MSK Back Pain Treatment

Back pain (backache) is, unfortunately, something that the vast majority of the population will experience at some point in life. Backache is thought to affect the region of one-third of the UK adult population each year. Lower back pain (LBP) in working-age adults is estimated to cost the NHS £1000 million in direct costs and £1623 million in overall costs per annum (NICE). However, back-related pain also has other costs for the economy and society. The overall toll is likely to exceed triple or quadruple the total yearly expense to the NHS. Backache and lumbago is not purely a modern-day problem and has been a condition or rather collection of associated symptoms that have affected humanity throughout history and since records began. As with many Musculoskeletal / MSK related conditions, pain in the back can occur for many reasons and create vastly differing symptoms, levels of discomfort, disability, and chronic pain, (see the article on Persistent Pain for further details on aspects of such conditions and treatment). Hence, backache is a multifaceted condition, which logically requires a specific all-encompassing solution. By taking a holistic approach to each patient's unique circumstances, one can formulate a straightforward solution to the presenting symptoms.

Many types of musculoskeletal condition can arise for one of four reasons, though there are some notable exceptions. The Osteopath (Leon Chaitow), frequently spoke of, lack of use, misuse, overuse and abuse. However, there are notable exceptions including specific diseases and congenital (birth-related) conditions and these equally affect the correct functioning of the musculoskeletal system and would not be related to the previous four categories. These possible injury mechanisms can lead to chronic pain if left unaddressed or further injury occurs. Chronic pain can be much harder to treat and resolve due to a combination of factors, and the articles on the "human stress response" cover some of these.

Typically there is a distinct associated event that relates to the patient's symptom onset, such as a traumatic event, (car crash, bike accident, horse riding fall, etc.). Before the specific incident, the patient may have had no pain or symptoms. Equally, pain or symptoms could be made worse or even better after a traumatic injury event. However, sometimes a patient may go to lift something innocuous or turn in a particular fashion and then suddenly "feel their back go". This type of injury would equally appear to have an undeniable "direct trauma" injury mechanism and pain onset. However, in many respects, such an injury may very well fit better into the second group, "gradual onset".

Symptoms can appear gradually over time and frequently, the patient is unaware of any specific or related injury event. Symptoms gradually get worse over a prolonged period, before patients seek advice or treatment. The author has found that the majority of people wait until symptoms are extremely painful or otherwise debilitating before seeking treatment. Sometimes there would appear to be a hope that everything will fix by itself. Based on the author's clinical experience, he has often noted contributory "indirect" factors relating to those patients that have just "felt their backs go". Some patients have had a previous history of unresolved trauma, and others have never had an episode of backache. That said, the author has always noticed adaptive or compensatory changes in both sets of patients. Adaptivechanges can lead to restrictions in 'normal" structural mobility and function, which in turn increases the loads placed on spinal joints and other soft tissue structures. Hence, the spine's ability to cope with specific loads or forces diminishes or becomes compromised over time and in part due to these dysfunctional adaptations. Habitual behaviours can also play a part in some types of back and neck pain. Relatively simple changes can have a hugely beneficial impact, such as creating an ergonomic work setup for home or in the office. Pain in the lower back is relatively common in pregnancy, especially as the pregnancy progresses. The natural ligament laxity caused by pregnancy, the change in centre of gravity and other noticeable changes to soft tissues and structures all can have an impact. Pregnancy involves many adaptive changes, which equally affects biotensegrity (link to pregnancy section of Biotensegrity and how everything is connected article). Pregnancy also increases the degrees of curvature in each of the sections of the spine. The changes become more noticeable as the pregnancy develops and lead to changes in loading.

Clinical experience has taught the author that one is likely to find a combination of adaptive changes in patients who present with either "direct trauma" or "gradual onset" type symptoms. The level and severity of these changes will usually relate to multiple variables, some of which may include:-

• Severity of injury
• Recency of injury
• The tissues or structures involved and thus healing duration
• Previous injury history
• Unresolved trauma
• Adequate Injury healing environment
• Age
• Other medical conditions
• How soon after injury one seeks treatment
• Effectiveness of treatment given
• Time for dysfunctional adaptations to occur
• Overall fitness
• Diet

Such variables all have a bearing on how well tissues can heal, what adaptive changes occur and the effect that all of these factors have on biotensegrity. One should note that pain can have both physiological and psychological impacts too and not purely as a result of the initial injury. There is a great deal of evidence concerning the relationship between long term pain and the impact this can have on psychological health. Equally, physiological changes can occur as a result of psychological aspects. The (articles about stress and wellbeing) help explain some of the links between the physiological and psychological aspects of the human body.

