Progress and growth are impossible if you always do things the same way you’ve always done them.
Backs are among the trickiest things in the world, especially when they start playing up. There are many, many different theories about what causes back pain. Logically, this clearly demonstrates that no-one really knows whether they are right or wrong in diagnosing its causes. They cannot all be right but neither can they all be wrong. But no-one knows for certain.
In my work as a general practitioner administering Nesfield’s Treatment, I see a wide variety of people of both sexes suffering the agonies of back pain. They represent a broad assortment of ages, with differing pain levels, pain locations and physical signs; disc prolapsed and bone degeneration. I am also able to examine their X-rays, CAT and MRI scans, and learn about their various previous diagnoses, or medical opinions, and treatments.
This information services mainly to confirm my opinion that the cause of back pain constitutes one of the great unsolved mysteries of the medical world. It has also guided me down my own path seeking an answer, or answers, to the causes of the affliction and, of equal importance, to find out why Nesfield’s Treatment works.
Soon after I started using the treatment, I became aware that Dr Rees’ procedure was controversial and that there had been a powerful backlash against it by mainstream Australian medicine. I had never heard of it during my medical training and in my subsequent work as a general practitioner. Yet, here I was, actively performing the procedure and achieving an exciting degree of success.
In tracing the backlash against the procedure, and reading, or hearing, what its critics had to say, I began to suspect that the reasons quoted by Dr Rees as to the mechanism of pain relief may well have been incorrect. From the time he first performed the treatment, Dr Rees had stated that he ‘cut the nerve supply to the zygapophyseal joint’ in effect a denervation, or nerve-cutting process. I concluded that, although the procedure was undoubtedly a highly effective treatment for some types of back pain, Dr Rees was wrong about why it worked; the scalpel he used was simply not long enough to reach the nerve supply to the zygapophyseal joints at the back of the vertebra.
Most patients I see have had many different opinions as to the diagnosis of their back pain and many different recommendations as to the treatment of their pain. Each practitioner believes that their advice is appropriate and that their treatment will help the patient. However, these recommendations often vary enormously. With such a diversity of opinion, it is likely that all theories have some fundamental flaws and that, in most cases, we do not know the cause of pain.
In short, I believe the critics of the procedure were right not to believe Dr Rees’ theory why the procedure was successful. But they were wrong to believe that it did not work.
In accepting this, and setting out to find my own answers, I arrived at one simple question. Was there something that most patients with chronic back pain had in common? If I could answer that, I might begin to understand why the procedure worked.
To my pleasant surprise, after studying my files, the answer was yes. I found that the vast majority of my patients suffering chronic back pain had tender areas in muscles around the vicinity of their pain – trigger points. Most patients are well aware of the location of these trigger points. More significantly, they know that if the points are massaged hard enough, some temporary pain relief usually follows.
My theory would best describe trigger points as clusters of sensory fibres. They are akin to outposts from major nerves within the body, just as capillaries are end branches of arteries. These nerves are not vital to the effective functioning of the central nervous system. Although trigger points are not visible to the naked eye and look identical to surrounding tissue (except under intense magnification) they are recognised medically. They are known variously as Points of Travell, Distil Points of Russell and Points Apopysaire. They have been listed in medical text books for a good number of years.
In recognising the commonality of trigger points in back pain sufferers, I realised that most non-surgical back pain treatments also target these trigger points e.g. physiotherapy, chiropractic, osteopathy, massage, acupuncture, injection and traction.
Most of the above treatments target these fiery little trigger points and apply diverse forms of stimuli to them to obtain varying degrees of pain relief. Most of the other methods, however, obtain only temporary alleviation whereas my method, when successful, appears to be permanent.
Recognising that trigger points are the common factor in chronic back pain and also the target of virtually all non-surgical back pain treatments, I concluded that trigger points were somehow intimately involved in the production of back pain. I also concluded that, in any given patient, there seemed to be two possible sources of pain. One pain, in my opinion, certainly emanated from the vertebral column complex – bones, discs, ligaments and nerves. The other pain came from the trigger points. Further, I concluded there was probably a connection between the vertebrae and the trigger points, with pain transmission from the trigger points to the central nervous system.
Again I compared my trigger point treatment with other forms of therapy – massaging, puncturing, stretching, pressure, ice, needling or injecting. I realised that, in reality, I was merely taking all of those treatments one significant step further. By surgically invading the painful trigger points and sweeping through them with a fine scalpel, I was physically entering a pain transmission or generation zone and probably short-circuiting it – permanently. It was logical to assume that I was dividing, or separating, sensory fibres. That, I believed, was why it worked.
