Back Pain - A Chiropractor's perspective, causes, treatment, causes, treatment

TotalMSK Blog Back Pain - A Chiropractor's perspective, causes, treatment in a Musculoskeletal context

Back Pain an age-old problem

Back Pain an Age old problemBack pain is, unfortunately, something that the vast majority of the population will experience at some point in life. Back pain is thought to affect in 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, lower back pain also has other costs to the economy and society at large, and the overall toll is thought to exceed triple or quadruple the total yearly expense to the NHS. Back pain 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, back pain can occur for many reasons and create vastly differing symptoms, levels of pain and disability. Hence, back pain is a multifaceted condition, which logically requires a specific all-encompassing solution. By taking a holistic approach to each patient's unique set of circumstances, one can formulate a specific solution to the presenting symptoms.

Possible causes of Back Pain (injury mechanisms)

Back Pain injury mechanisms RowingMany 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.

Lack of use

There is a great deal to be said about the phrase “use it or lose it”. Many functions within the body require movement to help move fluids around the body, e.g. venous return (deoxygenated blood supply), lymphatic flow (lymphatic fluid relevant to immunity) and synovial fluid (related to cartilage). Many joints within our body and spine include cartilage, and squeezing type action of movement helps maintain this. In some respects, cartilage is a bit like a “sponge” and nutrients and waste products are transferred in and out via a squeezing action via movement. There is also evidence that cerebrospinal fluid pumped around the body through respiratory action (breathing), and so this could equally be affected by movement. There is growing evidence of the benefits of activity on musculoskeletal health, immunology and other bodily systems. Evidence, suggests that a lack of use of the musculoskeletal system results in earlier degenerative changes, which is highly logical. Tissues and structures will also adapt to a lack of use, and thus they may not be able to cope when needed for a particular function, such as lifting something.

Misuse

There are multiple ways to misuse joints structures and soft-tissues of the spine. Misuse can also create adaptive changes, which affect the back directly or indirectly. Again, such adaptive changes can lead to injury at a later stage. One can misuse our body's in many ways, e.g. poor exercise technique when rowing or at the gym, habitual behaviours (laying on the sofa watching television, sitting in a slumped position for hours on end, not taking breaks). Equally, one could combine a misuse activity with lack of use type activity or vice versa.

Overuse

An overuse activity does not necessarily have to originate from physical activity and could easily result from a misuse activity. Quite often, a misuse activity can lead to overuse of joints structures, soft-tissue or a combination thereof. Overuse, injuries tend to arise from doing too much of something, be it a sport, social activity or habitual behaviour etc. Tissues and joints structures need time to adapt to the demands placed on them. Hence, why serious athletes go through a training process, which develops throughout the training schedule. Rowers are quite susceptible to lower back-related problems, as the repetitive motion of rowing can lead to overuse injuries. However, adaptive changes are likely to have already placed additional loads on the lower back by the time the issues become apparent.

Abuse

In some cases, there could be elements of misuse and overuse with some “abuse” type injuries. Generally, one could view any form of physical trauma unintentional or otherwise as “abuse” type injuries. Equally, consciously doing something which is likely to cause a spinal injury would certainly fit within this category. Some sports and pastimes have developed protective clothing to help reduce the chances of spinal injury, helmets, neck collars and even protective jackets as with horse riding.

Furthermore, all of the six possible mechanisms mentioned above can lead to "adaptive" changes within the body (see adaption article). Having a good level of “self-body awareness” can certainly help prevent many types of misuse and overuse injuries. In essence, one then knows when something is not quite right and can get it addressed before it becomes more problematic.

The complicated nature of the human spine (back)

Back Pain structures - 3d4medical.com image

Back pain can originate from several areas, due to the vast array of structural and functional components involved. To further complicate matters, numerous other structures are running between various sections of the back, including nerves, veins, arteries and lymphatics. Hence, there is plenty of opportunity for something to get irritated, especially when you consider the vast number of moveable joint structures. Furthermore, human movement requires the use of multiple joints structures (coupled motion) and tissues at any one time. The human spine consists of four broad sections and number of vertebrae within each section:- cervical (7), thoracic (12), lumbar (5), sacral (5 fused), coccygeal (4 fused). The image on the left illustrates these structures and includes the skull, ribs, sternum and pelvis, but no soft tissue structures. The design or shape of vertebrae within each section of the spine differs, which has connotations for function and movement. It is also noticeable from the image on the left that there are three distinct and natural curvatures in the spine. The lumbar (lower back) section and cervical (neck) section of the spine both have a "C" shaped lordotic curves. However, the thoracic portion of the spine has the opposite shape, a reversed "C" shape or kyphotic curvature. Although there are differences between the general population concerning the levels of degrees of curvature in these sections of the spine, this is perfectly normal. A combination of structural (bone and joints) and functional soft tissues (ligaments, muscles, tendons and fascia) maintain the natural curvatures of the spine. Such differences in the individual components helps explain why there is no such thing as a "correct", "perfect" or "Gold Standard" posture. However, one can still place "postural" related load on the spine and in effect increase forces on the tissues and structures that are maintaining the natural curvatures of the spine. In some respects, the term "postural fatigue" might be more descriptive, as muscles only have a finite capacity to cope with any given load. Multiple variables affect a muscles capacity to deal with any given force, including the type of muscle (size, condition), load (type, duration, angle), muscle nerve supply, nutrients, oxygen etc. Once, muscles fatigue, other structures and soft tissues start taking additional loads, which can, in turn, affect other muscles, and so on. The natural curvatures of the spine are functionally relevant to bodyweight distribution, movement, shock absorption and more.

