Low back pain

An estimated 70-80% of people have lower back pain at some time in their lives. What treatment you receive depends entirely on the kind of practitioner you consult, and X-ray abnormalities often have no association with the pain at all.

Hardly a day goes by in a normal general practice without someone coming in with back problems. Back pain can vary from excruciating pain, with the person unable to move from their bed, to chronic lower back pain, that comes and goes and varies on a daily basis. Statistics vary, but an estimated 70-80% of the population has lower back pain at some time in their lives and 30-50% of adults have lower back pain each year.

What treatment you receive for the problem will depend entirely on the kind of practitioner or therapist you consult, and there are many different approaches.

There are difficulties in diagnosis and the older the person the more difficult the diagnosis. X-rays of older persons will often show abnormalities of the spine with disc narrowing, bony protrusions, unevenness of cartilage surface etc, and yet there may be no pain. When pain occurs it becomes easy to blame the changes seen on X-ray and yet there may be no association between the back pain and spinal X-ray abnormalities. This often leads to unnecessary surgery and further aggravation of the pain.

While Medical Aids may require CT scans and /or MRIs before surgery is contemplated, there are few studies showing that these investigations really improve or affect patient outcomes. My impression is that while these specialized investigations may be extremely useful in a few patients, they also lead to unnecessary operations in many others.

Hernia protrusions seen on these specialized X-rays are not uncommon in people without any pain. Twenty to thirty percent of people may have herniated discs and yet appear to be completely normal, and even the extent of the protrusion may not correlate with the severity of the symptoms. Dr van Tulder and associates writing in the journal Spine 1997 concluded: ‘There is no firm evidence for the presence or absence of a causal relationship between radiographic findings and nonspecific low back pain.’

It is really important that each person understands this and does not agree immediately to back surgery.

What causes low back pain

The back is a complex structure that functions in a very integrated way with the rest of the body. It includes the spinal column and sacrum, spinal cord and nerves, intervertebral discs, layers of muscles, and deep investing fascia. Pain can be due to problems in any of these areas and there is often an associated muscle spasm over the area of pathology.

This muscle spasm will often be more painful than the pathology it is trying to cover and protect.

Specialist orthopaedic doctors like to concentrate on the pathology, which is nevertheless only the end point of a chain of events. The chain of events usually starts with a combination of poor posture and gait, inadequate support in sitting and lying down, wrong shoes and weak muscles. The role of stress is less well understood, but one needs to understand that MIND-BODY is one functional system in which mind may be seen as one pole and body the other pole. Anything happening to one pole will have an immediate effect on the other. The two ends of a pencil are not separate parts that need to be joined together, but represent the two poles with different functions. The one end is the active pole and the other the storage pole, but they make an integrated whole. Similarly if the mind is stressed then the body is stressed. Where that stress expresses itself will depend on the nature of the stress.

Using body symptoms as the language of the soul or mind, one comes up with the idea that back pain has to do with a problem of our support systems, of feeling lack of support in some area of our lives. The spine is the support of the body. The mind-body approach to the treatment of back pain has been well developed by Dr John Sarno in his book ‘Healing back pain: The mind body connection.’ Warner books 1991. He advocates shifting attention from the physical pain to the underlying psychological pain.

Management

It is essential to rule out an underlying medical problem requiring specialized treatment. These conditions would include infections, tumours, fractures and referred pain. Severe excruciating pain not responding to conventional analgesia or other alternative approaches may clearly require surgery.

1. Bed rest for a few days may be indicated although some people prefer sitting and even walking around. Check what feels best. Trust yourself.

2. Physiotherapy: This is the more conventional approach and usually medical doctors will refer patients to physiotherapists. Like everyone else today physiotherapists have different approaches. Do some homework and find out which one may suit you best.

3. Acupuncture: Back pain is highly ameliorable to acupuncture. No one should have surgery, unless the situation is critical, without a trial of acupuncture. Even severe acute pain will often respond quite dramatically. The response of acute severe back pain to a few needles in the back of the hand (not back) is enough to convince anyone that the ancient Chinese had a very powerful technique. The more conventional acupuncture route is to use back points and points on the lower leg.

4. Chiropractic treatment: Practitioners vary between those who do very physical manipulation and those who do softer techniques. A recent meta-analysis confirmed that manipulation is more effective than placebo for acute low back pain and strong evidence also supports its use in chronic low back pain.

5. Trigger point therapy: Trigger points in the muscle can cause severe pain. It is important to be sure about the diagnosis. Trigger points usually respond to injections with local anaesthesia or even acupuncture needles. Deep pressure at these points may also be successful.

6. Cranial osteopathy has excellent results.

7. Laser treatment using the Comra may successfully treat many forms of back pain.

Endnotes

Most back pain will resolve without any form of treatment within six weeks. Nevertheless the sooner it is treated the less likely it will become chronic. Recurrence rates are quite high (up to 75%) and every effort should be made to develop a programme of exercise to strengthen back and abdominal muscles.

As indicated above there may not be a clear relationship between the X-ray picture and the pain. This requires very clear thinking on the part of the patient and second opinions are always valuable.