Back pain

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Back pain (also known as "dorsopathy") is pain felt in the human back that may come from the muscles, nerves, bones, joints or other structures in the spine. The pain may be constant or intermittent, stay in one place or refer or radiate to other areas. It may be a dull ache, or a sharp or piercing or burning sensation. The pain may be felt in the neck (and might radiate into the arm and hand), in the upper back, or in the low back, (and might radiate into the leg or foot), and may include symptoms other than pain, such as weakness, numbness or tingling.

Back pain is one of humanity's most frequent complaints. In the U.S., acute low back pain (also called lumbago) is the fifth most common reason for all physician visits. About nine out of ten adults experience back pain at some point in their life, and five out of ten working adults have back pain every year [1].

The spine is a complex interconnecting network of nerves, joints, muscles, tendons and ligaments, and all are capable of producing pain. Large nerves that originate in the spine and go to the legs and arms can make pain radiate to the extremities.

While it is rare, back pain can be a sign of a serious medical problem:

• Typical warning signs of a potentially life-threatening problem are bowel and/or bladder incontinence or progressive weakness in the legs. Patients with these symptoms should seek immediate medical care.

• Severe back pain (such as pain that is bad enough to interrupt sleep) that occurrs with other signs of severe illness (e.g. fever, unexplained weight loss) may also indicate a serious underlying medical condition, such as cancer.

• Back pain that occurs after a trauma, such as a car accident or fall, should also be promptly evaluated by a medical professional to check for a fracture or other injury.

• Back pain in individuals with medical conditions that put them at high risk for a spinal fracture, such as osteoporosis or multiple myeloma, also warrants prompt medical attention.

In general, however, back pain does not usually require immediate medical intervention. The vast majority of episodes of back pain are self-limiting and non-progressive. Most back pain syndromes are due to inflammation, especially in the acute phase, which typically lasts for two weeks to three months.

Contents 1 Underlying causes 2 Treatment 2.1 Surgery 2.2 Treatments with uncertain or doubtful benefit 3 References 4 See also 5 External links

[edit] Underlying causes

Muscle strains (pulled muscles) are commonly identified as the cause of back pain but in fact muscle imbalances are by far the most common cause of low back pain, and pain from such an injury will often hang around for as long as the muscle imbalances persist. The muscle imbalances cause a mechanical problem with the skeleton which leads to pressure building up at certain points along the spine.

When low back pain lasts more than three months, or if there is more leg pain than back pain, a more specific diagnosis can usually be made. There are several common causes of low back pain and leg pain: for adults under age 50, these include spinal disc herniation and degenerative disc disease; in adults over age 50, common causes also include osteoarthritis (degenerative joint disease) and spinal stenosis. Non-anatomical factors can also contribute to or cause back pain, such as stress, repressed anger, or depression (mood).

Back pain is frequently experienced when no underlying anatomical problem is apparent. Some believe this pain to be caused by tension myositis syndrome. [2]

[edit] Treatment

The management goals when treating back pain are to achieve maximal reduction in pain intensity as rapidly as possible; to restore the individual's ability to function in everyday activities; to help the patient cope with residual pain; to assess for side effects of therapy; and to facilitate the patient's passage through the legal and socioeconomic impediments to recovery.

Not all treatments work for all conditions or for all individuals with the same condition, and many find that they need to try several treatment options to determine what works best for them. The present stage of the condition (acute or chronic) is also a determining factor in the choice of treatment. Only a minority (most estimates are 1% - 10%) require surgery.

• Heat therapy is useful for back spasms or other conditions. A meta-analysis of randomized controlled trials by the Cochrane Collaboration concluded that heat therapy can reduce symptoms of acute and sub-acute low-back pain ^[1].

• Medications, such as muscle relaxants^[2], narcotics, non-steroidal anti-inflammatory drugs (NSAIDs/NSAIAs)^[3] or paracetamol (acetaminophen).

• Exercises can be done the patient individually, or under supervision of a professional such as a physical therapist. Generally, some form of consistent stretching and exercise is believed to be an essential component of most back treatment programs. However, a meta-analysis of randomized controlled trials by the Cochrane Collaboration found that exercises are effective for chronic back pain, but not for acute pain ^[4]. One randomized controlled trial found that back-mobilizing exercises in acute settings are less effective than continuation of ordinary activities as tolerated ^[5].

