spineWhere do I start?

Studies have revealed that 1 in 4 people suffer from back pain at some stage in their lives. If you compare that to other pains, aches or medical conditions it is a very high statistic and yet it is one problem that does not appear to have a structured approach to its management and/or treatment.

How many articles do you see in the newspaper on Back Pain and how many millions of references on the Internet will you find if you type in ‘back’ and ‘pain’ together.
How can you sieve through all this literature and decide what is relevant to you, and then make an informed decision on what is the best path for you to take in your quest for pain relief from your specific affliction.

How many people claim to be able to treat back pain, and how many people run from ‘Billy to Jack’ and back again to ‘Billy’ in an attempt relieving themselves of this scourge.

You’ll find orthopaedic and neurosurgeons, rheumatologist and pain specialists, general practitioners, physiotherapists, chartered physiotherapists, osteopaths, chiropractors, massage therapists, accupuncturists, reflexologists, herbalists, holistic practitioners, spinologists, kinesiologists and every type of quack and bone setter imaginable.

I am not going to attempt to tell you which of these work and which don’t or if they are recommended, safe or unsafe because I cannot say what will or won’t work for any individual without assessing them first. I am also not condoning or opposing any form of treatment in this article. All I am trying to do today is make you aware that there is no ONE right way of dealing with all back pain, which works for everyone.

Unfortunately, the general public are faced with so many choices regarding their own back pain. Many of these recognised and alternative treatments can be nicely packaged and promoted in such a manner that the sufferer does not know what is likely to work for them.

The Spine

In order to understand our backs, we need to take a look at the anatomy of the spine.

The spine is made up of seven cervical (neck) vertebrae, twelve thoracic (upper back) vertebrae and five lumbar (low back) vertebrae. These bones are designed to take weight in the front part and then to move relative to each other. They are held together by ligaments and moved by muscles. The nerves, which come out between these bones, supply all the organs of the body and activate the muscles of the body to make it move.
As all of these structures are packed closely together, any dysfunction of one, will have an effect on another.

Possible causes of Back Pain

Back Pain may be divided firstly into three categories:

  • Acute Back Pain following a fall, accident, sport or sudden movement.
  • Chronic Back Pain which the sufferer may have for a period of months or years. This could be caused by sedentary lifestyle or heavy manual work, poor posture, repetitive sports, structural problems etc.
  • Acute on chronic pain, where the sufferer has a flare up of a chronic or previous back pain.

Types of Back Pain

Now, this is where it gets scary. – Any of the following can be the structure which causes your back pain, if it is due to a mechanical cause.

  • Discs
  • Facet joints
  • Ligaments
  • Muscles
  • Nerves
  • Fascia

It may also be a combination of several of these. There are also non-mechanical causes of back pain, which we won’t look into this time.

Discs

They’re everybody’s nightmare. If you don’t already have a disc problem, it doesn’t mean you won’t get one in the future so read on!
Discs are the shock absorbers of the spine. They are found between the bones and are made up of a jelly like centre (like a wine gum consistency) surrounded by tight criss crossing diagonal bands that attach to the bones above and below. They are called the annulus while the centre is called the nucleus.

The nucleus of the disc could be alikened to a ball bearing in that it acts as a medium between two solid structures (the vertebrae bones) and allows movements in all directions between the bones, while the ligaments and muscles keep the alignment of these bones.
The problem with the majority of people is that all day long, everyday, you tend to bend forwards. Now, I don’t just mean when you bend down to pick up something, I mean subtle bending movements in everything you do. From getting out of bed, sitting on the edge of, getting dressed, going to the loo, washing your hands, eating your breakfast and on and on, with the exception of doing overhead activities, such as painting a ceiling, reaching for a high ball etc.

So you constantly bombard the front disc with pressure and constantly increase the gap between the bones at the back of the spine. As a result the nucleus, or little ball of jelly, bulges towards the back (disc bulge A in diagram below).

spinal-segmentOver a period of time this bulge may become so large that it presses on the neural structures which travel in the spinal canal, down the spine, behind the discs and this will cause back pain. This may happen gradually but the most common scenario is that a few hours or days after a period of prolonged flexion (bending forward) e.g a long car drive, all day at a desk or digging in the garden, the disc bulge increases towards the back and then it’s a case of the hair that breaks the camels back;- you bend down to tie up your lace or pick up a toy off the floor and ouch!! The disc bulges too far and causes central low back pain.