Thus my own theory about why Nesfield’s Treatment worked was born.
In repeating my assertion that in the majority of cases the causes of back pain are unknown, I can almost hear various back pain experts howling me down. That, of course, is the problem. Everyone has their own different theory about what causes back pain – from orthopaedic and neurosurgeons; general practitioners, physiotherapists, acupuncturists, chiropractors, masseurs, iridologists and homeopaths.
Seeking the answer to the cause or causes of back pain is a little like trying to discover the meaning of life. Everyone has an opinion but no-one really knows.
By the time most patients reach me, my research shows they have been given an average of at least six entirely different diagnoses and six totally different treatment recommendations by at least six different experts. Understandably they are often totally confused. I ask every patient:
“What have other doctors told you is the cause of your pain?”
In order, the five most common replies are:
1. Osteoarthritis
2. No diagnosis
3. Degenerated disc
4. Degenerating bones
5. Pinched nerve
Note that the second most common reply given to patients after many years of suffering back pain is ‘no diagnosis’.
Many other diagnoses given to patients are both pathologically unsound and quite ridiculous:
Curved coccyx
No marrow from the lower spine down
It’s just a hell of a mess
It was caused by an accident
Tension
Neuralgia
Your bones are worn
You’re neurotic
Your pelvis is misaligned
Something’s out of place
Inflamed sinews
Strained ligament
Five nerves caught, one nerve dying
You need surgery
You’ll just have to live with it
Previously surgery has caused the pain
Your back’s buggered
It’s all in your mind
See what I mean?
No doubt each opinion has been given by a practitioner who sincerely believes that the advice is valid. Moreover, the diagnosis has been pronounced by a person, who in the patient’s eyes, often has an almost god-like aura of medical credibility and invincibility.
Back pain sufferers are extremely vulnerable human beings. They hobble, limp and crawl, or are wheeled, grim-faced into surgeries by their hundreds every day seeking expert help and advice – alleviation from their pain. Their condition is invisible and virtually indescribable. They are frequently at low ebb when they present themselves for treatment. It is not uncommon for patients to be depressed and even suicidal when they reach that stage. Many have been told they will have to live with their pain for good.
Many patients come away highly disgruntled and inappropriately treated – or not treated at all. Patients frequently feel that practitioners either do not believe their degree of pain or appear to have no concept of it. Worse, medical practitioners often appear unsympathetic to the patient’s condition, especially if the doctor suspects a malingerer seeking a compensation pay-out.
Over a period of years most chronic back pain sufferers will seek a variety of opinions and treatments until they get some degree of pain relief. Whilst most achieve pain relief at some stage, a small percentage do not and end up back where they started. They feel like they have been on a merry-go-round and the many opinions and treatments have achieved nothing. It is this group of patients that I usually see and the majority get some degree of relief following ‘Nesfield’s Treatment’.
Patients arriving in my surgery often have a less than glowing impression of doctors. I certainly try to be as understanding as possible, and as truthful. In some cases, I do not advise the patient to undertake Nesfield’s Treatment because I feel it will not benefit them, especially in cases where there are no trigger points. In many of these instances, I believe surgery may be a viable option for them and advise the patient accordingly. I seldom tell them they must live with their pain.
Conversely, where there are trigger points, I advise patients that if they undertake the treatment, they will have a 70 per cent chance of some reduction of their pain. I try not to build their expectations unrealistically and definitely not to expect a miracle cure. Nesfield’s Treatment is a more gradual process; it is usually at least a day or so, and sometimes three or four, before the patient realises the degree of pain relief gained from the treatment.
I find the initial reaction of patients curious, to say the least. Because their expectations are high, many simply expect to be cured by me, much as they would expect me to cure their respiratory infections by prescribing antibiotics, or if I was a dentist, by pulling out an infected tooth. It is a very simple approach – you are a doctor, fix me. Some expect a 100 per cent miracle cure.
I ask every patient to call me a week after I have performed the procedure on them. When they do, I inquire whether they have achieved a reduction of pain and if so, to what degree. Although a 100 per cent reduction of pain is uncommon, about 70 per cent of patients report a marked improvement in their condition. But – this is the curious part – their reactions are usually low key, or muted. Rather than yell down the line, euphorically telling me they are cured, it is usually just a matter-of-fact description of what has taken place, end of conversation.
Joy at their liberation from back pain usually comes much later, long after the treatment. I am told it often happens in private moments when people find themselves enjoying a long bushwalk, or playing tennis, or activities that were that were impossible during their regime of pain. The realisation suddenly comes to them that their lives have returned to normal and that they are free again; they feel joy then. When I hear my patient’s good news I also feel a sensation of happiness.
