The facts about back pain. A guide for patients
by Alan O. Szmelskyj DO, MSc, MISMA, FRSH
This article is written to help you understand a little bit more about your back pain. I have tried to write it in a non-technical manner. However, when dealing with technical subjects some jargon will creep in. To help the readability of this article the amount of jargon has been kept to a minimum. Jargon has been included when I believe it may help understand the answers to the questions posed. In such situations I have explained the technicalities and associated jargon.
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What is back pain?
Everyone who experiences back pain does so in a very individual way. For one person back pain might be an acute or short lasting pain, which seems to occur for no obvious reason. For another person it may be a persistent wide spread dull ache that lasts for many months. Long lasting pain that is present for more than three months is technically known as chronic pain. Back pain can have a massive effect on a person's quality of life. It can greatly interfere with normal work and social activities. Some people can become severely disabled by their back problems. Most people's back pain is usually due to some form of mechanical damage to spinal structures. A small percentage of cases are due to other reasons. Some of the signs of more serious back pain are outlined later in this article. How back pain presents, and whatever are the individual symptoms, the sad statistic is that six out of ten people will experience back pain at some time during their life.
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Who gets back pain?
If you have already had back pain, or you feel pain in some other part of your body, you are at more risk of developing further back pain. However, if you are fit and healthy you are less likely to experience back pain. Who you are and what you do in your life can make a big difference to your chance of getting back problems. For example, if you are a woman who regularly has to lift heavy objects, or if you have to stand or walk for prolonged periods, particularly when at work, then you are more likely to get back pain. A man doing such activities is usually less at risk. Psychosocial factors such as being unhappy or dissatisfied with your work can also make you more likely to develop back pain. If you have a very physically demanding job or sit for long periods of time you may be more likely to get back problems. For example, if you sit with the same posture in front of a computer for many hours per day, or if you drive more than 26,000 miles a year in your car, then you have an increased risk of getting back problems. Carers who have to lift and move patients, or those in the building industry, are prone to developing back problems because of the heavy loads they have to move or lift.
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Diagnosing the causes of back pain
A complete health and medical history and thorough examination of the spine and body parts including checking hip and knee joints are essential if the most accurate clinical diagnosis is to be established. In order to listen and to obtain all the relevant information to find out all about the intricacies of a patient's back pain takes a lot of time. An accurate diagnosis cannot be made in just a few minutes. In my opinion, at least 20 to 30 minutes of time should be devoted to the initial history-taking part of any back pain consultation. I believe that if less time is spent, then corners may have to be cut and potentially important parts of a patient's medical history or examination may be missed out. This makes any resulting diagnosis less accurate and robust. The consequence of an incomplete diagnosis is that the best treatment choices may not be considered, and the best care for the back pain sufferer may not be provided.
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What causes back pain?
Most back pain is due to poor body use patterns which are superimposed on an individual's background body make up. Very few people have an optimally functioning body. For example, most people have some architectural asymmetry in their body-frame. This means the spine and other joints do not function bio-mechanically as well as they could. Bio-mechanical or functional disturbances of the spine and other joints, for example, due to one leg being as little as half of a centimetre too long can lead to accelerated disc degeneration and prematurely arthritic spinal joints.
Quite often what are generally thought of as innocuous activities can result in pain developing due to the inflammation of muscles, tendons and ligaments. Sometimes the facet joints (tiny paired small joints present at each vertebral level that are found at the back of the spine) can be strained and inflamed to then cause days of excruciating back pain and even sciatica. If these problems occur on several occasions this can be a sign of background spinal architectural joint damage or muscle weakness or imbalance. If the weaknesses are not dealt with and these episodic bouts of problems are ignored then back pain can eventually become persistent and chronic.
Sometimes not knowing how to manage simple or non-severe bouts of back pain can allow it to become worse. For example, depending on the cause of your back pain, resting too much or ignoring pain and trying to carry on as normal, is not always the right thing to do.
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Slipped discs, trapped nerves and sciatica
Sometimes tears can develop in a spinal disc. This is often called a slipping disc. Technically, as professionals, we describe this as a herniating disc. The tear is often in the inner part of the disc. The tear allows the soft gel-like inner core (called the nucleus pulposus) to start oozing and bulging out through the tough outer layers (called the annulosus fibrosus) of the disc. The herniating gel-like tissue can then press onto the nerves as they come off the spinal cord. This nerve trapping, irritation and inflammation often produces back and even leg pain.
When all the tough outer layers of the disc have been breached, the disc is said to have prolapsed (slipped). When the pressure onto the nerves is more severe, feelings of numbness, tingling, 'pins and needles' and leg weakness can be experienced to varying degrees in a leg. This is true sciatica. If you have reduced control of your bladder function and are having problems with controlling your waterworks (this can include difficulty in stopping or starting the passing of urine, dribbling of urine and urinary incontinence), this may indicate very serious spinal problems. These symptoms need immediate investigation or you may be at risk of developing damage to your kidneys.
