Chronic Back Pain

Synonyms in the wider sense

Low back pain, Lumbago, pain in the small of the back, lumbar syndrome, lumbar root syndrome, compression syndrome, lumbar inter-vertebral syndrome, sciatic syndrome, sciatica, facet syndrome, vertebral joint pain, myofascial syndrome, tendomyosis, spondylogenic reflex syndrome, cervical-brachial syndrome

Definition

The term “back pain” stands for pain in the area of the sacrum. In English literature it is summed up as “low back pain”. Looking at the various terms above, we can see that back pain can have different causes. The cause of the pain does not necessarily have to be located in the back. Often different causes can be found (urological, gynecological ….) that must be sorted out through differential diagnostics.

It is the duty of the examining doctor to discover the cause of the clinical picture of back pains and treat the illness at its source.

Back pain that originates in the area of the vertebral column and the neck is described as a symptom-complex with regionally limited pain and differently extended disruptions of the function of the vertebral column. The following illnesses affect, e.g. the vertebral column and the neck: autonomic pain, cervicalgia, cervical syndrome, brachialgia, dorsalgia, lumbago, lumbalgia, sciatalgia, radicular pain, pseudo-radicular pain. In certain circumstances back pain can be dispersed. This is, for example, the case with the clinical picture of lumbar-glutealgia (spreading of the pain into the buttocks) or lumbar sciatica (spreading of the pain into the leg).

This sort of pain usually is chronic, i.e.: it is reoccurring. Normally there are no neurological symptoms in these cases.

Due to the fact that the reoccurrence is typical for this sort of pain, it is also called a chronic pain disease, normally without neurological symptoms.

x-ray picture of lumbar vertebral column: inter-vertebral disc (blue) vertebral body sacrum (red)

Epidemiology

Back pain is regarded as a widespread public illness; statistically it is the second most common reason for people to consult their doctor. As mentioned above, back pain is often chronic and, thus, re-occurring.

Often it proves difficult to find the basic cause for chronic back pain. We have already mentioned that there are a number of organic and psychological reasons that can be the cause of back pain. Under various circumstances, it is always possible that they may influence each other or increase their effects. It is the doctor’s duty to determine the cause and to confirm it through differential diagnosis. That is not always easy.

First, we want to look at back pain that originates from the area of the vertebral column and the neck. As examples, we have chosen some illnesses that are especially common in patients. They are:

• Lumbago – this refers to usually sudden, strong pain in the lumbar area. The pain can affect neighboring areas, followed by serious restriction of the mobility and penetrating pain. The reason for lumbago is, for example, damage in the region of an inter-vertebral disc, pressure pain in the area of the thorn processes and much more. Which is the final cause for lumbago must be defined and examined individually.
• Lumbaralgia / lumbar-sciatica / lumbar-glutealgia – as soon as pain extends into the legs for example in addition to back problems, we talk about Lumbar Sciatica.
• Prolapsed disc – this refers to the sudden and slowly progressing movement or escape of the nucleus pulposus (jelly-like nucleus of the inter-vertebral disc) of an inter-vertebral disc backwards into the spinal marrow channel or to the back and side towards a nerve root. The subsequent pressure on nerve roots can cause pain, paralysis and / or sensory irritations.

PICTURE OF THE INTERVERTEBRAL DISC

nucleus pulposus (jelly-like nucleus) annulus fibrosus (fibre ring)

Causes

The different clinical pictures that have been described above already show that the under-lying causes for back pain are diversified.

Common causes for the origin of back pain are degenerative changes that are based on wear and tear in the region of the vertebral column and inter-vertebral discs. Looking at the causes must always take into consideration individual reasons. Thus, for example patients with a hollow back or lordosis and those with weak back muscles will be affected more often than others.

Putting aside individual factors, there are potential reasons for the origin of back pain. We will name and explain the most important ones in the following.

