Back Pain

Back pain is a general term for any type of uncomfortable condition occurring throughout the back of the body. Back pain has several causes, but often it is due to overwork, repetitive motion, or trauma of the back. Generally, back pain is thought of as affecting three areas, the upper, mid or lower back.

Types
Any condition that involves pain is categorized according to the pain duration: Acute (recent start and short-term) or chronic (persistent). Acute low back pain generally lasts from a few days to a few weeks. Chronic back pain lasts for more than three months.

The back is made of many muscles and bones. The vertebrae are the bones that run down the center of the back. Inside of the vertebrae is the spinal cord. The spinal cord connects nerves from the rest of the body to the brain. Most back pain is caused by injury or strain of muscles and related structures, or nerve compression or injury.

Muscle related back pain

 * Sprains and strains of a back muscle in either the upper back or lower back
 * Spasm of a muscle of the back, or cramp like pain
 * Myofascial type pain, which is deep muscle pain transmitted to other parts of the body

Bone related back pain

 * Fracture or compression of any of the bones of the back; more common with trauma or in the elderly, but can also happen when someone has an underlying disease that affects the bone
 * Joint irritation between two bones of the back
 * Abnormalities of the bone structure such as scoliosis, spina bifida, excessive kyphosis (hump-back), or others.
 * Disruption of the discs (cushions) between the bones of the back

Nerve related back pain

 * A pinched nerve due to a disrupted disc, deterioration of a vertebra or other cause
 * Irritation to the spinal column
 * Spinal cord injury

Symptoms
Back pain has a wide range of symptoms and is usually an indication of an underlying problem

Acute pain symptoms include the following:
 * A traumatic injury or action to the back
 * A feeling of discomfort in any area of the back that came about suddenly
 * A decrease in the amount of motion in the back
 * Tightness or cramping in the muscles surrounding the area of pain
 * Shift in standing posture to one side
 * Pin-point pain

Below are some chronic pain symptoms:
 * Any of the acute pain symptoms that have persisted for greater than three months
 * Scattered pain in many areas of the back
 * Changing locations of the pain
 * Pain that comes and goes
 * Depression or other emotional problems

Underlying sources and causes
There are several potential sources and causes of back pain. However, the diagnosis of specific tissues of the spine as the cause of pain presents problems. This is because symptoms arising from different spinal tissues can feel very similar and is difficult to differentiate without the use of invasive diagnostic intervention procedures, such as local anesthetic blocks.

One potential source of back pain is skeletal muscle of the back. Potential causes of pain in muscle tissue include Muscle strains (pulled muscles), muscle spasm, and muscle imbalances. However, imaging studies do not support the notion of muscle tissue damage in many back pain cases, and the neurophysiology of muscle spasm and muscle imbalances are not well understood.

Another potential source of low back pain is the synovial joints of the spine (e.g. zygapophysial joints). These have been identified as the primary source of the pain in approximately one third of people with chronic low back pain, and in most people with neck pain following whiplash. However, the cause of zygapophysial joint pain is not fully understood. Capsule tissue damage has been proposed in people with neck pain following whiplash. In people with spinal pain stemming from zygapophysial joints, one theory is that intra-articular tissue such as invaginations of their synovial membranes and fibro-adipose meniscoids (that usually act as a cushion to help the bones move over each other smoothly) may become displaced, pinched or trapped, and consequently give rise to nociception.

There are several common other potential sources and causes of back pain: these include spinal disc herniation and degenerative disc disease or isthmic spondylolisthesis, osteoarthritis (degenerative joint disease) and spinal stenosis, trauma, cancer, infection, fractures, and inflammatory disease.

Radicular pain (sciatica) is distinguished from 'non-specific' back pain, and may be diagnosed without invasive diagnostic tests.

New attention has been focused on non-discogenic back pain, where patients have normal or near-normal MRI and CT scans. One of the newer investigations looks into the role of the dorsal ramus in patients that have no radiographic abnormalities. See Posterior Rami Syndrome.

Diagnosis
Diagnosing back pain depends on the type of pain. The symptoms and how the pain began are considered. Physical exams are necessary and sometimes imaging by X-rays, magnetic resonance imaging, or computerized tomography is used. These scans help determine if bones are in the right place, or if the discs or nerves are affected.

Management
The management goals when treating back pain are to achieve maximal reduction in pain intensity as rapidly as possible; to restore the individual's ability to function in everyday activities; to help the patient cope with residual pain; to assess for side-effects of therapy; and to facilitate the patient's passage through the legal and socioeconomic impediments to recovery. For many, the goal is to keep the pain to a manageable level to progress with rehabilitation, which then can lead to long term pain relief. Also, for some people the goal is to use non-surgical therapies to manage the pain and avoid major surgery, while for others surgery may be the quickest way to feel better.

