Back Pain

James O'Sullivan Lic. Ac. China  activehealth@eircom.net 

Back pain is an extremely common clinical problem, and will be presented to the complementary therapist on a regular basis.  The majority of cases of back pain settle down with symptomatic treatment e.g. rest, painkillers.  There are many causes of back pain, the commonest being musculo-ligamentous sprains and tears. Often, it is not possible to arrive at a precise diagnosis for every patient presenting with back pain. However, the therapist must be alert to the possibility of less common but more serious causes being present, and the necessity for referral to the patient’s GP for further assessment and investigation when appropriate.

Every adult will have a 90% chance of suffering from this problem at some stage in our life. If you do suffer it once, you will undoubtedly suffer again. Back pain can be a debilitating and distressing condition, with long term sufferers stifled with depression and feelings of helplessness, unable to lead fulfilled lives. People with back pain tend to suffer in silence because it is a condition that cannot be seen, like a skin disorder or a broken leg. The pain can occur anywhere along the full length of the spine, with low back pain being the most common.

Causes of back pain;

There is a long list of possible causes of back pain. The primary cause of back pain can arise from a number of areas, because the back is part of nearly every movement we make and it is subject to a lot of stress. As stated earlier, it is often not possible to establish a precise diagnosis in every case of back pain. The vast majority of cases are caused by injury to the soft tissues in the back i.e. the muscles and ligaments. Less commonly, a prolapsed intervertebral disc or osteoarthritis can be a cause, or trauma leading to a fracture.  Occasionally, other causes such as osteoporosis, primary bone cancer or secondary deposits from another site (e.g. the breast), TB or other infections in the bone, ankylosing spondylitis and referred pain from other sites such as the abdomen occur.

The slipped disc or prolapsed intervertebral disc. The term slipped disc is not a very accurate description as the disc did not slip anywhere, but rather the disc, which is a cushion between the bone vertebrae, is made up of a jelly like substance surrounded by cartilage. When the cartilage is weakened or torn in a trauma, the jelly like substance leaks out and makes contact with one of the nerves in the spinal canal and it is this that causes pain. The pain itself need not be at the site of the rupture. Because of the way out nerves work, the pain can be felt in another area. Sciatica is one such disorder, where the problem is located in the lumbar region and the pain can be felt right done the side or back of the leg.

Arthritis or some other degenerative disease also account’s for back pain, because of the wear and tear on the bone. The bone is covered by a sheath of hard smooth cartilage. When this is worn away there can be bony growths, which restrict the joints movement and cause pain.

Assessment of a patient with back pain

• A history of the pain is taken, using the 10 point method.

• Site

• Onset; sudden onset may indicate a muscle strain or disc problem, more gradual onset may indicate degenerative changes such as arthritis, osteoporosis or more serious causes such as multiple myeloma.

• Character; sharp pain especially on movement, would suggest a mechanical cause. Whereas a dull, gnawing pain at rest or at night might suggest a more sinister cause.

• Duration

• Severity

• Periodicity and frequency of occurrence;

• Radiation

• Associated features; Vomiting, weight loss or other constitutional upset would suggest a diseases process not confined to the back and should prompt referral for further investigation.  Numbness in the legs or buttocks, loss of sensation or difficulty in passing urine should prompt emergency referral as these symptoms indicate pressure on a nerve or the spinal cord which may need urgent surgery.

• Relieving factors

• Exacerbating factors; Pain worse on coughing or straining might suggest a disc problem.

Other points in the history that would be important include;

Age of the patient,; The older the patient is, the more alert the practitioner should be to the possibility of more serious causes of back pain being present.

A history of trauma or previous episodes of similar type pain would suggest a mechanical cause for the pain.

The patient is then examined , paying attention to the following points;

-is he or she in obvious pain? Is the posture normal? Can they walk comfortably?  Can they sit down? Have they difficulty dressing and undressing?

The spinal movements should then be examined, making sure to tell the patient to stop if any movement causes pain.  Forward flexion, extension, lateral flexion and rotation are looked at.

Following this, the therapist will usually have a good idea of what the problem might be.

Management of a patient with back pain;

• Usually, the patient will have seen a doctor before they consult the complementary therapist for treatment, and some may already have a diagnosis.  However, more and more patients are now going directly to therapists with their symptoms.

• Having taken there is a possibility of a serious cause for the patient’s symptoms and refer the patient to his GP for further assessment and investigation.

• However, in the vast majority of cases this will not be necessary.,

• The patient should be given general advice on safe lifting techniques, bending the knees when lifting something and avoiding bending from the waist.

• Advice on proper posture, maintaining the lumbar lordosis while sitting by means of sitting on a chair with an upright back  or the use of a lumbar roll when sitting or driving is also helpful.

• Exercise  in the form of walking or swimming , and encouragement to lose weight if obese is also indicated.

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james@active-health.org