Back Pain Management: Could Muscle Dysfunction Be an Overlooked Source?

When low back pain continues despite physical therapy, medications, injections, or other treatments, it is understandable to feel frustrated.

You may have been told that your MRI shows arthritis, a bulging disc, degenerative changes, or another abnormality. You may have completed treatment directed at those findings and experienced only temporary relief. In some cases, you may have been told that surgery is not appropriate, but you still do not have a clear explanation for why your pain continues.

That does not necessarily mean that nothing else can be done.

Chronic low back pain can have more than one cause. You may have another identifiable source of pain, and a pain management physician can help you understand what is happening and what treatment options may remain.

One possible but frequently less familiar source is dysfunction of the multifidus muscles, the deep muscles that help support and stabilize the lower spine. For appropriately selected patients, identifying this dysfunction can open the door to a different approach to back pain management.

Key Takeaways

Chronic low back pain may come from a disc, joint, nerve, muscle, or several structures at the same time.
An abnormality on an MRI does not always explain every symptom a patient is experiencing.
The multifidus muscles play an important role in stabilizing the lower spine.
When these muscles are not functioning properly, everyday movements may become painful or feel unstable.
ReActiv8 restorative neurostimulation is designed to activate the nerves controlling the multifidus muscles.
Not every patient is a candidate. A proper evaluation is needed to identify the source of pain and determine the appropriate treatment.

Why Chronic Low Back Pain Can Be Difficult to Treat

Back pain is a symptom, not a single diagnosis.

Some low back pain comes from irritation or compression of a nerve. This can produce pain, numbness, tingling, or weakness that travels into the buttock, leg, or foot.

Other patients experience mechanical low back pain. This type of pain may remain primarily in the lower back and become worse during movements or activities such as:

Standing for an extended period
Getting out of a chair
Bending or lifting
Walking
Working at a kitchen counter
Vacuuming or sweeping
Exercising or completing yard work

Some patients have both mechanical and nerve-related symptoms. Others may have pain coming from several structures at once, including the discs, facet joints, sacroiliac joints, nerves, and supporting muscles.

Dr. Abram J. Elsenraat, a pain management physician at Columbia Orthopaedic Group, explains that patients and physicians often want to place back pain into one simple category. In reality, several problems may need to be evaluated separately.

"A lot of times we're carrying around a bunch of different buckets, and we need to address them separately."

The important point for patients is that an unsuccessful treatment does not always mean all treatment has failed. It may mean that another source of pain still needs to be identified.

An MRI Finding May Be Only Part of the Answer

Imaging is an important part of many back pain evaluations, but an MRI report must be considered alongside the patient's symptoms, examination findings, medical history, and response to previous treatment.

Many patients have more than one finding on an MRI. A report may mention degenerative disc disease, a bulging disc, arthritis, scoliosis, narrowing around the spinal canal, or changes in the muscles surrounding the spine.
One finding may explain part of the pain but not all of it.

For example, a patient may receive treatment for a facet joint or sacroiliac joint problem and experience some improvement, yet still have persistent pain centered in the lower back. Another patient may have a bulging disc on an MRI without the typical leg symptoms associated with nerve compression.

This is why effective back pain management requires more than treating a single image. The physician must determine which findings are actually contributing to the patient's pain.

What Are the Multifidus Muscles?

The multifidus muscles are deep stabilizing muscles located along both sides of the spine.

Although they are smaller than many of the muscles people commonly associate with the back, they play an important role in controlling movement and helping stabilize the vertebrae of the lumbar spine.

These muscles should activate automatically during movement. They help provide support when a person stands, bends, lifts, walks, changes position, or completes other daily activities.

After an injury or prolonged episode of back pain, communication between the nervous system and the multifidus muscles can become disrupted. The muscles may not activate normally. Over time, they can weaken or develop atrophy and fatty infiltration.

Dr. J. Camp Newton, a board-certified anesthesiologist and fellowship-trained interventional pain management physician at Columbia Orthopaedic Group, explains: "Sometimes the cause of this chronic low back pain can be degeneration or malfunctioning of multifidus muscles."

What Does Multifidus Dysfunction Feel Like?

Multifidus dysfunction cannot be diagnosed based on symptoms alone, but certain experiences may lead a physician to investigate it as a possible source of pain.
A patient may describe:

Pain centered mainly in the lower back
Difficulty standing comfortably
Pain when rising from a seated position
A stiff, unstable, or "catching" sensation
A feeling that the back may give out
Pain during bending, lifting, or ordinary household activities
Limited improvement after physical therapy, medication, injections, or other treatments

Dr. Bradford R. Noble, a pain management physician at Columbia Orthopaedic Group, compares the experience to a rusty door hinge.