Dr. Richard Stuckey MB.BS. DRCOG. FAANaOS "Say Goodbye to Back Pain"
Monday, November 21, 2011
Monday, November 14, 2011
Facts and Fallacies about Back Pain
Nothing begins, and nothing ends
That is not paid in moan;
For we are born in other’s pain,
And perish in our own.
(Francis Thompson 1859 – 1907)
Pain is a hugely complicated subject and, in all sincerity, I profess no greater knowledge of it than the next doctor. There are, however, new ideas, or theories, surfacing about pain, some of which may well replace the old ones. These included what appears to be the important role sensory fibres play in the central nervous system and how they function in transmitting pain to and from the brain. This is of particular interest to me because I believe, until someone shows me better, that these sensory fibres are central to my work in treating back pain.
Some facts and fallacies about back pain; while many aspects of diagnosing and treating back pain are uncertain, there are some observations that are factual.
• Recent onset – or new – back pain almost always reduces quickly. A common situation is when a person (of any age) is doing something that they may do every day when suddenly they develop severe back pain. The pain is often excruciating. If no active treatment is sought, the majority of these cases (95 per cent) resolve within 3-4 weeks.
• X-rays are not the most accurate way of diagnosing causes of back pain. It has been shown many times that there is no correlation between degeneration on X-ray and the severity of pain. People who have extremely bad-looking spines on X-ray may experience no back pain at all. Conversely, people who have perfectly ‘normal’ X-rays may experience severe back pain. This applies similarly to CAT scan or MRI investigation. Abnormalities that are detected do not necessarily cause the pain. A number of trials have been carried out where MRI scans are taken on people who have never had back pain. Sixty percent of these were shown to have a significant disc protrusion and yet experience no pain.
• In my opinion the most common misdiagnoses of back pain sufferers over forty years of age, include arthritis, joint degeneration, osteoporosis, spondylitis and ‘wear & tear’. But no matter what investigations are performed, no-one can ever be 100 per cent sure of the cause of pain. My belief that vertebral degeneration as shown on X-ray, in the absence of trigger points, is not a cause of back pain will probably be strongly criticised by some colleagues.
• It is not necessarily true that there is nothing that can be done for back pain and that sufferers will ‘have to live with it’.
Here is a list of treatment options that may be considered and explored by back pain sufferers and their doctors. Some of these treatments are well-known, others are not. They are listed alphabetically, not in order of importance – there are no doubt various other methods of back pain treatment, which are commonly practised in some parts of the world, and not known to the author.
Acupuncture
Acupuncture is believed to work on the principle that the production of brief, moderate pain will cure severe, chronic pain. Stimulation, by placing small needles in various charted parts of the body, i.e. ear, calves, ankles, causes the release of pain-killing endorphins.
There has been a recent trend in acupuncture to specifically target the trigger points instead os set reference points and needle the same point on a number of occasions. This is thought to lead to localised muscle lengthening and to decrease pain that was due to muscle spasm. Although mainstream medicine has gradually embraced the theory of acupuncture and its effectiveness, it is still considered only an adjunct to conservative treatments and does not necessarily produce long-term relief from pain.
Analgesic/anti-inflammatory Drugs
Use of these is common treatment for back pain. Research suggests that, while the drugs are frequently prescribed, their actual cure rate is insignificant and often cause a lack of well-being in patients, although they do help temporarily to alleviate pain.
Bed rest
Bed rest is the most common and successful (95 per cent success rate) form of treatment for the onset of new back pain. Generally, patients are advised to lie on their sides with their hips and knees slightly flexed. More than a few days in bed is not recommended.
Electrotherapy (transcutaneous electrical nerve stimulation – TENS)
The principle of electrotherapy is that by electrically stimulating nerves, pain will decrease, although how it works is unknown. Interestingly, electrical current passes more easily though painful tissue and non-painful tissue. It is thought that the electrical current produces endorphins, like acupuncture. It is a medically respected treatment and does help patients become more functional. (NB it is an accepted medical practice even though it is not understood).
Enzyme injection (chemonucleolysis)
This is a comparatively recent method where the damaged disc is injected with an enzyme (from papaya). It dissolves the disc, thereby relieving the pressure it is applying to the nerve roots. The procedure has a relatively high long-term success rate. Studies after two years show a 77 per cent success rate in the reduction of pain, with 45 per cent of patients enjoying a pain-free status. Very few people however are suitable for this treatment. The procedure is not without its risks and requires hospitalisation. Three per cent of patients suffer complications, and 40 per cent suffer back spasms in the immediate post-operative period. Patient assessment is crucial for this treatment; a handful of patients have died from allergic reaction.
