There are literally thousands of articles and papers written about the subject of Back Pain. Much research has been done, modalities investigated and instigated, and treatment regimes espoused.
So where is it all going wrong, as we still have 120 million days a year of absenteeism in Britain due to Back and Musculoskeletal pain, and Back Pain is the third most common reason for patients to consult their GP. Every year there are also many thousands of Osteopaths, Chiropractors, Physiotherapists and others, treating Back Pain, so if there is all this ‘consulting and treating’, why are the figures not going down? The annual economic cost of low back pain in lost productivity and disability or sickness benefits is estimated to be more than £12bn, and the estimated annual cost to the NHS of treating back pain was 1.5 billion pounds. That is not counting the cost to the individual sufferer.
With 80% of the population experiencing a Back or Back related problem sometime in their lives and no obvious prospect of proper relief, is it any wonder that many think that it is hereditary or just something that most people have to live with.
The various well documented testing procedures have validity in the majority of presenting back pain, but can frequently exacerbate the underlying cause whilst defining the underlying symptoms and are really only of use in testing for persistent and/or hidden pathological causes.
There is no question as to the understanding and knowledge that abounds as to the complexity of symptoms that can arise from the various normally attributable causes, which have been assigned well-used labels.
The common causes are usually labeled as in the Symptom Page of my web site. But that is not enough, because the causes are more fundamental.
Let us put aside the labels, go back to basics and do some logical reasoning as to the real cause. I am going to try and attempt to explain my reasoning and I hope you will bear with me, as I believe that it will ultimately make sense.
I want to take the basic concepts of Pain, Inflammation, Arthritis and Wear and Tear. Look at what they mean and ask the question ‘what is it?’.
Pain can be caused by many things, but there are four basic ways in which pain can arise.
- Pathologically from a bacteria or virus or pathogen, cancer etc.
- Chemically from an internal or external source.
- Nerve/electrical stimulation/disturbance.
- Physically by internal or external damaging forces.
The pain is a signal to the body that something is wrong and elicits a conscious response or a sub-conscious/sympathetic reaction. How the body responds and reacts will depend on which of the above four reasons either individually or in various combinations are creating the stimulus for the pain signal. These responses and reactions in turn can then go on to create further responses and reactions and so on until the whole picture can become very complex and ultimately difficult to diagnose accurately with so much happening.
Inflammation as was explained to me in the distant past is ‘a natural reaction which can be defined as a series of changes which occur in a living tissue when it is injured, provided that the injury does not destroy it immediately’. The use of the word ‘injury’ is very wide and includes the above four reasons which also elicit pain. The unfortunate trend is to label it with an ‘itis’ or an ‘osis’ without trying to establish the reason for the ‘injury’.
The label of Arthritis is probably one of the most misconstrued and dismissive terms in the medical vocabulary because it is handed out so liberally and wrongly used to describe a cause, instead of being used to describe the ‘consequences of a reaction’ to a cause. The subsequent treatment is then geared towards treating the consequences of the reaction instead of finding the true underlying cause, which is creating the reaction in the first place. If we consider that the basic causes are the same as for the basic cause of Pain then we can attribute certain parameters.
Pathologically we have for example, Rheumatoid Arthritis, which can be definitively tested for and has very significant clinical symptoms, as do many other Pathological causes.
Chemically we have examples in for example Gout and other rheumatic type symptoms, which tend to affect the body in a general sense.
The biggest grey area is in the nerve stimulation/disturbance with often some chemical reaction mixed in as well. This has a whole plethora of labels and misconceptions extending to the common term of Osteoarthritis.
In the Physical sense there is the obvious damage and incomplete repair of damaged joints as a consequence of external forces. Also called Osteoarthritis.
At the risk of using another ‘Label’, the defining term, which is then common to, the physical cause, the nerve stimulation/disturbance and in some part the chemical inter-reaction, is Trauma. Not the Trauma associated with severe physical injury or mental disturbance, but a slight and significant irritation, which the body then responds to, by inflammation of the surrounding tissues and various other well noted responses.
So if we start with the premise that Trauma creates ‘osteoarthritis’ and its variants, perceiving the cause of the Trauma should be the goal of all that seek to treat effectively. There is not a lot of point in trying to treat the condition or the symptoms if the cause is still active and present.
Wear and tear is a term, which is so commonly used as an un-investigated dismissive throwaway, often masking a sad lack of understanding by the user as to the real underlying cause. Certainly there will be circumstances in sport for example, where the gross overuse and sustained severe physical trauma will degenerate a joint faster than the body can repair it. But too often it is attributed to other symptoms where degeneration has occurred for no obvious physical reason. The classic case is the degenerated hip when the hip on the other side is as good as new. Why? They have both walked the same distance so why should one ‘wear’ more than the other? I often ask patients to consider if their hands ‘wear’, no! Then why not? Because the hands and particularly the skin are being ‘repaired’ as are other parts of the body. The body wants to heal itself, it wants to work properly, so what is happening to a joint that is degenerating? If external physical trauma is not part of the history then there must be some other reason for the trauma in the hip.