Potential reasons for the origin of back pain are:

• Wear and Tear / Arthritis / degeneration
  • Bone growth in the region of the vertebral column (spodylophytes / osteophytes)
  • Narrowing of an exit point for a spinal nerve (foramen-stenosis) through bone growth or thickening of a ligament (hypertrophy of the ligamentum flavum)
  • Morbus Scheuermann
  • Inflammatory diseases such as Morbus Bechterew, Morbus Paget and decalcification of the bone structure (Osteoporosis)
  • Wear and tear especially affects people that have spent a long time doing physically hard work. Degeneration often affects the elderly.
  • Spinal channel stenosis
    Certain forms of bone growth can result in a narrowing of the spinal channel. A spinal channel stenosis then compresses the spinal marrow at that site. This results in pain, sensory irritations and even paralysis.
  • Facet-syndrome
    Wear and tear of the small vertebral joints leads to the so-called spondylarthritis (arthritis of the small vertebral joints). This facet-syndrome is one of the most common reasons for back pain in the elderly.

• Mechanical Reasons
  • Mechanical reasons summarize mainly mechanical irritations and reactions that can sometimes cause tremendous pain. Trapped nerves also belong in this category.
  • Especially after surgery in the region of the inter-vertebral discs, deformities in the area of the scar tissue very often cause strong pain (post-nucleotomy-syndrome)

• Injuries in the region of the vertebral column
  • Injuries in the region of the vertebral column can, for example, be the result of traffic accidents, which lead to a so-called whip-lash-syndrome. In more serious cases a shift of the vertebral body or tearing of a nerve or even a vertebral fracture can be the reason for back pain.

• Neo-plasia / growth of new tumours / tumour
  • As in almost all parts of the body tumors such as neurinomes and menigeoms can be found in the region of the vertebral column. Those tumors and their metastases (in the most severe cases) can cause considerable pain.

• Congenital reasons
  • Reasons for the origin of back pain can also be congenital. In the case of an open spinal channel as with the disease “spina bifida” appropriate action must be taken.

• Irritation of the nerves
  • In this category one finds the classic lumbago. This is an acute irritation of a nerve. That means that lumbago has nothing to do with wear and tear (see above).

• Inflammation
  • Inflammations in the various parts of the back can also be the reason for back pain. The cause for the inflammation is usually a bacterial pus focus (=abscess) in the region of the nerve roots and the spinal chord. In addition, suppurating alterations of the vertebral column can be regarded as the cause for back pain.

Many forms of back pain are caused by incorrect or bad posture of the vertebral column. Indirectly, people compensate for these incorrect postures by so-called avoidance postures, which consequently attempt to correct bad posture by the use of muscles. This means that other muscles have to work overtime and react by causing pain due to overuse and tension. This is the onset of a vicious circle (see below).

The intervertebral disc consists of a so-called annulus fibrosus, the cartilaginous outer ring made of connective tissue, and the nucleus pulposus, the jelly-like inner nucleus. In the case of a tear in the region of the annulus fibrosus, the nucleus pulposus is able to extend backwards, which can then irritate the nerve roots.

What causes back pain?

As already stated above, the reasons for back pain are diversified.

Very often they are triggered by muscular tension. Based on the tension, the parts of the muscles seem hardened and, thus, irritate the surrounding nerves. Due to the fact that some nerve pathways transmit to more distant areas (e.g. the legs), pain in other regions can quite often be linked to original back pain.

Of course, it is not only the above mentioned muscular tension that can cause back pain. It is also possible that a patient is suffering from a so-called root-syndrome. This syndrome depends on disposition, age, wear and tear and strain. A moved inter-vertebral disc puts pressure on the surrounding nerve and, thus causes back pain.

It is up to the diagnosis of the doctor to discover, which cause is responsible for the back pain.

We also need to regard the subjective perception of pain. Again and again we find that the limit for pain tolerance differs very much from one person to the other.