• Physical therapy and exercise, including stretching and strengthening (with specific focus on the muscles which support the spine), often learned with the help of a health professional, such as a physical therapist. Physical therapy, when part of a 'back school', can improve back pain ^[6].

• Massage therapy, especially from a very experienced therapist, may help. Acupressure or pressure point massage may be better than classic (Swedish) massage ^[7].

• Manipulation, as provided by an appropriately trained and qualified chiropractor, osteopath, physical therapist, or a physiatrist. Meta-analyses of the effect of manipulation suggest that manipulation has a small benefit similar to other therapies and superior to sham ^[8][9].

• Acupuncture has a small benefit for chronic back pain. The Cochrane Collaboration concluded that "for chronic low-back pain, acupuncture is more effective for pain relief and functional improvement than no treatment or sham treatment immediately after treatment and in the short-term only. Acupuncture is not more effective than other conventional and alternative treatments." ^[10]. More recently, a randomized controlled trial found a small benefit after 1 to 2 years ^[11].

• Education, and attitude adjustment to focus on psychological or emotional causes (e.g. TMS)^[12]. respondent-cognitive therapy and progressive relaxation therapy can reduce chronic pain ^[13].

• Most people will benefit from assessing any ergonomic or postural factors that may contribute to their back pain, such as improper lifting technique, poor posture, or poor support from their bed or office chair, etc. Although this recommendation has not been tested, this intervention is a part of many 'back schools' which do help ^[6].

[edit] Surgery

There are a number of different types of spine surgery to treat a variety of back conditions. Surgery should be considered if a patient has a significant neurological deficit, or if they fail non-surgical therapy. Regarding the role of surgery for failed medical therapy in patients without a neurological deficit, a [review http://www.cochrane.org/reviews/en/ab001352.html] by the Cochrane Collaboration concluded that "limited evidence is now available to support some aspects of surgical practice". The ongoing Spine Patient outcomes Research Trial (SPORT) is addressing the role of surgery ^[14]. Some of the more common forms of surgery are:

• Artificial disc replacement, a relatively new form of surgery in the U.S. but has been in use in Europe for decades, primarily used to treat low back pain from a degenerated disc.

• Discectomy/microdiscectomy, usually used to treat pain (especially pain that radiates down the arm or leg) from spinal disc herniations.

• Kyphoplasty and Vertebroplasty, minimally invasive procedures designed to treat pain from osteoporotic compression fractures and sometimes other forms of fracture, such as a fracture caused by certain types of cancer.

• Spinal cord stimulation, where an electrical device is used to interrupt the pain signals being sent to the brain.

• Spinal fusion, usually to treat chronic, severe pain from degenerative disc disease, spondylolisthesis, or deformity, such as from scoliosis.

[edit] Treatments with uncertain or doubtful benefit

• Injections, such as epidural steroid injections, facet joint injections, or prolotherapy have limited, if any, benefit ^[15][16].

• Cold compression therapy is advocated for a strained back or chronic back pain and is postulated to reduce pain and inflammation, especially after strenuous exercise such as golf, gardening, or lifting. However, a meta-analysis of randomized controlled trials by the Cochrane Collaboration concluded "The evidence for the application of cold treatment to low-back pain is even more limited, with only three poor quality studies located. No conclusions can be drawn about the use of cold for low-back pain" ^[1]

• Bed rest is rarely recommended as it can exacerbate symptoms ^[17], and when necessary is usually limited to one or two days.

• Electrotherapy, such as a Transcutaneous Electrical Nerve Stimulator (TENS) has been proposed. Two randomized controlled trials found conflicting results (PMID 10084439; PMID 2140432). This has led the Cochrane Collaboration to conclude that there is inconsistent evidence to support use of TENS (PMID 16034883).

[edit] References

[edit] See also

• Chronic pain
• Ergonomics
• Low back pain
• Lumbago
• Sciatica
• Spinal disc herniation
• Tension myositis syndrome
• Upper back pain

[edit] External links

• Low back pain - Americal Association of Neurological Surgeons
• Lower back pain - Familydoctor.org
• Back Pain During Pregnancy
• Low Back Pain Fact Sheet
• Back Pain Medical Journal for Patients
• Handout on Health: Back Pain