Professionally it is accepted that following appropriate examination, differentiation between patients with simple backache (the vast majority), with nerve root pain (a few) and with possible serious spinal pathology (as rare as “hens teeth!”), is fairly straightforward. Subsequent to appropriate history taking and basic triaging to rule out the possibility of serious injury or pathology it can be reliably assumed that the simple backache and the nerve root pain are being caused by Trauma.
So what is causing the underlying Trauma? Quite simply a very slight misalignment/rotation of some of the vertebrae in the spine (which can be easily detected and corrected very simply).
This can have a direct physical effect on the nerves as they pass through that part of the spine and create local and/or distant trauma and altered function.
The distortion can affect the physiological function of the disc and create the conditions, which lead to a prolapse or disc herniation. Slipped disc is another elderly label, but in reality the disc cannot ‘slip’.
After about 10 years the disc will show signs of altered shape as the body is adapting to accommodate the distortion. This altered shape is usually a narrowing of the disc, which is commonly labelled, wear and tear.
Even a very minor local trauma will cause the body to involuntary react and tighten the surrounding muscles to try and stabilise the spine. The resulting reactions and tensions thus created can create more trauma which can physically effect more nerves and create more local and/or distant trauma and altered function. More often than not I would consider that the pain experienced in the majority of back related symptoms are derived from this secondary cause which is being created by the trauma in the spine.
Sustained involuntary muscle contraction will also create trauma in the muscles themselves and their associated attachments to the bones. Visually apparent distortion of the spine, long or short term is thus created as the body adopts a posture commensurate with the muscle imbalances and the position of least pain.
Considering the very slight amount of misalignment/rotation of the vertebrae, the response and reaction of the body could reasonably be considered extreme in some cases. However, after 42 years of treating patients I have absolutely no doubt that the correction of the vertebrae is the underlying answer to the problem. Correct the basic cause in the spine and all the many other symptoms will usually disappear quite readily if the appropriate back care advice is followed.
Considering that the two basic forms of transmitting information and messages around the body are by electrical (nerve) and chemical means. There is an inevitable inter-reaction and if one means is disturbed i.e. the nerves, then it is logical to expect the other could be effected in some way to elicit a chemical response. So if a traumatised joint is showing a chemical difference to that of normal joint, are the changes due to the direct effect of the traumatised nerve or due to the bodies response to the trauma created in the joint? Or is there even a third factor in that there is an already existing minor chemical (rheumatic) trauma which is being locally activated by the trauma from the nerve and adding to the trouble in the joint?
The end result is that the resultant trauma in the joint creates the deterioration or interrupts the normal healing and repair mechanism, which then results in deterioration.
Referring back to the example of the hip, it thus follows that if the lower spine is examined and found to be misaligned, then correction and stabilisation of the vertebrae will sort the problem in the hip as I have found by experience to be the case.
I couldn’t begin to count the number of patients I have had who once walked in using sticks and zimmers and were able to throw them away. Likewise the numbers of patients who were heading for hip replacement and now have no pain and the large number of patients who were already in possession of a date for a spinal operation and were able to cancel it for good.
I am not saying that operations should never be required, just that many of them are unnecessary when there is another simpler way.
The web pages from the National Ankylosing Spondylitis Society also make interesting reading.
Typically they mention inflammation and an inflammatory process as being the cause. I have a suspicion that there may be a physical and a chemical cause in relation to the other symptoms where it can affect the eyes, lungs, bowel and heart. However I have had many patients who have been clinically diagnosed as having AS, with an onset of their back trouble at least 10 years previous, during which time it was described as Spondylosis. I realign the vertebrae and all their pains go away!!!
The interesting part to consider with AS is the attempt by the body to fuse the joints and ultimately stabilise the spine. This reaction is usually as a consequence of severe long term trauma in the spine and more obviously in the upper thoracic area where it can be palpated readily.
I have tried to give an insight on my way of thinking about back pain. It may be quite different from the norm and even controversial but it fits with the treatment and the results I achieve. It is not of course the whole picture in respect of back pain and musculoskeletal pain but considering the percentage, it is a very significant section of it.
There are other factors, which I have not gone into for the sake of keeping this article short, but may be found in the main part of my web site, if desired.
A. R. BRAZENALL DO. FHSMS. LVMC.