Back pain: illusion or a dangerous disease

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Back pain definition

Back pain may be defined as the pain affecting between the rib margins and the lower folds of buttocks. The amount of physical activities and bad postures influence back pain. Back pain limits movement of the spine. Back pain is frequently found to be a referred pain from other source of pain. Non-specific back pain is not related to fractures, ankylosis, direct trauma or systemic conditions. Specific back pains have specific pathological conditions and have some warning signs. Back pain is a condition that affect so many groups of people. Affected groups of back pain include healthcare professionals, like doctors, nurses, therapists, osteopaths, chiropractors, healthcare administrators, politicians and many more. Among them, 80% of chronic back pain sufferers have one or more elusive etiology. 70–80% of adults of almost all locations of world experience back pain at some point in their lives. The fifth decade is peak point for having back pain. There is drastic increase in incidence of back pain in the past two to three decades. This increase caused an increase in work loss, compensation or sick leave issues, and disability allowances with huge economic cost as its aftermath.

Myths we know about acute back pain

  • We have a common notion to back pain that prolonged bed rest is needed for this condition.­­­­
  • Many also think that patients with acute back pain do not need close follow-up. That is because many say 80–90% of acute back pain completely resolves without treatment within 2–3 months.

Myths are not true

  • Prolonged bed rest should be discouraged in most cases of acute back pain, as it causes stiffness, osteoporosis, bedsores and other dangerous conditions.
  • Regarding acute pain, it is a responsibility for all to prevent chronic pain. So, patients suffering from acute pain should be followed more closely to ensure that his/her pain does not convert to chronic pain.
  • It is found that only 40% of acute back pain, which are due to non-specific cause completely resolves without treatment within around 2–3 months. So, pathological conditions must be excluded first.

Myths about Chronic back pain

  • There are myths about chronic back pain. Many of the people think that the people, who show chronic back pain, are faking and doing so for any gains. They give explanation that they have any one sign of Waddell signs. In Waddell sign, there are some tests. In tenderness test, we see superficial and diffuse tenderness rather than deep tenderness, in case of fake ones. Non-anatomic tenderness also shows fake pain. Those have fake pain will feel pain during simulation test. Here, the person feels pain without any movement of said joint. When the person is distracted, the person can score more in tests like straight leg raising test. Those who do not have real pain will have regional weakness or sensory changes, which cannot be explained by anatomical knowledge. Those with false pain, have more exaggerated reaction to any acts. For example they show overreaction of pain while walking.
  • There is myth all around that what doctors can offer only symptomatic treatment in such case, as no organic cause is there.

Myths can be clarified

  • When Waddell signs are present, we cannot say definitely that this person have non-organic back pain. Back pain may lead a person of organic pain to such behavior. In his book Gordon Waddell said that, presence of more than three of the signs are clinically significant. But, this never exclude organic pain. This is indicative of only magnified clinical expression or magnified pain behavior.
  • Again, Chronic back pain is a problem which cannot be addressed by a single discipline. A multidisciplinary team approach is needed for assessment and proper management of back pain. Therefore, only specific medicine is not the only thing that the disease need. There are many things beyond medication for the back pain patients. However, the patients usually do not think those important.

Classification of back pain

  • Acute: those back pains having less than 6 weeks
  • Chronic: back pains lasting more than 6 weeks
    (an acute on chronic or sub-acute variety is still in debate)
    There are sub categories of chronic back pain. They are graded depending on severity.

Grade 1 is less severe condition where intensity of pain is low and chance of disability is low.

Grade 2 is mild severe condition where intensity of pain is high but chance of disability is low.

Grade 3 is moderately severe condition where pain limits daily activity moderately and chance of disability is high.

Grade 4 is a severe condition where intensity of pain limits daily work severely and chance of disability high.

Although, we cannot say for definite which acute pain goes to chronic, we can try to manage acute pain to prevent chronic pain. There are some factors, which if present back pain may turn chronic. These are

  • Characteristics or working conditions which involve mechanical insult
  • Issues related to pain
  • Medical considerations
  • Depression
  • Bad strategies of response to pain
  • Fear of beliefs about the disease
  • Absence of social or emotional support

History and physical examination in back pain

Because of availability of modern imaging systems, many of the centers are not willing to do routine clinical examination in patients with back pain. In many recent researches also concluded that history
alone correlated well with MRI results could be better approach for back pain. Clinical examination is
only considered in those patients who need surgery and we need document of neurological status. However, still many things are there that can only be seen by keen physician during clinical examination and not revealed by MRI.

Here are some points in favor of clinical examinations

  • MRI is too often picks pathology where there is none. This may be a procedure error.
  • You cannot order MRI in every patient.
  • Sometimes the real diagnosis can only be found on physical examination, e.g. detailed physical examination can point more pin point diagnosis like early cauda equina syndrome (example: the patient may not have noticed asymmetrical saddle sensory loss and reduced anal tone may be the only sign to diagnose it.)
  • From medico-legal point of view, a proper document of the physical examination findings of the patient while visiting you is important. Patient condition may deteriorate suddenly but your findings will defend you in court.
  • If you perform a proper and gentle physical examination, patient will trust you.
  • Finally, routine MRI with the patient in supine position may still miss
    some pathology that can be picked up only by standing or upright
    This new open MRI technology is also good because it can be used in patients with claustrophobia.

Management of back pain

The objective of our management is not to relieve pain only. It should be a holistic approach. We should treat the patient, not the back pain. There are many treatment options. They are explanation about the disease, rest, drugs, traction, spinal manipulation, exercises, acupuncture, infra red therapy, ultrasonic sound therapy, heat and cold therapy and some rehabilitating measures like Work Hardening and Vocational Conditioning, behavioral therapy etc. So, it is a multidisciplinary approach. However, are outlining some basic rules about back pain management.

Acute back pain:

  • Explanation
  • Rule out red flags
  • Stay active
  • Analgesics
  • Muscle relaxants

Sub-acute or acute on chronic

  • Expectations of patient
  • Regular Re-assessment
  • Active treatments
  • Cognitive behavioral therapy
  • Multidisciplinary approach
  • Occupational program for workers

Chronic back pain

  • Low disability: simple therapies
  • Severe disability: bio-psychosocial therapy
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