Epidural
This is often used where more conservative forms of treatment have failed. The theory is that injecting cortisone into the epidural space in the spine reduces inflammation on the damaged nerve root and surrounding tissue. The procedure requires hospitalisation, and is safe as long as meticulous technique is used to administer it. It has been known to cause tuberculous meningitis and other complications if not properly performed. Note that the procedure currently being carried out is considered medically ‘not proven’.
Exercise
This is a common treatment designed to strengthen muscles surrounding back injuries, or to increase the patient’s flexibility and mobility as well as improving fitness levels to prevent further injury. In some cases, exercise appears to decrease pain levels; in others, it may u increase the pain. Exercise programmes have a mixed success rate and in some cases are impractical because of the pain of movement experienced by the patient.
External supports
These include braces and corsets. They are designed to take pressure off injured areas in the back and neck during recovery, although some patients wear them permanently. In themselves, these supports do not cure back pain, but may assist in the recovery process. Many feel that external supports actually weaken back muscles and worsen the problem.
Hypnosis
This can be a successful treatment, at least in the short term. Because pain is thought by some not to be a purely physical phenomenon, but associated with thoughts, emotions and perceptions, it is possible to alter the state of awareness in a patient in a way that reduces, or changes their pain.
Injection therapy
Many substances have been injected into people’s backs with varying degrees of success. Different compounds can be placed in one of three areas:
I. Trigger Points: by merely needling these tender points some pain relief can be achieved. This technique is called ‘dry needling’ but would seldom produce more than six month’s relief. These points can also be injected with local anaesthetic or cortisone. Pain relief is often longer than needling alone but seldom longer than six months.
II. Ligaments: The ligaments at the base of the spine can be injected with irritant (sclerosant) solutions. This is thought to set up an inflammatory reaction within the ligaments and, when this settles, the ligament will become thicker, shorter and stronger thus better supporting the vertebral bones. In well conducted trials, it would seem that many people get pain relief where they have not responded to other treatments.
III. Intravenous: In some countries the use of intravenous colchicines is a popular method of back pain treatment. Colchicine is a powerful anti-inflammatory agent and in various trials (some controlled) it has been shown to produce significant pain relief in a large percentage of patients.
Manipulation
Mainstream medicine still considers spinal manipulation a controversial therapy. It is mainly performed by chiropractors. Although studies have shown there is probably no relationship between vertebral misalignment and low back pain, there is no doubt that manipulation does provide relief, often permanent relief. It is considered appropriate for some types of low back pain, including sciatica, spondylitis and stenosis but not for osteomyelitis, osteoporosis, and fractures, ruptured ligaments, acute arthritis and should not be undertaken during pregnancy.
My own belief is that the benefit from manipulation may well be due to stretching the trigger points and not due to ‘re-aligning the bones’.
Massage
This, too, is a common treatment for back pain and usually works well on a temporary basis. Massage is used by physiotherapists and other professionals trained in the art, and others who have developed their own forms of massage i.e. Swedish, Japanese etc.
All forms of massage target the trigger points and the main stimulus is directed there.
Muscle relaxants
Although these have been used as treatments for low back pain and muscle spasms for many years, their use is still considered controversial, particularly because some forms are addictive and others may cause depression. They appear to reduce back pain in carefully selected patients and should not be condemned outright.
Psychological support
This treatment is specifically targeted at restoring psychological balance in the back-pain sufferer, particularly overcoming depression. Clinical trials have produced mixed results, but the technique has been successful in improving patient attitudes and decreasing anxiety and stress levels. This technique is used extensively in pain clinics helping people to ‘live with their pain’.
Surgery
Surgery can be considered for those suffering; pressure on nerve roots (most commonly by herniated discs); spinal stenosis (narrowing of the spinal canal); vertebral instability.
Unfortunately, if surgery is performed for other reasons, the results are usually poor. There are three main forms of surgery:
I. Laminectomy – this is performed in hospital under general anaesthetic and is the less complicated and safer of these procedures. Essentially, the injured disc is removed along with surrounding bone. The nerve root, upon which the disc had been pushing, is thus liberated. Surgery takes between 1-2 hours. There is a minimum of blood loss and the patient is encouraged to stand and walk soon after surgery. Laminectomy works very well for leg pain and numbness but no so well for back pain. New techniques are being developed to surgically remove herniated discs without removing any bone. These techniques are far less traumatic for the patient but suitable for only a narrow spectrum of people.
