Back Pain

It is probably no exaggeration to say that the chiropractic profession exists today, and has grown to such strength in numbers, because of its very successful management of patients with back pain.

There is now good evidence of the effectiveness and cost-effectiveness of chiropractic treatment.1

Dr. Gordon Waddell, a leading orthopaedic surgeon from Scotland writes:

Failure to restore function means any pain relief will be temporary and reinforces chronic pain. In the management of occupational back pain, the chiropractic profession is leading the way. The problem is weakness, and loss of function, not disease. 2

Facts About Back Pain

1. Back pain is very common. Eighty-five percent of people will be disabled by an episode of back pain during their lives, and at any given time 7% of the adult population is suffering from back pain lasting 2 weeks or longer.3 Back pain is the second most common reason, after respiratory disorders, that patients seek medical attention.4 It is now known that back pain is common from early adolescence - a new Danish study reports a large increase during the ages 12-14, and that 50% of young women have had their first episode of back pain by age 18, 50% of young men by 20.5

2. Most back pain is caused by mechanical problems in joints and muscles. Over 90% of back pain is caused by functional pathology (e.g. restricted joint movements; stiffness; weakness or trigger points in muscle; nerve entrapment) rather than structural pathology (e.g. disease, tumours, fractures, disc herniation).6

3. Back pain is very disabling and costly. Back pain is the most frequent and expensive health care problem in the 30-50 age group, and it is the most common cause of work loss and disability.7

4. Disability and cost caused by back pain have been growing far more quickly than the population for decades and now represent an epidemic. Between 1971 and 1981 the U.S. population rose by 12.5% but the population disabled by back pain grew by 168% - 14 times faster than the population.

5. Back pain has not been well understood and managed under traditional medical care. For example:

• "Low back pain treatment has represented the least cost-effective expenditure of health care dollars that the author is aware of." Charles Burton, MD, neurosurgeon, Minneapolis. 8
  
• "We have not been honest with ourselves in the past when we have supported months of passive modality care that can offer no long-term benefit. We have not been fair to our patients when we have focused on pain rather than function. We, as medical clinicians, have relied only on the science available to us for the care of structural deficits… the time has come to develop rational principles of care." Vert Mooney, MD, orthopaedic surgeon, San Diego. 9
• "Modern medicine can successfully treat many serious spinal diseases and persisting nerve compression but has completely failed to cure the vast majority of patients with simple low back pain." Gordon Waddell, MD, orthopaedic surgeon, Glasgow. 10
• "The conventional wisdom is that herniated discs are responsible for low back pain, and that sacroiliac joints do not move significantly and do not cause low back pain or dysfunction. The ironic reality may well be that sacroiliac joint dysfunctions are the major cause of low back dysfunction, as well as the primary factor causing disc space degeneration and ultimate herniation of disc material." Joseph Shaw, MD, orthopaedic surgeon, Topeka. 11
  

The New Medical Approach to Back Pain

Since the early 1990s there has been a fundamental change in medical management of patients with low back pain, broadly adopted since the publication of authoritative national practice guidelines in the U.S.12 and the U.K.13 in 1994.

The guidelines change the approach from rest and "wait-and-see" to maintaining daily activities and earliest possible rehabilitation. The first line of treatment is manipulation and simple non-prescription medication, and the guidelines encourage GPs to refer patients for skilled manipulation.

As a result of the government-sponsored guidelines, developed by multidisciplinary expert panels, there is new common ground between chiropractic and the medical profession. Acceptance by the family GP is becoming more apparent and seems to be paralleled to the increasing use of chiropractic in the community. A study from the Medical Journal of Australia in 2000 revealed that 69% of GP's have referred patients to a chiropractor. Forty-one per cent of these refer a few times a year and 17% refer at least monthly.14

"Chiropractors were once dismissed as crackpots. Now even medical doctors call them your back's best hope." Carey, Medical Doctor15

At Shirley Rd Chiropractic we have always worked very closely with GPs and the medical profession. We believe that each profession has a complementary and important role.

Chiropractic and Back Pain

There has been clear evidence from many studies that has confirmed the effectiveness of chiropractic manipulation, and chiropractic management, for patients with mechanical low back pain (also called common, simple or non-specific back pain), the type of back-pain suffered by over 90% of patients.16-21

The most influential trial because of its size, scientific design, independence, and results has been one by Meade that was published in the British Medical Journal in 1990, with long-term results published in 1995. This trial was also important because it gave positive answers to two questions asked by many medical doctors:

· Are the benefits of chiropractic treatment long-term as well as short-term?
· Is chiropractic treatment valuable for patients with chronic pain?