There are people who are diagnosed with severe wear and tear who subjectively feel no pain. And the reverse case is possible just as well. Thus we can state that there often is no correlation between the strength of pain and the diagnosis.

As mentioned above, it is possible that people master their back pain through so-called avoidance postures. This avoidance posture itself then usually causes tension, because other muscle groups are used than is normally the case.

In order to prevent back pain, everyone should decide for him-/herself to become more mobile. This is easy even in everyday life (stairs instead of the elevator) and can be aided by further sports activity.

Diagnosis

Since there are different reasons for the origin of back pain, and it has been proved that there is a strong correlation between pain and psyche, a thorough anamnesis (= collecting of information regarding the patient’s history) is unavoidable.

Due to the fact that the connection between pain and psyche is so complex, we have committed a separate chapter to the psycho-somatic part of back pain.

Psychosomatic aspects of back pain will be online soon.

Hereby, it is often necessary to consider the profession of a patient. Knowledge about the profession makes it possible to regard or neglect certain risks (jobs that are almost exclusively done while standing or sitting, or which distinguish themselves through lifting heavy loads…).

In order to define the level of pain, the use of so-called pain diaries for the diagnosis is possible. When using a pain-diary, the patient documents his subjective pain every day by using an analogue scale. It is usually the doctor who analyzes the pain-diary.

In principle, an x-ray of the vertebral column can be regarded as the basic diagnosis. The x-ray-pictures enable the doctor to gain an insight about the posture of the vertebral column. In addition, he can see changes in the bone.

In order to exclude or specify the level of nerve damages further examinations are necessary. This can be done either through neurological examinations or furthermore through tomography (CT and MRT with or without the use of contrast medium), which makes if possible to correlate pain to a specific nerve. The different diagnostic methods allow the doctor to gather further information relating to therapeutic possibilities. At this point we want to mention that the additional use of contrast medium is only considered, when an inflammation of a tumor is suspected.

Myelography describes an examination during which contrast medium is injected into the dural sack of the patient. The dural sack is the area that surrounds the beginning of a nerve, before it leaves the spinal channel. Mixing the nerve water and the contrast medium, permits specified questions related to the spinal chord to be answered.

Therapie

Mobility

The best method to avoid back pain is mobility. For example start using the stairs instead of the elevator in every day life or leave the car at home for activities that are nearby. Go for walks…

However, when the back pain has started, it still applies for simple back pain: get mobile! Staying in bed for too long should be avoided. Think about your sport activities in order to get fit again. Depending on your individual level of performance, you need to strengthen your back muscles. Trendy sports like walking or Nordic walking are especially helpful here. Swimming and riding your bicycle are also suitable to strengthen your back muscles.

Due to the fact that in acute phases of pain it can be difficult to become active, it is sometimes advisable to use a pain killer at the beginning.

Pain killers

As mentioned previously, the mobilization of the patient is of utmost importance. Acute pain can however tempt someone to take it easy longer than necessary. In order to shorten those otherwise persisting phases of relaxation and to get the patient mobile again as quickly as possible, strong pain can be eased by pain killers.

However, it is important to mention that pain killers only diminish the pain, but do not treat the cause of it. They are only intended to get the patient free of pain, so that he can become mobile again.

It is up to the treating doctor to define the medical pain treatment. He can decide individually, which drug and which dosage is most sensible.

In addition to the use of pain killers (f. ex. Paracetamol, Aspirin, Diclofenac, Ibuprofen), it is possible to prescribe muscle relaxing substances such as Tetrazepam.

It is always important to mention that drugs do not only have an effect, but also side-effects. Especially some pain killers can cause stomach bleeding. A first indication of this is black stool. If this happens, you should immediately consult a doctor and stop taking the medication. Not least due to the side effects a continuous use of pain killers is not advisable. They are only meant to help the patient become mobile again as quickly as possible.

Natural Remedies / Devil’s Claw

Among natural remedies, the Devil’s Claw deserves to be mentioned. It can be used on its own for light pain, and in addition to other medication with stronger pain. The Devil’s Claw is known to ease back pain.

