commonly used in the many formulas for the different patterns of lower back pain (LBP). Du zhong is a major herb for LBP (excess or deficient; hot or cold). It is often combined with Xu Duan, which promotes tendon, ligaments & bone repair; benefits wandering joint pain due to chronic inflammation; neuralgia and blood circulation. Chuan Niu Xi benefits herniated disks. Gao Ben benefits the entire spine. As in Western herbology, species of Solomon Seal are used. Huang Jing (Polygonati Rhizoma) is for LBP and leg weakness due to jing deficiency. Yu Zhu (Polygonati odorati Rhizoma) is for pain, spasm & joint dryness.

Du Huo Ji Sheng Tang is the prototypic formula for all type of back pain. But there are many more Chinese herbs & formulas for pain according to specific patterns of disharmony:

Huang Qi Gui Zi Wu Wu Tang stands out for neck & shoulder pain due to spinal spurs; while also showing efficacy for periarthriitis, synovisitis, and peripheral neuropathy (Chen, 2009). 

Dang Gui Si Ni Tang stands out for pain & numbness in any part of the body due to underlying blood deficiency and/or other causes, by increasing peripheral blood flow.

Gui Lu Er Xian Jiao stands out in longitudinal studies as having the same efficacy as Fosamax (without the side effects) in increasing bone mass density in menopausal women when taken as diligently as Fosamax for osteoporosis.

Anti-Inflammatory Herbals
COX I and COX II are the two main pathways involved in inflammatory pain. Western herbs that benefit the COX I pathway are white willow bark, birch, and wintergreen. All of these contain a constituent similar to aspirin, without cause the same GI side effects. Chinese herbs that moderate COX II are gan jiang (ginger), fang ji, zhi mu, and dang gui (Chen), and turmeric. Xuan Shen is notable because it has been found to moderate Cox I, and COX II. Supplements that may inhibit the COX II pathway are Zyflamed, Quercetin with Bromalain, and MSM.

Topical Therapies
Moxa Elite Patches come in different Chinese herbal formulations according to type of pain: trauma/strains (Nui), rheumatism (Feng), and injury & damp/ stiff swelling (Shang). Or location of pain: lower back (Yao), cervical (Jing), and shoulder (Jian). A provider can determine which is the best for you to use at home. I love these patches because they warm up allowing the herbs to penetrate deeply into tissues for up to 12 hours.  They are effective and smell very good- not like menthol.

Essential oils affect pain in many ways depending on the oil. See 
Aromatherapy for Pain. Some EOs have mild cortisone-like anti-inflammatory properties. Others  improve blood circulation; release pain- relieving endorphins; healing soft tissue & tendons; calming nerves; and relax spasm.

Ointments Creams. Page (2008) has some suggestions for topical relief of arthritic pain:
  • Hot paraffin compresses to soothe & warm achey joints
  • Celadrin cream for stiffness
  • BHI Traumel cream (homeopathic) and arnica gel for soreness
  • Capsaicin cream, or cayenne-ginger compress
  • Boericke & Tafel Triflora Arthritis Gel

Therapeutic baths should be followed with wrapping up to allow for a gentle sweat. Those with hypertension, cardiovascular disease, pregnancy, or those taking diuretics should use the mineral salt baths & sweats with caution. Simply alternating the warm and cool water in the shower is a tonifying and cleansing alternative (Page, 2001, p. 148).

  • oxygenating baths
1 cup of 35% hydrogen peroxide (food-grade)
rosemary, peppermint & mullein herb tea bath

  • alkalinizing/ detoxifying baths
8 oz. of baking soda. 
3 lbs of epsom salts or Dead Sea salt for arthritic pain

  • thalassotherapy baths use the electromagnetic action of seaweeds to draw out excess fluids from congested cells and release it through the skin, while replacing it with beneficial micronutrients like potassium, iodine, and vitamin K.

Acupuncture
Acupuncture includes needling techniques, and body work such as tuina, cupping, and gua sha (scraping). Acupuncture alone (excluding herbs) has shown to work BEST for trauma, repetitive stress, and mild arthritis. GOOD for ligament strain and spondylosis. MODERATELY for low-grade herniated disks. FAIR for severe spinal osteoarthritis. PROTRACTED for chronic sciatica, and high-grade herniations. NOT IDEAL for pain from ligament tears. It may require 1 to a few treatments for acute sprains or exacerbation; and 10-15 treatments to stabilize chronic LBP due to remote history of traumatic injury. Chronic back pain from spodylosis or spinal stenosis may require weekly maintenance treatments. 

Distal acupuncture points reduce pain via the supraspinal descending (efferent) spinal pathways, which  inhibit the perception & response to pain by glands in the brain (pineal, hippocampus & hypothalamus). They trigger the release of pain-modulating serotonin, norepinephrine, ACTH, and oxytocin (pain memory).

Local acupuncture points around the area of pain work via the dorsal horn of the ascending (afferent) spinal cord tracts, which engage the spinal gate-control mechanism. They modulate pain impulses from C & Delta nerve fibers, and trigger the release of pain-relieving endogenous opioids.


INTEGRATIVE MEDICINE TIP: Pain Expert (widget). Select the area of your pain on the model and the widget will help you fine tune an alternative pain management treatment using the Imbue Pain Patch & Imbue Muscle & Joint Formula. Dr. Borten has also authored How to Manage Your Joint Pain Without Drugs, a multi-part series on all things drug-free for pain management.


SOURCES
Borten, P. Ru Xiang – Frankincense. Chinese Herbal Medicine, A Database of Chinese Herbs and Formulas. Retrieved from http://chineseherbinfo.com/ru-xiang-frankincense-mastic-boswelliacarterii-fragrant-milk/
Kimmatkar N1, Thawani VHingorani LKhiyani R. (2003). Efficacy and tolerability of  Boswellia serrata extract in treatment of osteoarthritis of knee--a randomized double blind placebo controlled trial. Phytomedicine 10(1):3-7.
Langevin H & Sherman K. (2007). Pathophysiological model for chronic low back pain integrating connective tissue and nervous system mechanisms. Medical Hypothesis 68:74–80.
Page, L. (2008). Healthy Healing's detoxification: Programs to cleanse, purify and renew. Healthy Healing LLC
Sengupta K, Krishnaraju A, Vishal A, Mishra A, Trimurtulu G, Sarma K,  Raychaudhuri S, Raychaudhuri S. (2010). Efficacy and tolerability of Boswellia serrata extract in treatment of  osteoarthritis of knee--a  randomized double blind placebo controlled trial.  International Journal of Medical Science 7(6), 366-77.
Unknown Author. Acupuncture treatment for chronic low back pain: A Case study. Retrieved fro  www.cpdo.net/cpda/Acupuncture_treatment_CLBP_case_study.doc
Vishal AMishra ARaychaudhuri S. (2011). A double blind,  randomized, placebo       controlled clinical study evaluates the early efficacy of aflapin in subjects with       osteoarthritis of knee. International Journal of Medical Science 8(7), 615-22.



1 Comment to Back Pain Part I- Alternatives:

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Cervical traction on Monday, June 09, 2014 10:43 PM
It is extremely helpful for me. Thank you for taking the time to discuss this blog Back Pain Part I- the Alternatives, I feel strongly about it and love learning more on this topic. If possible, as you gain expertise, would you mind updating your blog with more information?
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