The Meade trial compared chiropractic and medical management as actually experienced by patients in normal life. In summary:

• The study involved 741 patients in a randomised, controlled trial by medical researchers funded by the British Medical Research Council. The study compared standard chiropractic and medical/physiotherapy (hospital outpatient back pain clinics) treatment for patients with low back pain of mechanical origin. A maximum of 10 treatments was allowed over a 3 month period.
• Measurement of results was both objective and subjective and was done at 6 weeks, 6 months, 1 year and 2 years (i.e. during and long after completion of treatment).
• The chiropractic patients did significantly better, including those with severe or chronic pain, and these superior results were maintained after 1 and 2 years.
• Meade concluded that chiropractic treatment had long-term success in the management of patients with mechanical back pain, was highly cost-efficient and should be funded within the British National Health System.
  

What structures cause common back pain?

Common acute back pain is due to chemical abnormalities created by a soft tissue tear. The tear represents a mechanical disruption which is usually microscopic.22 The tear is normally in the muscle fibres and/or ligaments.23 While X-Rays often demonstrate no changes after an acute back pain injury they may help the chiropractor identify the cause of the injury.

Recurrence of Back Pain

In a study of 373 patients under 40 years of age, 89% had a recurrence within 10 years and only 33% had no lost time from work from future back problems.24 Another study suggests that two thirds of the people who have had back pain in the past can be expected to have some symptoms every year.25

While this all sounds very negative it is our goal at Shirley Rd Chiropractic to work with people in such a way that helps to minimize recurrences and help people take a more pro-active role in their care.

Disc Herniation

Medical and chiropractic authorities now agree that the treatment of back and/or leg pain from disc herniation by skilled manipulation is proven both safe and effective,26,27 and that disc herniation should now be seen primarily as a non-surgical disease to be treated by conservative methods.28

What is a Disc and why does it 'slip?'

The anatomy of the human spine includes 24 bones (vertebrae) each separated by a spongy, jelly filled sac, known as an intervertebral disc. Click here to learn more about your spine and nervous system. Normally, before the age of 30, the discs are very strong and forgiving, so that trauma to your spine (poor posture, car accidents, falls, sports etc.) will cause the vertebrae to shift out of place (subluxate) and not the discs. However, prolonged wear and tear takes its toll on the disc structure.

One of the first changes to take place is deterioration of the disc's jelly-like centre (the nucleus pulposis). The resilient fluid filled disc becomes dry, replaced by coarse collagen fibres. The 'drying' of the disc causes it to become saggy and less supportive.

As the disc sags the cartilage plates of the two vertebrae get closer to each other. This causes the disc to bulge. If this process is allowed to continue further damage occurs.

Normally, the disc acts as a supportive shock absorber for the spine. However, the degenerative changes that occur as a result of the loss of pressure within the disc, promote instability of the spinal joints. The instability allows a greater amount of uncontrolled movement to occur in the joints of the spine. This leads to more thinning and eventually bulging of the disc occurs.

Your body weight is no longer supported by the centre of the disc but instead the walls of the sac (annulus fibrosis.) The thinner and weaker a disc becomes the greater the chance of a disc protrusion gets. This process is commonly referred to as a "slipped disc". Increased tension on the annulus leads to bony spurs forming on the edges of the vertebrae in an attempt to stabilize the spine.

If the disc is allowed to bulge far enough it will protrude into the space in which the spinal cord and nerves sit. Pressure on the neural tissue, by the disc, results in symptoms ranging from a mild ache to severe sciatic pain. The severity of the symptom is not always a good indication of the state of the disc. The mild backache that you experience from time to time may be as a result of a thinning disc or a tearing annulus fibrosis.

It is crucial for people experiencing acute back pain to seek help. It is also very important for those people who have been involved in car accidents or are subjected to other forms of repeated trauma (golf swing, cricket, tennis, etc.) and even those who spend a lot of time sitting at a desk to seek assessment by someone who is professionally trained to assess the function of your spine.

Sacroiliac Joint Dysfunction

Back pain often results from dysfunction of the sacroiliac (SI) joints. These are the joints that are found on each side of the pelvis connecting the sacrum (large triangular bone at the base of the spine) to each hip bone (ilium). Much controversy has surrounded these joints, as there was a viewpoint that the joint did not move and could therefore not cause pain. This has since been found to be false and more recently the importance of the SI joint has been described this way:

"The sacroiliac joint appears to be the single greatest cause of back pain. The range of motion is small and difficult to describe but, when normal joint play is lost, agonizing pain can be precipitated … (the sacroiliac joints) are complex and not fully understood, but it is clear to the authors that they can have a profound effect on body mechanics … anyone who still holds the view that these joints are immobile can never hope to achieve control of common back pain."