Unfortunately, the term 'sciatica' is often used rather loosely and inaccurately to describe any pain that is felt down the back of the leg but which may not be due to pressure onto the actual sciatic nerve. Other pains going down the back of the leg, but not caused by direct pressure onto nerves, are called referred pains. Referred pain can come from areas of tight back or buttock muscles or from the facet joints of the spine, from the pelvic ligaments and joints or from the spinal ligaments. Occasionally referred pain can be due to an organ problem. This is why it is so important to have the most accurate diagnosis possible. As any experienced clinician will tell you the best and most accurate diagnosis can only be made once a detailed clinical history and a thorough clinical examination have been completed.
Although disc herniations and prolapses can produce sciatica, one rather common and over-looked cause of sciatica is an inflamed facet joint. The facet joint is technically called the apophyseal joint. Thus, this condition is known as lumbar apophysitis. Only a careful and thorough examination can help to differentiate a facet joint strain from an acute disc problem. However, sometimes only a high resolution MRI (Magnetic Resonance Imaging) scan can confirm the diagnosis. It is very important to determine the diagnosis because the ideal management of disc and facet joint disorders is very different.
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Other causes of back pain
Although mechanical injury and strain to the spine are the most common reasons why back pain can be experienced, other causes also need to be ruled out. These include arthritis, sometimes called spondylosis, various types of pelvic or abdominal disease. Kidney infections, coeliac disease and spinal tumours, are just three examples of other more serious or potentially life threatening disorders that can produce back pain. There are many more that I could list.
Various rheumatic diseases including Ankylosing Spondylitis, Polymyalgia Rheumatica or Fibromyalgia can lead to back pain. Anxiety and depression can also be responsible for some cases of back pain. Once again only a thorough consultation with an appropriately trained professional can help rule out these disorders as the cause of a person's back pain.
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Treatment for back pain
As well as treating the pain and symptoms of back pain, an ideal management programme should include identifying and improving the state of any underlying predisposition to back pain. This will allow for the best possible recovery and also help prevent or reduce the risk of future problems.
There are many forms of treatment and therapy available for back pain. Writer and BBC TV presenter, Dr Mark Porter, says "Doctors are not very good at treating simple back pain." Painkillers or low dose Diazepam can make life more comfortable and ease painful muscle spasm. There isn't much evidence to support the use of creams and sprays. Most complementary health practitioners would often claim to be able to help back pain and, indeed, there are numerous medical treatments varying from drugs to exercises to surgery that may, again, be useful to some people with certain types of back pain.
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Osteopathy for back pain
According to medical writer and broadcaster, Dr Mike Smith, "Osteopathic treatment tends to be pleasant and relaxing and tailored to suit the needs of the individual concerned." A survey by the Consumers Association found that osteopathy had the highest satisfaction level for patients who were experiencing back pain and was the most effective form of complementary therapy for patients with back pain. Another survey done by a Health Authority Trust in the South-west of England found that osteopathy was more effective and less expensive than either physiotherapy or chiropractic treatment for the management of low back pain. The most recent analysis of the best scientific studies (known as controlled randomised trials) of osteopathy show that it is an effective treatment for back pain.
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Can slipped discs be popped or manipulated into place?
Sometimes I have patients presenting to me saying that their previous osteopath, chiropractor or physiotherapist was able to 'put their disc back into place'. In my opinion, probably the majority of such 'discs' being put back after the spine was manipulated were very probably locked and inflamed facet joints. These joints usually respond very well to the spine being manipulated and the facet joint surfaces being separated and released. This joint release happens most dramatically when the spine makes a 'popping' sound. The sound that is heard when the spine is manipulated is basically the same sound you hear when you see people crack their knuckles in their hands. Typically when a spinal joint is manipulated in this way, the back often immediately feels less stiff and painful. However, the sound that is heard is not a disc or a joint being replaced. It is simply a vacuum pop. If you have any doubts that this is so, then very closely examine your fingers on your hands. The next time your finger joints crack, recheck your hands. Double check the relevant finger joint and ask yourself is the joint in, or is it out? You will find it is neither. The finger joints will be exactly where they were before they popped.
Real disc herniations and prolapses can be made worse if inappropriate or over-forceful attempts are made to make the joints 'pop'. When genuine disc damage does suddenly seem to appear, it can do so quite unexpectedly. For example, it can result from just going for a slightly longer car journey or sitting on a friend's soft sofa or doing some extra weeding, or housework or bending over to fasten your shoe laces or picking something up, even if it's not very heavy. All these and many other similar activities can put a little extra strain on your back and allow a herniating disc to make itself felt. When this happens and a disc strains this easily, then the disc is probably already very badly damaged from previous repetitive, excessive or inappropriate overuse.