Symptoms can vary somewhat in severity depending on the tissues or structures involved. Equally, there can be large variations in the time taken for symptoms to resolve and partly due to the tissues and structures involved. Many forms of pain can result in muscle spasms, which can be extremely painful and thought of like the bodies initial attempt to avoid further damage or prevent damage in the first place. In many respects, muscles spams prevent movement by contracting to stop joints from moving, much like a brace or splint. However, muscle spasms can often stay in a painful contracted state long after the initial trigger. Spasms can often occur with muscle strains or ligament sprains, which are equally painful. Back problems may present with different types of pain, dull aching type, or much sharper. Similarly, pain can be very localised, more diffuse or even radiate to other areas. Radiating pain can often be due to either specific muscle pain referral patterns or a more neurological (nerve) related basis, as in sciatic type symptoms. For example, a bulging slipped, or prolapsed disc may produce a combination of neurological (nerve) and related muscular symptoms and varying degrees of severity. Disc related symptoms will typically involve multiple tissues, structures and often some protective muscle spasm. Sciatic (sciatica) type pain may include numbness, weakness, a sensation of cold or heat in the affected tissues, tingling, shooting or electrical type back, hip, leg and even foot pain.

It is also worth noting that not all symptoms may relate to back issues. Hence, it is well worth seeing a suitably qualified professional and generally sooner rather than later. Pain tends to affect how we move, and our bodies will find the most comfortable way to move to avoid pain. The human body is extremely good at learning patterns, including altered movement patterns due to injury. Tissues within the body will also adapt to these altered movement patterns during and after the initial injury, creating additional problems later. Hence, the sooner one seeks professional help, the less time for these adaptations to develop. Although moving is generally a good thing in most forms of back-related pain, it is not always advisable. For example, pain after trauma may result from a fracture, equally conditions such as Osteoporosis can result in various forms of fracture. Some severe conditions are medical emergencies and may involve the loss of bowel and or bladder control, lack of sensation in buttocks, or loss of feeling to either or both legs.

Although, back-related pain can be extremely debilitating and in some cases extremely serious and a medical emergency, the human body still has a remarkable ability to heal (given the right environment). Even if the human body is provided with the correct or best environment to enable healing, the process is far from instantaneous (see Soft tissue repair, healing and scar tissue article). Due to multiple variables, tissues can take anywhere from minutes to years to fully heal and even when provided with the best healing opportunity. Tissues undergoing healing are also more susceptible to further injury, which can create additional functional impairment and further compensatory adaptive changes. Given the correct healing environment, many patients are often surprised to hear that even bulging discs can heal or reabsorb. Equally, although imaging can be helpful in terms of diagnosis, the evidence suggests that it is not the “be-all and end-all”. There is even evidence that imaging is often overused (Chiropractors and x-rays), frequently has no bearing on the end treatment given, and does not necessarily explain the reason for symptoms of symptoms. Research shows a high percentage of asymptomatic (symptom-free) patients who have routine imaging for non-back pain-related symptoms and which highlight disc bulges within the spine or other such pathologies _{[1, 2]}. Other patients may have pain and disc bulges or other relevant pathology, which appear on imaging results. Historically, there seems to have been a tendency to assume that just because something is present on an x-ray, CT scan or MRI, it must be the reason for symptoms of the symptoms, often leading to surgery. Surgery by its very nature is a highly invasive procedure, which will result in trauma, functional tissue adaptations and changes to biotensegrity. However, there are cases where surgery may be the best option or necessary to save a life.

One cannot stress enough how important it is to understand why one is experiencing pain symptoms in the first place. As mentioned earlier in the article, there are many structures involved in the human spine and body, meaning there are lots of areas for possible injury or irritation. Hence, it is advisable to seek advice from a suitably trained, qualified and experienced professional. Unfortunately, the author has seen numerous patients whose symptoms have been made considerably worse by referring to "Dr Internet" and then attempting self-treatment. Individuals may have opted for a form of self trigger point therapy or foam rolling (see articles) or self-stretching. Some types of backache may respond well to the correct type of self-treatment. However, it is easy to make symptoms far worse if one applies the incorrect type of self-treatment, or at the wrong time due to other biotensegrity considerations.