Some common symptoms of this are:

  • Difficulty or inability to straighten up.
  • Pain on cough or sneeze.
  • Ease in sitting but pain on getting up from sitting.
  • Worse in morning.
  • Aggravated by certain movements.
  • Impaired straight leg raise.

The early treatment would involve using ice and trying to lie flat on your stomach.
Analgesics are often useful in the early stages until the acute bulge settles a little. However, it is important to seek physiotherapy assessment and treatment early.

The majority of these central discs do settle spontaneously and some professions feel you should wait and see does it settle. In my opinion, it is extremely important to contact a chartered physiotherapist at this stage, not necessarily for treatment only, but certainly for advice, because if this is your first episode, it will probably be the first of a number of episodes.

Nipping it in the bud or breaking a cycle of recurrent disc bulges is easily done with exercises which must be accurately prescribed. If you do, or have already entered the cycle of recurrent disc bulges you will find that they tend to get more severe and last for longer each time. This is because the damage to the outer ring (annulus) increases with each episode making subsequent bout of back pain worse.

Sciatica

Then the dreaded happens! It may not wait until you’ve had a few episodes, it may come with the first.

If the bulge does not occur centrally, but to one side, or if it moves to one side later, it may press on some part of the neural structure known as the sciatic nerve and this will cause pain to radiate out to one side of the back, or to various lengths down the leg. The further down it goes usually indicates the severity of the bulge.

Professional help should always be sought here. Again, the majority of these are treatable if properly assessed and diagnosed. Prognosis is always better the earlier this help is sought.
It is also important to remember that not all leg pain comes from discs, there are many other causes of leg pain, click here for more on leg pain.

Herniated Disc

If the jelly like nucleus in the centre of the disc bulges out through the outer ring or annulus, then you have a herniated disc. This is really what is meant by a “slipped disc” which is a term inappropriately used to describe a bulging disc (disc B below).

bulging-disc
If the nucleus or centre of the disc actually protrudes out through the annulus or outer ring of the disc then it is a ruptured disc (disc C in the diagram above) and this will not respond to conventional treatment and surgery may be required.

Your GP or physiotherapist should refer you for an MRI scan if they suspect this and referral to an orthopaedic or neurosurgeon should be considered.

Advice for Back Pain

As people vary so much, giving blanket advice on the back is inappropriate as although the symptoms described in this article may appear to be “exactly what you have”, there are many other back complaints with similar signs or symptoms. So an accurate diagnosis should be made before starting any exercise programme. The one sure piece of advice I can give you is don’t just live with it – do something about it.

Prognosis:

The prognosis is very good but is dependent on a number of factors.

  • The severity of the bulge.
  • The number of previous episodes.
  • The stage at which intervention is sought.
  • The ability of the patient to follow advice.
  • Lifestyle.

* Please note – Not all leg pain is related to discs. Very similar symptoms can be produced by myofascial trigger points, facet joint impingements and sacro-iliac joint dysfunction. Accurate assessment is essential.

More About Discs

“The Quick Fix”

When a person suffers low back pain and it is due to a bulging lumbar disc, the pain can be very severe and debilitating, and in most cases the sufferer just wants relief by whatever means.
The lengths I have heard some people go to to get relief is unbelievable. The advice some people receive and worse still – actually believe – can be frightening.

Since coming to Kilkenny, I have heard of people going to non qualified personnel and having various manipulations, sometimes involving such implements as a wheel brace, a floor brush or a spanner being used in very forceful manipulations in an attempt to “put in their disc”.

Now I ask you, if your car wasn’t working would you subject it to a forceful manipulation with a wheelbrace. I don’t think so, and amazingly enough you can replace your car, but can you replace your body?? No, if your car wasn’t working, and you couldn’t fix it yourself, you would take it to a qualified mechanic to sort out the problem. So why do less for your body.

It is essential that whoever you choose to diagnose and treat your back problem has a proper qualification.