II. Fusion – This operation is performed under general anaesthesia. The object of the operation is first to remove the injured disc and any other material pressing on the spinal cord or nerve roots. The two vertebrae are then fused together by one of a number of techniques. One is using a bone graft (usually taken from the pelvic bone). Another is to join the vertebrae by screwing steel rods across them. New techniques are being developed to use a flexible material (Dacron) to stabilise the vertebrae but not to fuse them in a rigid fashion. Different techniques will suit different cases.
Post-operatively, patients experience a great deal of pain and need to be monitored closely for the first 48 hours and may remain in hospital for two weeks. It may take 12 months before normal activities can be resumed. The results vary enormously. Some claim 90% success whilst others claim 50% success. This variance may reflect different criteria to gauge success and failure.
Long term studies show that the success rate for laminectomy and fusion drops considerably after five years and may reduce to as low as 50 per cent.
III. The newer procedure of disc replacement is emerging as a means of correcting damaged discs without fusing the vertebrae.
Temperature therapy
There are three kinds of temperature therapies:
I. Cold (cryotherapy) This can be an effective treatment. It uses ice or cold packs. Studies show that two thirds of patients who undergo it will experience approximately a 33 per cent reduction in their pain, although it is usually only temporary. It should not be used on patients with sensitive skin and can sometimes produce muscle spasm. It usually only cools the skin over the injured area rather than the tissue under the skin.
II. Heat (thermotherapy) although this can be used to ease pain and reduce muscle spasm, it should not be used where patients suffer decreased circulation or sensation loss because it can cause damage to the skin i.e. burning.
III. Deep heat (shortwave diathermy/ultrasound) penetrates below soft tissue near the skin, delivering heat to bone, muscle and ligament. Should not be used in areas where the pain is acute or recent. Ultrasound delivers heat more deeply than diathermy.
Traction
This treatment has been used in one form or another for several hundred years. The basic theory of traction is that it stretches the vertebrae and surrounding muscles in order to provide relief and to return the spine to its original form. There are several types of traction, ranging from stretching patients on a bed either manually, or using mechanical devices that apply continuous stretching or sporadic stretching. Another form of traction is to hand the patient upside down by the ankles from a frame, using gravity to stretch the spine and surrounding muscles. Although it is a common treatment, traction does not have a high success rate in permanently alleviating back pain. In some cases it can make it worse.
I believe back pain relief occurs from this form of treatment more from stretching of trigger points rather than the bones.
That is not paid in moan;
For we are born in other’s pain,
And perish in our own.
(Francis Thompson 1859 – 1907)
Pain is a hugely complicated subject and, in all sincerity, I profess no greater knowledge of it than the next doctor. There are, however, new ideas, or theories, surfacing about pain, some of which may well replace the old ones. These included what appears to be the important role sensory fibres play in the central nervous system and how they function in transmitting pain to and from the brain. This is of particular interest to me because I believe, until someone shows me better, that these sensory fibres are central to my work in treating back pain.
Some facts and fallacies about back pain; while many aspects of diagnosing and treating back pain are uncertain, there are some observations that are factual.
• Recent onset – or new – back pain almost always reduces quickly. A common situation is when a person (of any age) is doing something that they may do every day when suddenly they develop severe back pain. The pain is often excruciating. If no active treatment is sought, the majority of these cases (95 per cent) resolve within 3-4 weeks.
• X-rays are not the most accurate way of diagnosing causes of back pain. It has been shown many times that there is no correlation between degeneration on X-ray and the severity of pain. People who have extremely bad-looking spines on X-ray may experience no back pain at all. Conversely, people who have perfectly ‘normal’ X-rays may experience severe back pain. This applies similarly to CAT scan or MRI investigation. Abnormalities that are detected do not necessarily cause the pain. A number of trials have been carried out where MRI scans are taken on people who have never had back pain. Sixty percent of these were shown to have a significant disc protrusion and yet experience no pain.
• In my opinion the most common misdiagnoses of back pain sufferers over forty years of age, include arthritis, joint degeneration, osteoporosis, spondylitis and ‘wear & tear’. But no matter what investigations are performed, no-one can ever be 100 per cent sure of the cause of pain. My belief that vertebral degeneration as shown on X-ray, in the absence of trigger points, is not a cause of back pain will probably be strongly criticised by some colleagues.
• It is not necessarily true that there is nothing that can be done for back pain and that sufferers will ‘have to live with it’.
