It is said that there are 2 types of people, those with a back ache and those that are going to get it! Back ache has been an affliction that can strike anyone, anytime, that can disappear as quickly as it came or persist for a lifetime. The quest to find the ultimate solution to the age old problem has eluded even the most committed of researchers.
Before embarking on a discussion around the treatment of lower back pain one really needs to be more specific around the causes of lower back pain (LBP). There are many different causes, and the treatment protocols can be very different depending on the cause.
For each cause of LBP there are 2 categories:
1. Acute – ‘new’ pain; from initial onset to 3 months in duration
2. Chronic – pain that has persisted for longer than 3 months.
Fortunately, pathological causes of back pain are relatively rare. Pathological refers to a disease process, in this instance affecting the spine, or parts of the spine such as the joints, discs, spinal cord or other bony structures, that will, initially, manifest as pain. An infective process (tuberculosis, bacterial infection), a destructive process (rheumatoid arthritis) or even cancer of the spine are just some of the examples that one would consider pathological.
Such disease processes, although they may initially be mild, usually progress fairly rapidly to the point of being debilitating. Often these conditions originate from a primary site somewhere other than the spine. Tuberculosis often starts in the lungs, rheumatoid arthritis may have been evident in the joints of the hands, and the primary cancer site may have been the prostate or breast. When the spine becomes affected it is simply a progression of the original disease.
In the case of pathological LBP, the pain may begin gradually and present as either disc problem or mechanical LBP (see below). In the initial, or acute phase of the problem, the real underlying cause is often missed and the pain is treated conservatively, either with medication, physio, chiropractic, rest or an over the counter remedy.
However, in the case of these pathological conditions the pain rarely responds adequately to the conservative treatment leading to further investigation and, eventually, the correct diagnosis.
At this point the treatment is essentially medical and can include stronger and stronger medication, radiation, chemotherapy and surgery.
Patients often complement their medical management of these conditions with nutritional or homeopathic intervention, meditation, energy ‘medicine’ and so on, and some have claimed miraculous ‘cures’. Each case has to be managed on its own merits, however, as there are many variables that can enhance the body’s self-healing and auto-regulatory processes.
INTER-VERTEBRAL DISC PROBLEMS
A more common cause of back problems, but still relatively rare, are the true inter-vertebral disc problems.
The inter-vertebral discs are the ‘cushions’ that are found between each vertebra of the spine. They serve as the spine’s shock absorbing system and also enable some vertebral motion.
When subjected to excess force, especially rotational or twisting forces, there is the potential for the strong fibro cartilage holding and protecting the disc to tear, thus allowing the disc to bulge, protrude or even herniate.
If the tear and resultant protrusion are large enough, nerve root compression occurs with resultant pain referral along the distribution of the specific nerve that is involved. The area of referral will depend on the level of the protrusion. If it’s in the cervical or neck area, pain, tingling and/or pins and needles will be felt in the arm, and if in the lower back or lumbar area symptoms will be felt in the leg.
If the protrusion is severe enough, causing marked nerve root compression, the pain will be severe and debilitating. Coupled with this, and perhaps more serious, is the loss of reflexes and muscle function that can occur if the compression is allowed to continue for too long.
In many cases even these more serious disc conditions can be successfully managed conservatively. Conservative management may include rest, ice, anti-inflammatories and chiropractic. Time and the appropriate therapy, or combination of therapies, in most cases will see the symptoms improve and eventually resolve.
In some cases, however, surgery is needed to remove the disc to prevent permanent nerve damage. While surgery should always be the last resort there is certainly a time when surgery may well be indicated.
The third cause of LBP, and by far the most common, is mechanical sprain/strain syndrome, also referred to as ‘facet syndrome’.
Mechanical strains and sprains are responsible for the world wide epidemic of lower back pain. Where mechanical back problems are concerned there is good news and bad news. The good news is that in most case the problem is manageable and resolvable; however, the bad news is that it’s not curable.
In order to more fully understand the nature of mechanical back trouble it is necessary to have an appreciation of how the vertebra all fit together. The spinal column is made up of a number of vertebrae stacked one on top of the other. They are separated in the front by the disc and at the back by the vertebral joints or facets. The facet joints facilitate spinal mobility (without them we would have rigid spines) and are supported by ligaments, tendons, connective tissue and capsular structures. It is the facet joint(s) and their supporting structures that are prone to trauma, repetitive strain and the over-use of daily living.
FACTORS CONTRIBUTING TO MECHANICAL BACK PAIN
Mechanical back trouble rarely has just one cause. Multiple factors usually contribute to the onset of these problems, including an initial traumatic event such as lifting something awkwardly or that’s too heavy, repetitive strain (sitting at the computer or driving for hours), general over-use and, that dreaded word, stress.
If the spine and its articulations are subjected to regular trauma (sports such as squash, tennis, hockey and cycling, not to mention the contact sports), repetitive strain (movements that are repeated time and time again) and over-use (computer, driving), mechanical problems will tend to recur – which is why they are not curable.