Not All Advice Is Good Advice

How many pregnant women listen to endless gory stories about childbirth prior to having their baby? Similarly, how many back pain sufferers are subjected to endless tales of woe from fellow sufferers of “what I did” and “what I didn’t do”.

How often are we warned about using other peoples prescribed medication.
In a similar way, exercises prescribed for one individual may be contra indicated for another.

For example, depending on the direction of a disc bulge, the exercises prescribed may be bending forwards, bending backwards or bending to the side. Doing one of the other exercises may actually exacerbate your disc bulge.

The Quick Fix May Not Be The Best Fix

Let me give you an analogy.

Imagine you had a drawer at home that was a bit stiff and got stuck every now and then. Imagine that every time it’s stuck, you hit it a little kick. As a result, the drawer would open and close freely again; for a while. Eventually it would start to stick again and so you’d give it another little kick. And so on and so on, until one day you’d kick it and it falls apart.

Now, if you had taken that drawer out the first time it stuck, and looked for the reason why it stuck, and did something about that, then the drawer would move smoothly from then on.
Similarly if every time you get a bulging disc you get it a “quick fix” and knock it “back into place”, then it will continue to bulge again. These episodes will start to happen more frequently and become more severe until one day the “quick fix” just doesn’t work anymore and the disc is so badly damaged from repeated trauma that it requires surgery.

Now, the first few times you get a bulging disc, if you went and sought accurate diagnosis, advice and treatment, the cause of your specific bulging disc would be recognised. This may be any number of things, such as:-

  • Weak muscles
  • Too much movement at one segment of your back
  • Too little movement at one segment of your back
  • Tight muscles in one area
  • Your posture
  • Your job or lifestyle

If the cause of the problem was addressed and dealt with, then you should be able to break the cycle of disc injury and so heal your disc.

Also, you will be properly advised on how to prevent disc injuries, how to recognise when a disc is beginning to bulge, and what to do at the first sign of a disc bulge. As a result, you should be able to stop the cycle of disc bulges which you are already in, or just about to face into.
Good luck!

Back Pain – Joint Problems

Anatomy

Each vertebrae (bone) in the spine is made of a body at the front . These are the weight bearing part of the bone, and they are separated by the discs . At the back of each vertebrae is a space (the spinal canal) through which the spinal cord passes.
Behind the main body of the vertebrae there are two little joints which lie at an oblique angle, making them ideal for movement ,but not for weight bearing.

How Pain occurs

The most common ways which pain can be caused by the facet joints are :-
1. Impingement
2. Displacement or subluxation
3. Ligament damage
We’ll look at impingement today.

Impingement

This usually occurs over a period of time if the facet joints are pressed close together . It will ultimately cause wear and tear of the joints and possibly arthritis. It occurs because of a combination of any of these:

  • Posture
  • Muscle spasm
  • Post injury
  • Post disc problems
  • Post pregnancy
  • Flat feet

Signs and Symptoms

  • Dull ache in back nearly all the time
  • Aggravated by standing
  • Difficulty sitting or bending after prolonged standing
  • Pain on forward flexion
  • Pain after strolling, but not so much after a brisk walk
  • Reduced movement in Low back
  • Darts of pain on certain movements
  • Sometimes leg pain

Leg Pain

If the facet joints are tightly impinged there may be irritation of the nerves as they pass out from the spinal cord to travel down the leg. This may be because of pressure on the nerve or irritation of the nerve tissue as a result of inflammation.
There may also be leg symptoms because of pain referral from myofascial trigger points. (We’ll dedicate a whole article to these soon.)

Management

As this is often a chronic problem, management will involve changing or removing the cause of the problem. Even if the initial cause of the dysfunction was a disc injury or trauma to the spine the posture needs to be altered to fully alleviate the symptoms.
Often before you can start to change posture, you need to have the offending joints mobilised, and have tight muscles stretched. Pressure will need to be taken off the neural structures, or myofascial trigger points may need to be released to alleviate symptoms in the leg.

While treatment of the above is taking place, you need to do a stretching and strengthening programme so that when the pressure is taken off the joint the spine will be supported in its correct alignment to prevent the further problems.

Your job, lifestyle and hobbies should be examined to see if there are any minor changes which could be introduced to take pressure off your joints.

It’s never too late to start this.