From the Book

Introduction

While traveling with my family in Western Africa, I was given the opportunity to meet with the local medicine man in Korogo, Ivory Coast. I felt privileged to listen to a man revered for his wisdom, practicality, and compassion. The agreement to meet came through a series of intermediaries, and he asked beforehand that I bring antimalarial and antidiarrheal medications. He wished to hear me speak about these medications—their origin, their mode of action—and he planned to utilize them along with his own botanical remedies. The reality of today’s medicine presents itself in many forms. Whereas I understood the chemical and pharmacologic properties of the antimalarial drug mefloquine, I had no idea of its unique source in Mother Nature.

The medicine man viewed life as a constant interplay between humans and nature. His role was as a mediator between the afflicted human and the remedies provided by nature. Most medical conditions were infectious in nature, which he could treat effectively with natural botanical mixtures and the proper dose of rest.

As we embraced the eternal day, graced by each other’s presence and the shade of a tree centuries old, the village slowly gathered about this sacred space. The overall setting was pure and primitive relative to our technological, scatological standards. And yet, what seemed to reign here was an ordained sense of order. Mud huts were immaculately clean. Gums were healthy as teeth yellowed naturally with age. The local water was toxic to my pristine, naive stomach, yet quenched the thirst of the village in need. Everyone had their place, including the gods. Life was simple, in a complex circular hierarchy involving the masters, the elders, the mothers, the children, the land, the gods, and one’s allegiance to order.

I asked the medicine man about pain, and his answer shocked me into opening my eyes to the village around me. Here, pain served a useful, singular purpose. When a worker became injured, he or she experienced pain with the injury. Pain subsided as the injury healed. The medicine man knew of low back pain and disc herniation, and this, too, he expressed as a short-lived companion of injury. As we went further into our discussion of pain, we seemed to be lost in translation when it came to chronic pain. The villagers too, looked confused as I conjured up images to describe this debilitating and familiar disease. It was eventually understood that the concept of a chronic pain syndrome was not merely untranslatable, but incomprehensible.

Although malaria flirts with the villagers of Korogo, chronic pain afflicts more than 60 million Americans. And, although our Western world has seemingly conquered malaria, we are constantly reminded that our dance with life is filled with other afflictions. But why chronic pain—so much of which is chronic low back pain? To answer this question, we must step back and reanalyze our understanding of pain and our understanding of our own dance with life, our dance within our society.

The medicine man looked at me with frank eyes and asked, “But why would pain persist for months or years in someone? I have never seen this, nor have my teachers, through generations, ever spoken of such a human condition.”

In this book I will try to answer the medicine man’s question. I can only do so from my perspective as a Western-trained physician and as one who listens, day in and day out, to patients from America and other parts of the Western world. This is my conceptual framework, one that I trust is commonplace with you, the reader. Specifically, I hope to bring an understanding of low back pain to light, a malady whose ubiquity and chronicity shapes the destiny of our home, workplace, and medical office.

We have no universally accepted understanding of low back pain in its myriad presentations. Nor do we have a universal approach to management. Chiropractors, acupuncturists, orthopedic surgeons, neurosurgeons, rheumatologists, neurologists, osteopaths, physiatrists, nurses, physician assistants, massage therapists, physical therapists, athletic trainers, kinesiologists, homeopaths, naturopaths, primary care physicians, neighbors, friends, relatives—all have an opinion of proper diagnosis and management. Many overlap, and many diverge. Although I cannot assume to have a unifying answer for all, this book is an attempt to find common ground among the seeming disarray of low back pain world views.

We begin with a discussion of pain. We must try to understand pain not simply as an anatomic focus, but also as a physiological expression within an individual person. Yes, low back pain may arise from a herniated disc, but the intensity or chronicity of low back pain may be influenced by the faulty biomechanics of the disc segment as much as by the fear, apprehension, rage, or sadness of the individual carrying the disc. Pain is multifaceted, and serves to warn as well as to reveal. Emotions—like pain itself—have their physical expression. As we keep this in mind, we may appreciate the meaning of chronic pain, and discover more about the human soul as it works in tandem with the body.

We move from a discussion of pain to an overview of the anatomy and physiology of the lower back. From there, we delve into the diversity of management approaches to low back pain, and we then analyze various low back pain syndromes. The anatomic and physiologic conceptual framework of our discussion spring from the mind of modern medicine. I blend this conceptual framework with the richness of anecdotes and stories of healing, because these provide the fertile ground for teaching, comprehending, and bridging science with the human heart.