A damaged hinge may feel stiff, unstable, or resistant during movement. In a similar way, a back that is not receiving adequate muscular support can become painful during movements that should normally feel routine.

"It's like we're applying oil to this squeaky hinge so that it functions nice and smooth again."

How Is Multifidus Dysfunction Diagnosed?

Patients do not need to determine for themselves whether the multifidus muscles are causing their pain.

A physician may consider several pieces of information, including:

Where the pain is located
Which movements make it worse
Whether pain travels into the leg
How long the symptoms have continued
Which treatments have already been attempted
Findings from a physical examination
MRI or CT imaging
Evidence of multifidus atrophy or fatty infiltration
Whether another condition better explains the symptoms

An MRI can help a physician see changes within the multifidus muscles. A CT scan may also provide useful information for patients who cannot undergo an MRI. Specific physical examination tests can provide additional evidence of impaired muscle control.

The diagnosis is based on the full clinical picture, not one symptom or one line from an imaging report.

What Happens When Common Back Pain Treatments Do Not Work?

Conservative treatment remains the appropriate starting point for many forms of low back pain.

Depending on the cause, back pain management may include:

Temporary activity modification
Physical therapy
Home exercise
Anti-inflammatory or other non-opioid medications
Weight management
Chiropractic treatment
Massage or acupuncture
Steroid injections
Radiofrequency ablation
Other minimally invasive procedures

These options can provide meaningful relief when they address the correct source of pain.

However, some patients continue to have mechanical low back pain despite an appropriate course of physical therapy, medication, injections, or other treatments. If multifidus dysfunction is contributing to the problem, a physician may consider a treatment designed to restore activation of those muscles.

One such option is ReActiv8 restorative neurostimulation.

What Is ReActiv8 Restorative Neurostimulation?

ReActiv8 is an implantable neurostimulation system designed to help manage certain cases of intractable chronic low back pain associated with multifidus muscle dysfunction.

The system includes a small implanted pulse generator and leads placed near the nerves that control the lumbar multifidus muscles. When the device is activated, it delivers electrical stimulation to those nerves, causing the muscles to contract.

The goal is to help restore neuromuscular control and improve the muscles' ability to stabilize the spine over time.

The U.S. Food and Drug Administration approved ReActiv8 in 2020 as an aid in managing intractable chronic low back pain associated with multifidus muscle dysfunction. The FDA indication applies to adults whose dysfunction is supported by imaging or physiological testing, who have not improved adequately with treatments including pain medication and physical therapy, and who are not candidates for spine surgery.

How Is ReActiv8 Different From Other Neurostimulation Treatments?

ReActiv8 is not the same as traditional spinal cord stimulation.

Spinal cord stimulation is generally used to change how pain signals are transmitted or perceived. ReActiv8 targets the motor nerves responsible for activating the multifidus muscles.

Dr. Elsenraat explains: "This actually helps your body regain and restore its natural function."

Because ReActiv8 is intended to help restore muscle control, improvement is generally expected to develop gradually. This is different from a treatment designed primarily to produce immediate pain relief.

The process is closer to muscle rehabilitation. Repeated activation helps the muscles begin functioning more effectively, but rebuilding that function requires consistency and time.

What Does Treatment Involve?

ReActiv8 is placed during an implant procedure. Columbia Orthopaedic Group's physicians describe the procedure as generally taking about an hour, with patients typically returning home the same day. The exact procedure, anesthesia plan, and recovery experience can vary based on the patient's health and individual circumstances.

After the implant site has healed, the system is programmed and treatment sessions begin.

Patients typically activate the system for:

One 30-minute session in the morning
One 30-minute session in the evening

During treatment, the patient rests while the system stimulates the nerves and produces controlled muscle contractions.

Patients should not expect an immediate change after one or two sessions. Early improvement may appear as easier movement, better stability, or an increased ability to complete daily activities. Changes in pain and function may continue to develop over several months.

Consistent use is an important part of the treatment.

Who May Be Evaluated for ReActiv8?

ReActiv8 may be considered for certain adults who have:

Persistent mechanical low back pain
Pain located primarily in the lower back
Evidence of multifidus muscle dysfunction
Continued pain despite medication, physical therapy, or other conservative care
Difficulty with standing, bending, lifting, walking, or daily activities
No current indication for corrective spine surgery
The ability to safely undergo the implant procedure and operate the system

These factors do not confirm that someone is a candidate. They indicate that a more detailed evaluation may be worthwhile.