Not all treatments work for all conditions or for all individuals with the same condition, and many find that they need to try several treatment options to determine what works best for them. The present stage of the condition (acute or chronic) is also a determining factor in the choice of treatment. Only a minority of back pain patients (most estimates are 1% - 10%) require surgery. And, for all forms of spinal surgery, one of the common complications universally reported is "next disc syndrome". Presumably, once the affected disc is surgically compromised, then gravity shifts its effects to the next higher disc, and that one commences a more rapid degenerative course.

Medication

 * Use of medications, such as muscle relaxants, opioids, non-steroidal anti-inflammatory drugs (NSAIDs/NSAIAs) or paracetamol (acetaminophen). A meta-analysis of randomized controlled trials by the Cochrane Collaboration found that there is insufficient clinical trials to determine if injection therapy, usually with corticosteroids, helps in cases of low back pain A study of intramuscular corticosteroids found no benefit.

General notes about referral to Chiropractic care
Chiropractors, pursuant to the laws of most States, and under Federal programs, are physicians, trained (in five academic year graduate programs) to perform their own physical, orthopedic, and neurological examinations, take and interpret laboratory tests, and radiological examinations. A competent DC will not undertake to treat a patient until s/he has completed his/her own evaluation.

Chiropractors may elect to combine manipulative therapy with any of the common physio-therapeutic modalities here below described, to facilitate healing, decrease swelling and/or reduce inflammation. And, they will normally cooperate well with the allopathic or osteopathic physician who is willing to provide concomitant medication for pain and or inflammation in the acute stage of care.

Ethics of referral for MD's and DO's
Pursuant to the Court ruling in  Wilk v American Medical Association  (et al), all AMA members and under rules of the Joint Commission on Accreditation of Hospitals allow referral and close collaboration with Doctors of Chiropractic.

Chiropractic v Generic Manipulation methods

 * Chiropractic manipulation, as provided by an appropriately trained and qualified chiropractor: I.e., studies published in the British Medical Journal in 1990 involving 741 patients under Chiropractic care, and in a follow-up in 1995 also in the BMJ, which specifically utilized Chiropractic techniques (high velocity, low intensity) manipulation showed it was vastly better than any other method of treating back pain.


 * Generic Joint manipulation (high intensity, low velocity), in newer studies, but in which the therapy was performed by osteopaths, physical therapists, or a physiatrist showed equivocal benefits over any other method of treatment. Studies of the effect of manipulation suggest that this approach has a benefit similar to other therapies and superior to placebo.

Contraindications to Chiropractic referral
NB: The only universal contraindications to referral to Chiropractic services are:
 * cancer
 * active fracture
 * osteomyelitis

Physiotherapy

 * Physical therapy consisting of generic manipulation and exercise, including stretching and strengthening (with specific focus on the muscles which support the spine). 'Back schools' have shown benefit in occupational settings. The Schroth method, a specialized physical exercise therapy for scoliosis, kyphosis, spondylolisthesis, and related spinal disorders, has been shown to reduce severity and frequency of back pain in adults with scoliosis.


 * Heat therapy is useful for back spasms or other conditions. A meta-analysis of studies by the Cochrane Collaboration concluded that heat therapy can reduce symptoms of acute and sub-acute low-back pain. Some patients find that moist heat works best (e.g. a hot bath or whirlpool) or continuous low-level heat (e.g. a heat wrap that stays warm for 4 to 6 hours).


 * Cold compression therapy (e.g. ice or cold pack application) may be effective at relieving back pain in some cases.


 * Massage therapy, especially from an experienced therapist, can provide short term relief . Acupressure or pressure point massage may be more beneficial than classic (Swedish) massage.


 * Cold compression therapy is advocated for a strained back or chronic back pain and is postulated to reduce pain and inflammation, especially after strenuous exercise such as golf, gardening, or lifting. However, a meta-analysis of randomized controlled trials by the Cochrane Collaboration concluded "The evidence for the application of cold treatment to low-back pain is even more limited, with only three poor quality studies located. No conclusions can be drawn about the use of cold for low-back pain"


 * Electrotherapy, such as a transcutaneous electrical nerve stimulation (TENS) has been proposed. Two randomized controlled trials found conflicting results. This has led the Cochrane Collaboration to conclude that there is inconsistent evidence to support use of TENS. In addition, spinal cord stimulation, where an electrical device is used to interrupt the pain signals being sent to the brain and has been studied for various underlying causes of back pain.


 * Inversion therapy alone, is useful for temporary back relief due to the traction method or spreading of the back vertebres through (in this case) gravity. The patient hangs in an upside down position for a period of time from ankles or knees until this separation occurs. The effect can be achieved without a complete vertical hang ( 90 degree) and noticeable benefits can be observed at angles as low as 10 to 45 degrees.


 * Ultrasound alone, has been shown not to be beneficial and has fallen out of favor.

Other Conservative treatments

 * Exercises can be an effective approach to reducing pain, but should be done under supervision of a licensed health professional, especially a physical therapist, chiropractor, osteopath or physiatrist. Generally, some form of consistent stretching and exercise is believed to be an essential component of most back treatment programs. However, one study found that exercise is also effective for chronic back pain, but not for acute pain. Another study found that back-mobilizing exercises in acute settings are less effective than continuation of ordinary activities as tolerated.