Here is a list of treatment options that may be considered and explored by back pain sufferers and their doctors. Some of these treatments are well-known, others are not. They are listed alphabetically, not in order of importance – there are no doubt various other methods of back pain treatment, which are commonly practised in some parts of the world, and not known to the author.
Acupuncture
Acupuncture is believed to work on the principle that the production of brief, moderate pain will cure severe, chronic pain. Stimulation, by placing small needles in various charted parts of the body, i.e. ear, calves, ankles, causes the release of pain-killing endorphins.
There has been a recent trend in acupuncture to specifically target the trigger points instead os set reference points and needle the same point on a number of occasions. This is thought to lead to localised muscle lengthening and to decrease pain that was due to muscle spasm. Although mainstream medicine has gradually embraced the theory of acupuncture and its effectiveness, it is still considered only an adjunct to conservative treatments and does not necessarily produce long-term relief from pain.
Analgesic/anti-inflammatory Drugs
Use of these is common treatment for back pain. Research suggests that, while the drugs are frequently prescribed, their actual cure rate is insignificant and often cause a lack of well-being in patients, although they do help temporarily to alleviate pain.
Bed rest
Bed rest is the most common and successful (95 per cent success rate) form of treatment for the onset of new back pain. Generally, patients are advised to lie on their sides with their hips and knees slightly flexed. More than a few days in bed is not recommended.
Electrotherapy (transcutaneous electrical nerve stimulation – TENS)
The principle of electrotherapy is that by electrically stimulating nerves, pain will decrease, although how it works is unknown. Interestingly, electrical current passes more easily though painful tissue and non-painful tissue. It is thought that the electrical current produces endorphins, like acupuncture. It is a medically respected treatment and does help patients become more functional. (NB it is an accepted medical practice even though it is not understood).
Enzyme injection (chemonucleolysis)
This is a comparatively recent method where the damaged disc is injected with an enzyme (from papaya). It dissolves the disc, thereby relieving the pressure it is applying to the nerve roots. The procedure has a relatively high long-term success rate. Studies after two years show a 77 per cent success rate in the reduction of pain, with 45 per cent of patients enjoying a pain-free status. Very few people however are suitable for this treatment. The procedure is not without its risks and requires hospitalisation. Three per cent of patients suffer complications, and 40 per cent suffer back spasms in the immediate post-operative period. Patient assessment is crucial for this treatment; a handful of patients have died from allergic reaction.
Epidural
This is often used where more conservative forms of treatment have failed. The theory is that injecting cortisone into the epidural space in the spine reduces inflammation on the damaged nerve root and surrounding tissue. The procedure requires hospitalisation, and is safe as long as meticulous technique is used to administer it. It has been known to cause tuberculous meningitis and other complications if not properly performed. Note that the procedure currently being carried out is considered medically ‘not proven’.
Exercise
This is a common treatment designed to strengthen muscles surrounding back injuries, or to increase the patient’s flexibility and mobility as well as improving fitness levels to prevent further injury. In some cases, exercise appears to decrease pain levels; in others, it may u increase the pain. Exercise programmes have a mixed success rate and in some cases are impractical because of the pain of movement experienced by the patient.
External supports
These include braces and corsets. They are designed to take pressure off injured areas in the back and neck during recovery, although some patients wear them permanently. In themselves, these supports do not cure back pain, but may assist in the recovery process. Many feel that external supports actually weaken back muscles and worsen the problem.
Hypnosis
This can be a successful treatment, at least in the short term. Because pain is thought by some not to be a purely physical phenomenon, but associated with thoughts, emotions and perceptions, it is possible to alter the state of awareness in a patient in a way that reduces, or changes their pain.
Injection therapy
Many substances have been injected into people’s backs with varying degrees of success. Different compounds can be placed in one of three areas:
I. Trigger Points: by merely needling these tender points some pain relief can be achieved. This technique is called ‘dry needling’ but would seldom produce more than six month’s relief. These points can also be injected with local anaesthetic or cortisone. Pain relief is often longer than needling alone but seldom longer than six months.
II. Ligaments: The ligaments at the base of the spine can be injected with irritant (sclerosant) solutions. This is thought to set up an inflammatory reaction within the ligaments and, when this settles, the ligament will become thicker, shorter and stronger thus better supporting the vertebral bones. In well conducted trials, it would seem that many people get pain relief where they have not responded to other treatments.
III. Intravenous: In some countries the use of intravenous colchicines is a popular method of back pain treatment. Colchicine is a powerful anti-inflammatory agent and in various trials (some controlled) it has been shown to produce significant pain relief in a large percentage of patients.