Other conditions may be causing or contributing to the pain. A physician must review the patient's symptoms, physical examination, imaging, previous procedures, surgical history, and overall health before recommending treatment.

Previous spine surgery, spinal hardware, significant instability, advanced scoliosis, nerve compression, or another identifiable pain source may affect candidacy. Even when ReActiv8 is not appropriate, other back pain management options may remain.

Is ReActiv8 a Cure for Chronic Low Back Pain?

ReActiv8 should not be presented as a guaranteed cure.
It is a prescription implanted medical device used as an aid in managing a specific form of chronic low back pain. Individual outcomes vary, and improvement may take time.
As with any implant procedure, there are potential risks, including infection, discomfort near the implant, complications involving the device or leads, and risks associated with surgery or anesthesia. Patients should discuss the possible benefits, limitations, risks, and expected recovery with their physician.
The larger goal of an evaluation is not simply to determine whether a patient qualifies for one device. It is to identify what is causing the pain and create a treatment plan based on that diagnosis.

What if ReActiv8 Is Not the Right Treatment?

An evaluation can still be valuable even when a patient is not a candidate for restorative neurostimulation.

Chronic low back pain can involve multiple pain generators. Treatment may require addressing those problems separately and in a logical order.

Depending on the diagnosis, options may include:

A different physical therapy or rehabilitation approach
Medication management
Targeted injections
Radiofrequency ablation
Minimally invasive lumbar decompression
Spinal cord or peripheral nerve stimulation
Treatment for sacroiliac joint pain
Evaluation by an orthopaedic spine specialist
Another nonsurgical or surgical treatment

Columbia Orthopaedic Group brings pain management physicians, spine specialists, imaging, and other orthopaedic services together within one coordinated organization. This allows patients to move from evaluation to the next appropriate level of care with fewer handoffs.

You Do Not Have to Diagnose Your Own Back Pain

Patients often arrive at an appointment carrying a collection of diagnoses, imaging reports, previous procedures, and treatments that did not provide the relief they expected.

You do not need to sort through all of that alone.

You also do not need to know whether your pain comes from a disc, joint, nerve, or muscle before requesting an evaluation.

The role of a pain management physician is to listen to how the pain affects your life, review what has already been tried, examine how your back moves, study the available imaging, and determine which findings are most likely to be causing your symptoms.

As Dr. Newton explained during the patient education discussion: "If you're still suffering from pain, regardless of what you think the cause is, it never hurts to come in and be evaluated."

You may have another identifiable source of pain. Understanding that source is the first step toward knowing which options remain.

Frequently Asked Questions About Back Pain Management and ReActiv8

Do I need an MRI before making an appointment?
No. A physician can begin by reviewing your symptoms, medical history, previous treatment, and any imaging you already have. An updated MRI, CT scan, or additional testing may be recommended after the evaluation.

Is ReActiv8 intended to treat sciatica?
ReActiv8 is designed to help manage mechanical chronic low back pain associated with multifidus dysfunction. It is not primarily intended to treat nerve pain traveling down the leg. Some patients have more than one source of pain, so an individualized evaluation is important.

How quickly do patients improve?
Improvement is generally gradual. Some patients first notice that movement feels easier or that their back feels more stable. Meaningful changes in pain and function may take several months and vary by patient.

Can the ReActiv8 system be removed?
Yes. ReActiv8 is an implanted system, but it can be removed when medically necessary or when the patient and physician determine removal is appropriate.

Is ReActiv8 covered by insurance?
Coverage varies by insurance carrier, plan, medical necessity requirements, and prior-authorization policies. The care team can help patients understand the verification and authorization process.

Find Out What May Be Causing Your Back Pain

If chronic low back pain is interfering with work, sleep, exercise, household activities, or your ability to enjoy daily life, another evaluation may provide answers that previous treatment did not.

The pain management physicians at Columbia Orthopaedic Group can review your symptoms, imaging, physical examination findings, and treatment history to help determine what is causing your pain and which options may be appropriate.

You do not need to know whether you have multifidus dysfunction before making an appointment. You only need to know that your pain is continuing and that you are ready for a clearer path forward.

Request a Back Pain Management Evaluation
Call Columbia Orthopaedic Group at (573) 876-8141 or request an appointment online.

This article is intended for general educational purposes and is not a substitute for an individual medical evaluation. Treatment recommendations, eligibility, risks, and outcomes vary by patient.