Sacroiliac joint pain typically is felt when sitting to standing, is located on one side and is often caused by a twisting injury.

References:
1. Chapman-Smith, D. (2000) The Chiropractic Profession. NCMIC Group. West Des Moines, Iowa.
2. Chapman-Smith, D. (1993) The Chiropractic Report. July: 1-6
3. Deyo, R.A. (1987) Descriptive epidemiology of low back pain and its related medical care in the United States. Spine 12: 264-268.
4. Deyo, R.A., Cherkin, D.C., Conrad, D., Volinn, E. (1991) Cost controversy crisis: low back pain and the health of the public. Ann. Rev. of Pub. Health 12: 141-156.
5. Leboeuf-Yde, C. & Kyvik, K.O. (1998) At what age does low back pain become a common problem? A study of 29,424 individuals aged 12-41 years. Spine 23: 228-234.
6. Kirkaldy-Willis, W.H. & Bernard, T.N. (1999) eds. Managing low back pain. 4th edition. New York: Churchill Livingstone.
7. Spengler et al. (1986) Back injuries in industry: a retrospective study. Part I: Overview and cost analysis. Spine 11: 241-245.
8. Burton, C. (1981) Conservative management of low back pain. Postgrad. Med. 70: 168-185.
9. Mooney, V. (1988) Foreword. In: Mayer, T.G., Gatchel, R.J. Functional restoration for spinal disorders: the sports medicine approach. Philadelphia, Pennsylvania: Lea & Febiger.
10. Waddell, G. (1987) A new clinical model for the treatment of low back pain. Spine 12: 632-644.
11. Shaw, J.L. (1992) The role of the sacroiliac joint as a cause of low back pain and dysfunction in low back pain and its relation to the sacroiliac joint. Vleeming, A., Mooney, V., Snijders, C., Dorman, T. eds. Proceedings of the First Interdisciplinary World Congress on Low Back Pain and its Relation to the Sacroiliac Joint. San Diego, California: University of California, November 5-6.
12. Bigos, S., Bowyer, O., Braen, G. et al. (1994) Acute low back problems in adults. Clinical practice guideline no. 14. Rockville, Maryland: Agency for Health Care Policy and Research, Public Health Service, U.S. Department of Health and Human Services: AHCPR Publication No. 95-0642.
13. Rosen, M., Breen, A. et al. (1994) Management guidelines for back pain. Appendix B In: Report of a clinical standards advisory group committee on back pain. London, England: Her Majesty's Stationery Office (HMSO).
14. Pirotta, M.V., Cohen, M.M. et al. (2000) Complementary therapies: have they become accepted in general practice? MJA 172: 105-109.
15. Carey, B. (1998) Back magic. Health. May/Jun: 108-112.
16. Hadler, N.M., Curtis, P., et al. (1987) A benefit of spinal manipulation as adjunctive therapy for acute low back pain: a stratified controlled trial. Spine 12: 703-706.
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18. Meade, T.W., Dyer, S. et al. (1995) Randomised comparison of chiropractic and hospital outpatient management for low back pain: results from extended follow-up. British Medical Journal 311: 349-351.
19. Shekelle, P.G., Adams, A.H., et al. (1991) The appropriateness of spinal manipulation for low back pain: project overview and literature review. Santa Monica, California: RAND; Monograph No. R-4025/1 - CCR/FCER.
20. Kirkaldy-Willis, W.H. & Cassidy, J.D. (1985) Spinal manipulation in the treatment of low back pain. Can. Fa. Phys. 31: 535-540.
21. Bronfort, G. (1997) Efficacy of manual therapies of the spine. Amsterdam: Vrije universiteit EMGO Institute.
22. Mooney (1995) J. Musculoskeletal Medicine. Oct: 33-39.
23. Drezner & Herring (2001) Managing Low Back Pain. Phys. & Sports Med. 29(8).
24. Frank (1993) British Medical Journal. April 3: 901-909.
25. McGorry, R.W. (2000) Spine 25: 834-841.
26. Cassidy, J.D., Thiel, H.W., Kirkaldy-Willis, K.W. (1993) Side posture manipulation for lumbar intervertebral disc herniation. J. Manip. Physiol. Ther. 16: 96-103.
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28. Bozzao, A., Gallucci, M. et al. (1992) Lumbar disc herniation: MR Imaging assessment of natural history in patients treated without surgery. Neuroradiology. 185: 135-141.