Manipulation
Mainstream medicine still considers spinal manipulation a controversial therapy. It is mainly performed by chiropractors. Although studies have shown there is probably no relationship between vertebral misalignment and low back pain, there is no doubt that manipulation does provide relief, often permanent relief. It is considered appropriate for some types of low back pain, including sciatica, spondylitis and stenosis but not for osteomyelitis, osteoporosis, and fractures, ruptured ligaments, acute arthritis and should not be undertaken during pregnancy.
My own belief is that the benefit from manipulation may well be due to stretching the trigger points and not due to ‘re-aligning the bones’.
Massage
This, too, is a common treatment for back pain and usually works well on a temporary basis. Massage is used by physiotherapists and other professionals trained in the art, and others who have developed their own forms of massage i.e. Swedish, Japanese etc.
All forms of massage target the trigger points and the main stimulus is directed there.
Muscle relaxants
Although these have been used as treatments for low back pain and muscle spasms for many years, their use is still considered controversial, particularly because some forms are addictive and others may cause depression. They appear to reduce back pain in carefully selected patients and should not be condemned outright.
Psychological support
This treatment is specifically targeted at restoring psychological balance in the back-pain sufferer, particularly overcoming depression. Clinical trials have produced mixed results, but the technique has been successful in improving patient attitudes and decreasing anxiety and stress levels. This technique is used extensively in pain clinics helping people to ‘live with their pain’.
Surgery
Surgery can be considered for those suffering; pressure on nerve roots (most commonly by herniated discs); spinal stenosis (narrowing of the spinal canal); vertebral instability.
Unfortunately, if surgery is performed for other reasons, the results are usually poor. There are three main forms of surgery:
I. Laminectomy – this is performed in hospital under general anaesthetic and is the less complicated and safer of these procedures. Essentially, the injured disc is removed along with surrounding bone. The nerve root, upon which the disc had been pushing, is thus liberated. Surgery takes between 1-2 hours. There is a minimum of blood loss and the patient is encouraged to stand and walk soon after surgery. Laminectomy works very well for leg pain and numbness but no so well for back pain. New techniques are being developed to surgically remove herniated discs without removing any bone. These techniques are far less traumatic for the patient but suitable for only a narrow spectrum of people.
II. Fusion – This operation is performed under general anaesthesia. The object of the operation is first to remove the injured disc and any other material pressing on the spinal cord or nerve roots. The two vertebrae are then fused together by one of a number of techniques. One is using a bone graft (usually taken from the pelvic bone). Another is to join the vertebrae by screwing steel rods across them. New techniques are being developed to use a flexible material (Dacron) to stabilise the vertebrae but not to fuse them in a rigid fashion. Different techniques will suit different cases.
Post-operatively, patients experience a great deal of pain and need to be monitored closely for the first 48 hours and may remain in hospital for two weeks. It may take 12 months before normal activities can be resumed. The results vary enormously. Some claim 90% success whilst others claim 50% success. This variance may reflect different criteria to gauge success and failure.
Long term studies show that the success rate for laminectomy and fusion drops considerably after five years and may reduce to as low as 50 per cent.
III. The newer procedure of disc replacement is emerging as a means of correcting damaged discs without fusing the vertebrae.
Temperature therapy
There are three kinds of temperature therapies:
I. Cold (cryotherapy) This can be an effective treatment. It uses ice or cold packs. Studies show that two thirds of patients who undergo it will experience approximately a 33 per cent reduction in their pain, although it is usually only temporary. It should not be used on patients with sensitive skin and can sometimes produce muscle spasm. It usually only cools the skin over the injured area rather than the tissue under the skin.
II. Heat (thermotherapy) although this can be used to ease pain and reduce muscle spasm, it should not be used where patients suffer decreased circulation or sensation loss because it can cause damage to the skin i.e. burning.
III. Deep heat (shortwave diathermy/ultrasound) penetrates below soft tissue near the skin, delivering heat to bone, muscle and ligament. Should not be used in areas where the pain is acute or recent. Ultrasound delivers heat more deeply than diathermy.
Traction
This treatment has been used in one form or another for several hundred years. The basic theory of traction is that it stretches the vertebrae and surrounding muscles in order to provide relief and to return the spine to its original form. There are several types of traction, ranging from stretching patients on a bed either manually, or using mechanical devices that apply continuous stretching or sporadic stretching. Another form of traction is to hand the patient upside down by the ankles from a frame, using gravity to stretch the spine and surrounding muscles. Although it is a common treatment, traction does not have a high success rate in permanently alleviating back pain. In some cases it can make it worse.