 * A randomized control trial, published in the British Medical Journal, found that the The Alexander Technique provided long term benefits for patients with chronic back pain. . A subsequent review concluded that 'a series of six lessons in Alexander technique combined with an exercise prescription seems the most effective and cost effective option for the treatment of back pain in primary care'.


 * Acupuncture has some proven benefit for symptomatic relief of back pain ; however, a recent randomized controlled trial suggested insignificant difference between real and sham acupuncture.


 * Education, and attitude adjustment to focus on psychological or emotional causes - respondent-cognitive therapy and progressive relaxation therapy can reduce chronic pain.

Surgery
Surgery may sometimes be appropriate for patients with:
 * Lumbar disc herniation or degenerative disc disease
 * Spinal stenosis from lumbar disc herniation, degenerative joint disease, or spondylolisthesis
 * Scoliosis
 * Compression fracture

Of doubtful benefit
Most low back pain can be treated without surgery. Treatment involves over-the-counter pain relievers to reduce discomfort and anti-inflammatory drugs to reduce inflammation. The goal of treatment is to restore proper function and strength to the back and to prevent recurrence of the injury. Effective pain relief may involve a combination of prescription drugs and over-the-counter remedies. Although the use of cold and hot compresses has never been scientifically proven to quickly resolve low back injury, compresses may help reduce pain and inflammation. For some people, compresses may allow greater mobility. Bed rest reduces muscle cramping is recommended for only one to two days at most. Activity reduces muscle cramps and weakening, which decreases the risk of future back pain. Physical therapists prescribe exercises to help keep a person moving. Exercise may be the most effective way to speed recovery from low back pain and help strengthen back and abdominal muscles. In the most serious cases, when the condition does not respond to other therapies, surgery may relieve pain caused by back problems or serious injuries to the muscles and bones.
 * Bed rest is rarely recommended as it can exacerbate symptoms, and when necessary is usually limited to one or two days. Prolonged bed rest or inactivity is actually counterproductive, as the resulting stiffness leads to more pain.

Outcome
Most people with back pain recover without long term functional loss. Self-care usually resolves pain within 72 hours. Recurring back pain resulting from improper body mechanics or other non-traumatic causes is often preventable. Engaging in exercises that do not jolt or strain the back, maintaining correct posture, and lifting objects properly can help prevent injuries. Many work-related injuries are caused or aggravated by stressors such as heavy lifting, vibration, repetitive motion, and awkward posture. Applying ergonomic principles — designing furniture and tools to protect the body from injury — at home and in the workplace can greatly reduce the risk of back injury and help maintain a healthy back.

Impact
Estimates suggest that the cost of low back pain in the United States exceeds $100 billion per year. More than half of these costs is due to lost wages and productivity. The U.S. National Health Interview Survey of adults found that 34 million people had experienced low back pain in the previous 3 months, and 31% of participants had low back and/or neck pain. Participants with low back pain or neck pain were more likely to have psychological distress and other illnesses than were participants who had no pain.

Research
The National Institute of Neurological Disorders and Stroke (NINDS) and other institutes of the National Institutes of Health (NIH) conduct pain research in laboratories at the NIH. They also support pain research through grants to major medical institutions across the country. Currently, researchers are examining the use of different drugs to effectively treat back pain. In particular, they are looking at chronic pain that has lasted at least six months. Some studies are comparing different health care approaches to the management of acute low back pain (standard care versus chiropractic, acupuncture, or massage therapy). These studies are measuring symptom relief, restoration of function, and patient satisfaction. Other research is comparing standard surgical treatments to the most commonly used non-surgical treatments to compare quality of life among patients suffering from spinal stenosis (a narrowing of the vertebral column). In a landmark study in 1990 published in the British medical journal involving 741 patients, Chiropractic manipulation was found to be significantly superior to ANY other method of treating low back pain. The same group was followed and in 1995 the BMJ published the follow-up study showing that those results were still demonstrable in that patient population. Later studies showing lesser results apparently did NOT include Chiropractic methods of manipulation and this may be the reason for the significant difference.

To date, the studies assessing the effectiveness of acupuncture for the control of back pain have been poorly designed. One of the best studies of acupuncture was performed at several medical centers in Germany. In the study, patients with chronic low back pain were given either acupuncture or conventional treatment, which consisted of drugs and physical therapy. The study found that 47% and 27% of patients given acupuncture or conventional treatment, respectively, responded to treatment. Patients given a sham-acupuncture, designed to assess the placebo effect, had a response rate similar to that of the acupuncture group Thus, the effects of acupuncture on low back pain control may have a large psychological component and relief may not be the result of acupuncture itself. Data suggest that any benefit of acupuncture in the short-term control of back pain is lost during the long-term. In the study, patients who received either acupuncture or conventional treatment for back pain reported similar amounts of back pain and a similar quality of life more than five years after the interventions. Therefore, acupuncture does not appear to have advantages over conventional treatment of back pain in the long-term.