Some of the self-help activities that patients have been partaking in have been somewhat surprising. Consumer's have reported that specific activities appeared to make symptoms feel better at the time, only for things to get a lot worse longer term. Such activities have varied from specific yoga positions to performing kettlebell exercises. The author has even treated patients who have seen massage therapists in the first instance, only to find that symptoms became worse later (see difference in sports massage education and training link). Different professions have differing levels of education, training and thus "scope of practice". Professional standards of "scope of practice" relate to an individual has training to assess, treat, and whether they are qualified to diagnose. All primary care practitioners are qualified to evaluate, diagnose and treat various back-related conditions, unlike other soft-tissue professionals. That said, although soft-tissue therapists cannot diagnose, they are often more than capable of treating back problems, depending on the level of their training. Generally, the human body is subconsciously very good at finding comfort or pain avoidance when injured. Such a position tends to reduce load or pressure on any involved or injured tissues. However, it is best to get injured tissues treated and back to pain-free movement as quickly as possible. General medicine has moved a long way since the days of advising weeks or months of bed rest for backache or foam neck braces for whiplash as in the 1980s. Prolonged lack of movement has been shown to create a mixture of detrimental and adaptive changes to tissues and structures, thus affecting healing and longer-term outcomes. Walking tends to be a beneficial method of providing pain relief for many forms of back problems though there are cases where movement can worsen. Generally speaking, movement is good and when performed as is "tolerable", so discomfort is usually okay, but one should avoid moves that create pain or until a later date. Equally, if a particular activity makes symptoms worse, one should avoid that activity until a later date.

The author has noticed a surprising trend and an expectation that the body can instantaneously heal itself. Such an assumption is regardless of the decades of well-established research concerning the healing processes for various soft-tissues and structures and the time taken. As mentioned, earlier different types of tissues and structures heal at different rates, in part due to available blood supply. Equally, there can often be a false view that the best-case scenario can be sped up to instantaneous by finding the right professional or therapist, which again is contrary to the evidence. Although one can get treated by multiple therapists at the same time and in some cases this can be highly beneficial, in other cases, it may be counterproductive. If numerous therapists are treating a patient at the same time, then the patient needs to make the therapists aware of this fact. Equally, patients should provide permission for the therapists to discuss a coordinated treatment approach and avoid the chances of counterproductive treatments. Practitioners develop treatment plans and aftercare advice based on a combination of training, education and clinical experience. See the article on Finding a good, ethical Musculoskeletal health professional - An MSK Therapy perspective, which covers the types of characteristics and behaviours one would expect with a patient-centred practitioner.

As a Myotherapist whenever the author creates a patient treatment plan, it will be unique to the patient's particular circumstances. Any such treatment plan will equally take into account the likely soft tissue repair period, aftercare advice (homework) and the program adapts with the patient's progress. There have been occasions where patients have chosen not to follow aftercare advice, which is as at least as relevant as treatment. Equally, some patient's make the decision not to finish a treatment plan, as soon as they are out of pain after one or two treatments. Unfortunately, just because something is no-longer painful does not mean that it has fully healed. Equally, taking lots of anti-inflammatories, pain killers (analgesics) to hide or mask the feeling of pain, fails to resolve the underlying problem. In effect, one can be causing more injury and additional tissue adaptations which will, at some point, result in further consequences. Injuries cause adaptive tissue changes at the time of injury, during healing and post-injury. Adaptations frequently create dysfunctional movement patterns and dysfunctional tissues, which based on clinical experience tend to lead to further and "gradual onset" type injuries at a later stage. Such resulting injuries may be a reoccurrence of the original injury or something very different. Unresolved trauma from the original injury or other adaptive and dysfunctional changes often have a later impact over a prolonged period. The author has seen first hand, how patients that do not follow-through with a set treatment plan enter into a cycle of symptom reoccurrence. The cycle typically involves no form of treatment once the patient is out of pain, followed by symptom reoccurrence months later, requiring several closely interspersed treatments to get the patient pain free again, before the cycle starts again. Such a process never really provides the body with the opportunity to address dysfunctional adaptations or enable the patient to develop a sufficient level of body self-awareness as to what "normal" is. If one understands what "normal" should feel like, then it is far easier to notice when something is not quite right and to get the problem addressed before it becomes more serious. Sometimes, our body's need a little outside help with general musculoskeletal maintenance, as the daily demands of life, gravity and other forces are always at work. The author typically treats back-related pain and other types of musculoskeletal conditions with a combination of manual therapy techniques, including, joint mobilisation, advanced soft-tissue therapy techniques and prescriptive-exercise.