Image produced with kind permission of 3d4medical.com from Essential Anatomy 5

(Copyright © 2018 3D4Medical. All rights reserved.)

If one were to isolate each of the portions of the spine, then one would find that the amount of functional movement decreases as one moves from cervical to lumbar. Hence, usually, one can rotate one's heads to around ninety degrees to the left and right, and cervical vertebrae are relatively narrow in height, as can be seen in the following image. As one moves from the top of the spine to the bottom, the compressive load-bearing capacities of the vertebral bodies of the spine increase, as does the shape width and height. Although the human head is relatively heavy (around 10lbs), the cervical portion of the spine does not need to carry vast amounts of weight. There are always tradeoffs between structural and functional capabilities, as any engineer will know. The cervical spine is highly mobile, yet not capable of taking large loads/forces.

Cervical neck pain bones - 3d4medical.com image

Image produced with kind permission of 3d4medical.com from Essential Anatomy 5

(Copyright © 2018 3D4Medical. All rights reserved.)

The lumbar spine can cope with much higher loads/forces, particularly of a compressive nature, though it is relatively immobile in comparison to the cervical spine. Unlike the cervical spine, the lumbar spine has to cope with the weight of everything above it and not just the head. One can see the difference in size and shape of the lumbar vertebrae in the following image.

lumbar back pain bones - 3d4medical.com image

Image produced with kind permission of 3d4medical.com from Essential Anatomy 5

(Copyright © 2018 3D4Medical. All rights reserved.)

The thoracic section of the spine also has the additional attachments for the ribs. Ribs have several functions including protecting organs and for respiration. The ribs are attached to the thoracic spine via a combination of ligaments, cartilage and other soft tissue structures and attach to the sternum of the chest. The following image demonstrates the difference in thoracic vertebrae shape.

thoracic back pain bones - 3d4medical.com image

Image produced with kind permission of 3d4medical.com from Essential Anatomy 5

(Copyright © 2018 3D4Medical. All rights reserved.)

Below the lumbar vertebrae, one finds the sacrum and coccyx, which are both fused bones. The sacrum (5 fused bones) carries a great deal of load for the spine, and a common disc injury site is between lumbar vertebrae L5 and the start of the sacrum S1. One finds the coccyx (4 fused bones) below the sacrum. There is also a joint structure between the sacrum and coccyx, and this can be another origin of back, hip or leg pain. Two further joints exist on either side of the sacrum, and these attach the two halves of the pelvis. The Sacroiliac Joints (SIJ)'s, as they are known can also be a source of back, hip or leg pain.

sacral or coccyx bone pain - 3d4medical.com image

Image produced with kind permission of 3d4medical.com from Essential Anatomy 5

(Copyright © 2018 3D4Medical. All rights reserved.)

Although there may be four distinct sections of the spine, there are various soft tissues, muscles, fascia, ligaments and tendons which crossover the multiple sections. Equally, soft tissues from other parts of the body can have an impact on the spine, either directly due to physical attachment(s) or indirectly via associated tensional forces (see biotensegrity article).

There are multiple structures within the back and which can easily result in pain, restricted movement and disability. Structures include ligaments, muscles, bones, cartilage, discs and fascia, all of which play a part in biotensegrity. Any of these structures or tissues can become injured or irritated, directly or indirectly via other parts of the body. One typically finds some form of inflammation when tissues are damaged, and this often results in increased internal pressure. Equally, there are some medical conditions which create an autoimmune response and can affect joints and also involve a painful and debilitating inflammatory response such as Rheumatoid Arthritis (RA). However, just because something initiates an inflammatory response certainly does not mean that anti-inflammatories are the best answer. As a Chiropractor and soft-tissue therapist, the author's main aim of treatment is identifying and removing the "irritant" and thus creating an environment for the body to heal. The author achieves this through a combination of McTimoney Chiropractic for the structural aspects, and soft-tissue work and prescriptive exercise for the adaptive or functional changes. The combination of techniques seems to produce faster and longer-lasting results for patients.

Typical Back Pain Symptom onset

As a musculoskeletal chiropractor, the author has lost count of the number of patients he has seen with varying degrees of back pain and with differing origins. Typically, one can split patients into one of two groups, based on symptom onset.