Patients often ask me why their back has 'suddenly gone' on a particular occasion, when on numerous occasions in the past, when doing similar activities, no problems have ever been felt. The answer is that sudden disc injury does not just suddenly happen. One almost invariable pre-requisite is the presence of previous spinal degenerative (wear and tear) damage. Wear and tear results in a weakness and a loss of architectural strength and flexibility of the disc. The disc becomes less supple and therefore, over the years, when subjected to the same tens of thousands of bad repetitive movements, it gradually weakens and tears. Finally, when one extra bad movement or poor posture is adopted, it allows the final fibres of the anulosus fibrosus to give way, allowing the gel like discal pulposus bulge to press onto sensitive nerve tissue, producing potentially excruciating pain.
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Acupuncture for back pain- can you get NHS funding?
Did you know that following a review of research on acupuncture treatment of back pain, National Institute of Clinical Excellence (NICE) issued new guidelines in May 2009 recommending that the NHS should fund up to 10 acupuncture treatments for back pain.
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Why does back pain become persistent?
The same reasons that allow back pain to develop in the first instance can also allow it to become chronic or long lasting. Additional risk factors for the development of persistent back pain include restricted spinal movement and the presence of pain going down the leg. Women are also more at risk of long term back pain. For some people the lack of an early diagnosis and appropriate advice and treatment can lead to chronicity.
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Back pain that is not diagnosed or treated
If acute intermittent (that is short lasting) bouts of back pain are not adequately treated, then there is the possibility that your back pain will become more persistent and chronic. In other words it may never go away.
If your back pain problem has any of the features described earlier in this article, do not ignore it. Seek some form of professional expert care. Also, if you have had frequent bouts of back pain, or if they are becoming more persistent, then get professional advice. It is very important to get an accurate diagnosis for what may be causing your back pain. To better understand what osteopathy can offer in the management of your back pain, please see the article on our website entitled 'Osteopathy and low back pain'.
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Signs of serious back pain
It is also important to remember that an accurate and timely back pain diagnosis can be life saving. This is because there are other certain more serious or even life threatening conditions that can cause back pain. For example, an enlarged and weak main abdominal artery (known as an aortic aneurism), which often presents as back pain, can rupture and a person will be dead in minutes. Some other diseases resulting in back pain are mentioned earlier on in this article in the section Other causes of back pain. Additional things to be wary of which might indicate more serious reasons for back pain include:
- if you are less than 20 years of age
- if you are older than 55 when your back pain develops
- if your back pain is due to a non-mechanical cause
- if you have also got pain in your thoracic area or the back of your rib cage
- if there is a past history of cancer, steroid use or HIV infection, if you feel unwell
- if there is sudden or unexplained loss of weight
- if you have other areas of your body that show signs of neurological dysfunction
- if there is any structural deformity
- reduced sensation around your anus, for example being unable to feel toilet paper when wiping your bottom
- abdominal pain with your back pain
- burning or excruciating pain when passing urine.
Naturally, you may not be able identify some of these things yourself and, therefore, it is important that you seek an appropriate qualified professional, such as an osteopath or your own doctor to actually discuss and describe these symptoms and have them explored appropriately. Adequate time should be spent with you to allow all the potential and relevant questions to be asked. A five or ten minute consultation and the absence of a thorough clinical examination may result in an inaccurate diagnosis being made.
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Risk factors for developing long term back pain
Other factors to consider that might increase your risk of long term back problems include if:
- your health is generally poor
- you are a heavy smoker
- you have any amount of psychological distress or depressive symptoms
- you are unhappy in your job
- there are ongoing stresses such as marital or financial ones
- there are other personal problems of a medical or legal nature that are on going
- the strength in your back is reduced or your endurance is reduced
- there are signs of tingling or numbness down your leg
- you have a previous history of back pain.
The more of these risk factors you have, the greater is the possibility that your problem will become persistent. Again, the presence of any of these factors indicates you should seek advice and treatment sooner rather than later.
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I hope it is obvious and logical from reading this article that it makes sense to have your back pain professionally evaluated and to have an accurate diagnosis and, if necessary, prompt and appropriate treatment. Doing so should allow you to minimise or eliminate the misery that so many people suffer when they get back pain. Our osteopaths are highly qualified and appropriately experienced to discuss with you and to guide you in making the best choices for the care of your back pain and your health.
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In addition to this article, which you may have just read and which was especially written for our web page I would also recommend reading the following two articles: Osteopathy and Low Back Pain and Persistent Back Pain. These two articles were published in two professional journals and will give the interested reader a deeper understanding of how osteopathy can help with the treatment of back pain.
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