I believe back pain relief occurs from this form of treatment more from stretching of trigger points rather than the bones.
Sunday, November 6, 2011
Different treatments for back pain
What is benign, intractable back pain? Medically it is not life threatening, not surgically treatable, and does not respond to forms of therapy. It is very frustrating to doctors because they feel they have an obligation to assess, diagnose and treat their patients. Non-medically it is an affliction which affects families, jobs, self-esteem and quality of life.
A more colourful description, however, comes from a back patient:
It is as though a fiendish torturer has plunged a pair of sharp pliers through the flesh at the top of the buttocks, located the sciatic nerve deep in the hip, grabbed hold of it and twisted it, pulling it taut. The pain is excruciating; you can’t stand and you can’t walk, or sometimes make even the slightest movement, because of a white-hot lava of pain that runs in a fiery seam down from your lower back and hip, into your thigh, down your leg, right to the tip of your big toe. At the height of its intensity, you wish to vomit, burst your bowels, faint or die – and sometimes all four at once.
This account sounds awful and I hope I never experience it, and certainly not to that degree. It is the most useless, meaningless, tiresome and debilitating form of pain known to mankind. It appears to serve no real purpose, except to continue torturing those poor souls who experience it.
Traditionally, pain is recognised as a warning sign that something is wrong in the body. Benign, intractable pain defies that comparison. It seems merely to create pain for pain’s sake – like vandalism – and usually signals nothing other than the troublesome fact that more pain of an identical nature will immediately follow. In its most perverse form, it can be likened to a car horn that suddenly goes off in the middle of the night for no good reason and then continues to blare away, keeping the whole neighbourhood awake – until someone disconnects the battery.
That is not such a bad analogy, especially when related to some forms of back pain and the treatment I prescribe for it.
Pain is nebulous, very personal and subjective. There are some medical experts who say quite seriously that pain, as we know it, does not exist; that it is purely an individual interpretation of some sort of stimulus that varies enormously from person to person. I do not accept that and neither do most medical schools.
There is an amusing, apocryphal story about two doctors fiercely arguing about pain. The first doctor argued strongly that there was no such thing as pain, the second argued there was. The second doctor suddenly punched the first one and sent him to the ground, screaming and clutching at his bloodied nose, ‘What’s that .....?’ cried the first doctor in agony. ‘That’s pain’ replied the other.
Certainly pain cannot be measured medically. The only people who can measure it are the pain sufferers themselves. Click here to find out more about back pain relief.
A more colourful description, however, comes from a back patient:
It is as though a fiendish torturer has plunged a pair of sharp pliers through the flesh at the top of the buttocks, located the sciatic nerve deep in the hip, grabbed hold of it and twisted it, pulling it taut. The pain is excruciating; you can’t stand and you can’t walk, or sometimes make even the slightest movement, because of a white-hot lava of pain that runs in a fiery seam down from your lower back and hip, into your thigh, down your leg, right to the tip of your big toe. At the height of its intensity, you wish to vomit, burst your bowels, faint or die – and sometimes all four at once.
This account sounds awful and I hope I never experience it, and certainly not to that degree. It is the most useless, meaningless, tiresome and debilitating form of pain known to mankind. It appears to serve no real purpose, except to continue torturing those poor souls who experience it.
Traditionally, pain is recognised as a warning sign that something is wrong in the body. Benign, intractable pain defies that comparison. It seems merely to create pain for pain’s sake – like vandalism – and usually signals nothing other than the troublesome fact that more pain of an identical nature will immediately follow. In its most perverse form, it can be likened to a car horn that suddenly goes off in the middle of the night for no good reason and then continues to blare away, keeping the whole neighbourhood awake – until someone disconnects the battery.
That is not such a bad analogy, especially when related to some forms of back pain and the treatment I prescribe for it.
Pain is nebulous, very personal and subjective. There are some medical experts who say quite seriously that pain, as we know it, does not exist; that it is purely an individual interpretation of some sort of stimulus that varies enormously from person to person. I do not accept that and neither do most medical schools.
There is an amusing, apocryphal story about two doctors fiercely arguing about pain. The first doctor argued strongly that there was no such thing as pain, the second argued there was. The second doctor suddenly punched the first one and sent him to the ground, screaming and clutching at his bloodied nose, ‘What’s that .....?’ cried the first doctor in agony. ‘That’s pain’ replied the other.
Certainly pain cannot be measured medically. The only people who can measure it are the pain sufferers themselves. Click here to find out more about back pain relief.
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