Coldness and warmth

While coldness seems to feel soothing at the beginning of acute pain, after that stage it is generally warmth that is preferred.

In general, it is warmth that eases acute pain. Constant warmth is achieved by wearing appropriate clothes like a vest or warm clothes that protect against wind.

Another way to achieve warmth is external such as a bath, sauna, and treatment with Fango, red light or medication that stimulates the blood circulation (ABC plasters or heat rubs).

Often the described methods are combined (suitable clothes, external methods and medication, which stimulate the blood circulation), not least due to the fact that the effectiveness of warmth to treat back pain has been scientifically proven in the meantime.

With all methods, one must observe eventual side effects. The use of heat rubs and ABC plasters has again and again been seen to cause allergic skin reactions. Red light can cause burns.

Below we have listed further therapeutic methods.

Other Methods

Chirotherapy (resetting)

Chiropractic is a healing approach that is accepted by traditional medicine, which is based on a diversity of manipulating techniques. Chirotherapy (manipulative treatment, manual therapy) can for example adjust trapped nerves by moving the vertebrae. Since the method bears certain hazards, it should only be performed by trained therapeutics (chiropractic or doctors with the additional training in chirotherapy or manual therapy). With uncomplicated back pain not spreading into foot or toes chirotherapy is performed within the first 6 weeks.

Bed-rest

Absolute bed-rest is not the ideal treatment for your back. It should only be considered in extreme cases, and even then you should try to become mobile again within the next two days. It can be helpful to use pain medication at this step, as mentioned previously.

It should be the aim to become as active or even more actively mobile as before the pain within the shortest possible time.

In case your activity level has been reduced to a minimum before the illness, it is now time to consider new types of sport. Change your every-day behavior in a way that makes you be more active: stairs instead of the elevator, walking instead of taking the car…

Massage

Even though a good massage is very popular with patients suffering from back pain, a permanent effect in reducing pain could not be proved yet.

Again it must be stated here that a passive form of treatment in no way replaces your own initiative to becoming mobile.

The so-called “back-school” describes the learning of special exercises to build up the muscles in the back. Also it teaches people about the structure of the back and its function.

Standardized schooling programs (back school)

A special focus is placed on different straining situations in order to achieve the patient’s capacity to correct their body positioning at all times. Among other things, techniques are taught to relieve the stress on the vertebral column in extreme situations, e.g. when the patient must carry heavy loads. For example, you learn how to lift heavy loads such as water tanks from the floor.

Scientific studies have proved that the best results (changing of behavior) can be achieved, if a so-called intensive program, which lasts three to five weeks, is seen through.

There are different schooling programs, some of which are paid for by the National Insurance. Those are usually suitable for people with chronic back pain, thus for patients suffering from back pain for a longer period of time (approximately six weeks).

Physiotherapy

With physiotherapy (remedial or medical gymnastics) such as the back school the aim is to reduce wrong patterns of movement. This is done by using exercises to reduce damages that are caused to the moving apparatus. Hereby, it is important that the patient, himself, learns exercises that he can continue within the surroundings of his own home. It is absurd to believe that physiotherapy once performed will make back pain disappear for good. Again, it is up to the patient’s own initiative.

The physiotherapeutic exercises consist of exercises for stretching, straining, relaxation etc. In addition, every-day movements should be practiced anew – as with the back school – in order to achieve an every-day relaxation for the back.

Only if you continuously practice your exercises at home, can you achieve minimization of the pain! The strengthening of the back muscles depends on the constant practice of the exercises.

Acupuncture

In many medical areas acupuncture has established itself as an alternative to traditional therapy. Acupuncture is an old Chinese treatment method from the Traditional Chinese Medicine (TCM) that is based on a philosophical concept. According to this philosophical principle every illness of the human body is the result of a disharmony between the opposing powers Yin and Yang. It uses different techniques, all of which apply needles to different depths of the so-called meridians. This is done in order to equalize energetic disruptions within the organism.

