This is not intended to be an in-depth article on the management of back pain. Rather, Dr Bernard Brom shares his personal views on this problem views on his problems and shares what he has learnt about the back in over 30 years of practice as a doctor of Integrative Medicine.
Back problems affect most people at some time or another, and 70 – 80% of us are affected by low back pain at some time in our lives. Often it happens in the most unexpected way – just a little turn or even simply getting up from a chair may be followed by an excruciating spasm of the back muscles. It is this muscle spasm that causes the stiffness and immobilisation that are inevitable consequences of the initial acute injury.
The pain is usually localised to the left or right side of the back, but it may be centrally placed. It may radiate down the leg, or even be confined to the leg or foot only. Radiating pain usually suggests that there is pressure on a nerve, and if the pain radiates down the leg, the condition is called sciatica. The sciatic nerve is a pencil-thick nerve emerging from the spine, and it can be pressed on by the disc between the vertebrae or by some bony outgrowth.
LIFE HISTORY OF BACK PAIN
Many patients are concerned that a first episode of back pain heralds the beginning of a lifelong struggle. This is not in fact the case. Many back problems are due to small tears in the ligaments holding the vertebrae together, and while the healing of ligaments is not as efficient as the healing of muscle tears, they will recover in time. Muscle strains and tears can also cause back pain, but these usually heal rapidly within days. My own experience is that even disc injuries and protrusions will respond to various treatments and do not always become chronic unless neglected. The body wants to heal and has a template of what health and normal structure look and feel like. This is why cuts and wounds heal so perfectly, leaving just a very small scar behind. It must be so, otherwise how does one explain the fact that disc problems heal even without surgery?
As we age there is a degeneration of tissues, including the discs and ligaments. Small bony outgrowths from the vertebrae may project outwards or inwards, causing dam- age to surrounding tissue with movement. This accounts for the fact that pain can be- gin suddenly when the underlying cause is a chronic slow degeneration or wearing away of tissue. In these cases the treatment may be prolonged.
While most low back pain is due to benign local problems, a number of symptoms should raise suspicion that the problem may require further investigation:
- Pain following violent injury or accident
- Atypical pain (night pain, unrelenting pain)
- History of cancer
- History of steroid use
- Neurological symptoms such as bowel or bladder incontinence, walking impairment, weakness
- Fever or night sweats
- Pain relieved with forward flexion (which suggests spinal stenosis).
Symptoms of sciatica, i.e. pain radiating down one leg from the back or pain only somewhere along the path of the sciatic nerve, is not necessarily a medical emergency, although this does depend on the symptoms and length of time the symptoms have been present. Clearly if there is increasing weakness of a limb with muscle atrophy occurring rapidly, urgent surgical consultation should be considered. However, many patients with sciatica do well with conservative measures.
Success rates of any treatment are difficult to measure because the underlying abnormality is difficult to define.
- As we get older the prevalence of narrow disc spaces increases together with other signs of degeneration, but this may not be the cause of the back pain (64% of 45-year-old people have silent disc herniation on MRI (magnetic resonance imaging) and nevertheless walk around pain free).
- Soft-tissue injury cannot be detected with X-rays or even MRI.
- Surgeons often operate on the wrong area because of these difficulties and therefore make the problem worse in some cases.
- The extent of the herniation does not correlate with the severity of the symptoms, and in general there is no strong evidence for a correlation between non-specific low back pain and radiographic findings.1
- Even CT (computed tomography) scans are not helpful as patients without back pain may show evidence of disc prolapse and spinal stenosis. Eighty percent of acute back pain will resolve within six weeks regardless of the treatment given.2 With such a poor correlation between the radiological picture and the patient’s symptoms there is firstly good reason not to do expensive and unnecessary X-rays and secondly good reason not to base the decision to operate on these X-rays.
There is no clarity on the best treatment for low back pain. As indicated, most patients with acute back pain will get better on their own, simply with rest. There is no doubt in my mind that acupuncture and/or low-energy laser treatment will help to hasten recovery, and I think many patients will agree that chiropractic treatment also makes a difference to the way the back heals. In addition, a range of other approaches such as mas- sage and hydrotherapy may be helpful.
Chronic back problems will also respond to the above approaches. Again my experience is with acupuncture, and I am convinced that this technique has helped hundreds of my patients who have had lower back pain for months and even years. Because of my personal results with acupuncture I can also understand that other techniques which are not invasive, such as Body Alignment, Body Stress techniques, the Bowen technique and many others involving touching and small manipulations, can start a process of healing.
How is it possible that gentle movements, a needle placed in the tissue, or simply finger pressure can shift discs, remove inflammation and help in acute and chronic back pain? Medicine has what I like to refer to as a masculine and feminine side, and each has its place. The masculine side is powerful and invasive, the feminine is gentle, supportive and nourishing. Just as women are often regarded as the weaker sex, despite their ability to bear children and provide the milk for their nourishment and growth, so the feminine side of medicine is generally not regarded as powerful enough to accomplish real healing.
Feminine energy is subtle and supports the natural healing capacity of the body. It does not use power but gently encourages the body to heal. It does this through contacting the energetics of the body, through opening channels of healing, and through opening the mind of the person to the possibility of self-healing. Everyone understands the power of mind over matter, the power of the placebo response, spontaneous healing, and even the power of prayer. This is the feminine energy at work. Dr John Sarno at the New York University School of Medicine has developed a technique to treat back pain without drugs or surgery and without manipulation, heat or exercise using a mind-body approach that works well for some people. He advocates shifting attention from physical pain to underlying psychological pain (family stress, financial concerns, etc.).3
These can be used in addition to any of the above physical measures.
- Various massage oils such as Arnica massage oil, SRL gel (Natura) and topical cooling gel (Herbal Ice) can be applied or rubbed in locally.
- Phytodolor (Flordis), a herbal compound made from golden rod, ash and aspen, has been specially formulated for back pain.
- MSM (A non-toxic, non-metallic sulfur compound) reduces inflammation, promotes blood flow and reduces muscle spasm.
- Homeopathic remedies include Traumeel tablets or ointment for the acute inflammatory symptoms.
While most acute back pain will resolve within six weeks, there is a high rate of recurrence, with up to 75% of patients having one or more relapses and 72% continuing to have pain after one year. It is therefore important not to neglect back pain.
Remember that X-ray changes are so common that they are an unreliable guide to the need for surgery. Or to put this another way, the back pain may have nothing to do with what is seen on the X-ray.
The best treatments are probably acupuncture, transcutaneous electric nerve stimulation and various forms of manipulation, but preventive treatment in the form of back exercises, postural changes, and seating and sleeping adjustments are very important as well.
- Van Tulder MW, et al. Spinal radiographic findings and non specific lower back pain. A systematic review of observational studies. Spine 1997; 22: 427-34.
- Cherkin DC. Primary care research on low back pain. The state of the science. Spine 2002; 23: 1997-98.
- Sarno JM. Healing Back Pain. The Mind Body Connection. New York: Warner Books, 1991.