A Direct trauma/event:-

Back pain origin direct traumaTypically 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".

Gradual onset:-
Back pain origin gradual onset - pregnancy

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 back pain. That said, the author has always noticed adaptive or compensatory changes in both sets of patients. Adaptive changes 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 adaptions. Back pain can be a relatively common factor of 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 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 adaptions 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 back 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.

Types of Back Pain Symptoms

Back Pain and Neck Pain

Back pain 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 in part due to the tissues and structures involved. Many forms of back 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. Different types of back pain may present with dull aching type pain or a much more sharp kind of pain. Similarly, back 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 of a more neurological basis, as in the case of sciatic type symptoms. For example, a bulging disc may produce a combination of neurological and muscular related symptoms and varying degrees of severity. Disc related symptoms will typically involve multiple tissues, structures and often some protective muscle spasm.

It is also worth noting that not all back pain symptoms may relate to back issues. Hence, it is well worth seeing a suitably qualified professional and generally sooner rather than later. Back pain tends to affect how we move, and our body's 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, which can create additional problems later. Hence, the sooner one seeks professional help, the less time there is for these adaptions to develop. Although moving is generally a good thing in the case of most forms of back pain, it may not be dangerous. For example, back pain after trauma may be the result of a fracture, equally conditions such as Osteoporosis can result in various forms of fracture. There are also some severe conditions which are medical emergencies and may involve the loss of bowel and or bladder control, lack of sensation in buttocks or loss of feeling too either or both legs.

Back Pain and the ability to heal

Back Pain and tissue healingAlthough, back 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 healing article). Tissues can take anywhere from minutes to years to fully heal and even when provided with the best healing opportunity, due to multiple variables. Tissues undergoing healing are more susceptible to further injury too, which can create additional functional impairment and further compensatory adaptive changes. Many patients are often surprised to hear that even bulging discs can heal or reabsorb, given the correct healing environment. Equally, although imaging can be useful 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), that it frequently has no bearing on the end treatment given and that it does not necessarily explain the cause of symptoms. Research shows that there is 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. However, other patient’s may have symptomatic back pain and no disc bulges or other obvious pathology. Equally, some patients may have pain and disc bulges or other relevant pathology, which may be indicative of the symptoms. Historically, there seems to have been a tendency to assume that just because something is present on an x-ray, CT scan or MRI that it must be the cause of the symptoms, often leading to surgery. Surgery by its very nature is an extremely invasive procedure, which in itself will result in trauma, functional tissue adaptions and changes to biotensegrity. However, there are cases where surgery may be the best option or necessary to save a life.

Self-treatment for back pain

self-treatment back pain

One cannot stress enough as to how important it is to understand why one is experiencing back pain symptoms in the first place. As mentioned, earlier in the article, there are a vast array of structures involved in the human spine and body, meaning there are lots of areas for possible injury/irritation. Hence, it is advisable to seek advice from a suitably qualified professional, and based on extensive experience the author would recommend a primary care health practitioner in the first instance, e.g. a Chiropractor, G.P., Osteopath or Physiotherapist (listed purely in alphabetical order). 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 self-trigger point therapy, foam rolling (see articles) or self-stretching. Some types of back pain 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. Patient'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 been to see 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 what an individual is trained to assess, treat, and whether they are qualified to diagnose. All primary care practitioners are trained to evaluate, diagnose and treat various forms of back pain, unlike other soft-tissue professionals. Generally, the human body is subconsciously very good at finding a position of 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 back pain, or foam neck braces for whiplash 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.

Back Pain Treatment perspective

Back pain treatment perspectiveThe 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/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.

Back Pain treatment ChiropracticAs a Chiropractor and soft tissue therapist 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 tissue healing 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. Injuries cause adaptive tissue changes at the time of injury, during healing and post-injury. Adaptions 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. In some cases, 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 adaptions 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 article was written by Dr Terry Davis MChiro, DC, BSc (Hons), Adv. Dip. Rem. Massag.,  Cert. WHS.


About the Author

The author possesses an unusual mixed background for a Chiropractor (McTimoney). His education, training and practical experience span over two decades and relate to both physical and mental aspects of health. He has also been required to push his own body and mind to the limits of physical and psychological endurance as part of his time serving in Britain’s elite military forces. His education includes a bachelor of science degree in Business Management, with a specialisation in psychology and mental health in the workplace, an Integrated Masters in Chiropractic, MChiro and a multitude of soft-tissue therapy qualifications. His soft tissue qualifications range from certificate level right through to a BTEC Level 5 Advanced Diploma in Clinical Sports and Remedial Massage Therapy. Terry also has practical experience and certification in Work Health and Safety and Training and Assessment. He has also taught at Advanced Diploma (Myotherapy / Musculoskeletal Therapy) level in Australia, both theoretical and practical aspects of the discipline. Terry’s combination of knowledge through, education, training, his elite military experience and personal injury history have paid dividends for the patients he sees and has treated.