Even though all studies to date about the effectiveness of acupuncture have yielded no conclusive results – meaning the studies could neither prove its effectiveness nor its ineffectiveness - most patients describe a pain relief.

Trans-cutaneous electrical nerve stimulation (TENS)

Transcutaneous electrical nerve stimulation (TENS) describes the treatment of tense muscles with electrical impulses. It is the aim to loosen the tensions of the muscles and, thus achieve a higher mobility. Usually TENS is used in combination with other therapeutic methods. TENS is especially useful in the treatment of Chronic back pain (persisting for more than 6 weeks).

Behavioral Therapy

During behavioral therapy which is a part of psychotherapy, we try to influence and change old behavioral patterns through conversations and exercises. The justification for this kind of therapeutic approach lies in the above briefly mentioned fact that bodily strain and psychological stress are often combined.

This form of treatment is often considered with patients who have undergone various other therapies without great success.

Surgery

Only rarely is there a surgical approach to back pain. Only if we look at serious problems with the inter-vertebral discs, it becomes necessary to consider surgery.

In those cases there are three possibilities for the surgical approach:

• The classic removal of the inter-vertebral disc through open surgery on the vertebral column
• The removal of the inter-vertebral disc through microscopic methods (endoscopic) with only a small incision on the vertebral column
• The dissolving of the inter-vertebral disc through chemical substances injected in the inter-vertebral disc. The chemical dissolving of the inter-vertebral disc is less painstaking, but also less effective than classic surgery.
• Alternatively to removing the inter-vertebral disc, ever more frequently the intervertebral prosthesis is considered. Presently, the inter-vertebral prosthesis is an alternative treatment for damaged inter-vertebral discs, but its future is currently unsure.
• The Racz-Catheter is a method developed in 1982 by the Texan Anesthetist and pain therapist Professor Gabor Racz. The Racz-catheter technique is a minimal-invasive method of treating chronic back pain of various causes. It is a special catheter (thin tube) which other than normal catheters contains a metal guiding wire through which it can be led to the exact origin of the pain, so that the pain can be treated directly at its source.

Corset treatment (Orthesis)

A corset treatment (lumbar belt, orthesis) describes the splinting of the back in order to stabilize it. This form of stabilization also is meant to minimize pain. However, it has a big disadvantage; due to the resting posture, the muscles in the back are reduced, which means that an additional weakening of the back muscles can cause further pain. In order to prevent a further weakening of the muscles, it is not recommended to wear a corset for more than a very short period.

Personal therapeutic methods

What can I do myself?

Remember the old saying: "Movement brings you blessings"! Try to leave your resting posture. Learn the important rules for the way your body can overcome daily issues, for example in a back school, and practice the exercises continuously at home. The freedom from back pain depends mainly on your own initiative.

If you have been among those people that are not very active in their daily life, before back pain attacked you, then take this as a warning and change your behavior:

• Cover short distances by walking or cycling instead of in the car
• Use the stairs rather than the elevator. Walking, swimming and riding your bicycle exercises the muscles additionally, without straining your back.
• In order to get into the swing of things again you may use a pain killer at the beginning

You have to especially learn to make it as easy as possible for your back during strenuous jobs (lifting and carrying heavy loads, sitting for long periods, one-sided strain…)

If you belong to the group of people who must spend the major part of their professional day sitting, then you need to make sure that you have phases of relief for your back:

• Loosening and stretching exercises help to relief and relax the muscle
• Avoid one-sided strain
• Carry heavy loads by spreading the weight equally, not one-sided
• Do not stay in the same position for longer than 30 minutes
• Do not lift and carry with your back bent, but with a straight back
• Reduce possible bodily overweight, because this weight also strains your back
• Play sports. Sport helps to build up muscles and to reduce your weight.

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