Special Areas of Interest - Low Back Pain
Many people think Osteopaths only treat low back pain - this is not the case by any means. We can help patients with all sorts of problems arising from the musculoskeletal system. Nevertheless, it is an area where Osteopathy is particularly effective and probably about half of our patients first come seeking help for low back pain.
It often said that "80 per cent of back strains get better within 8 weeks, regardless of any treatment" (see "The Times", Body and Soul supplement, 17 January 2004). But who can afford to be incapacitated with low back pain for 8 weeks, and what about the other 20 per cent who cannot get better by themselves?
Diagnosis of the problem is the key to success in treating patients with low back pain, as there are a multitude of variables which contribute to the condition. In the first instance, care must be taken to spot any serious disease giving rise to the patient's pain, but, in most cases, low back pain makes life wretched, but is not life-threatening.
The lumbar spine is a complicated area, where damage to structures such as intervetebral discs, ligaments, tendons and muscles, with or without the involvement of nerve roots giving referred pain elsewhere, must all be considered. Some well-known causes of back pain are:-
Intervertebral disc damage
This is the so-called "slipped disc" - even though it doesn't slip anywhere. The disc is the shock absorbing pad which lies between each bone of the spine. Think of it as being a bit like a doughnut, with a gooey, liquid substance - the "nucleus pulposus" - in the middle, surrounded by rings of tougher fibres ("anular fibres"), and all encapsulated within a skin around the outside. In a so-called "slipped disc" - more correctly "herniated" or "prolapsed" disc, the tough rings of fibres develop a fissure or tear, allowing the liquid in the middle to seep outwards - a process which may well take years. The process is not painful because there are no nerves in the centre of a disc. Only when the liquid reaches the outer part of the disc, and causes a bulge within its skin, does it give back pain. As you may imagine, getting to the painful stage is often the 'last straw' in a process which has been going on for a long time - thus patients often feel they have done little or nothing to warrant such severe pain. If the process goes a step further, and the liquid bursts out of its skin, it may well hit a nerve root and pain will be felt acording to the area that nerve root supplies. At this stage the patient may well have raging leg pain ("sciatica", as it is often the sciatic nerve which is compressed).
Osteopathy can do much to reduce the abnormal compression of a disc and to relieve the pressure of a disc protrusion on nerve roots. If, however, the problem does not begin to resolve quite rapidly, or signs of nerve root compression are becoming worse, the Osteopath will refer you back to your General Practitioner, and surgery may, in a few cases, be necessary.
Facet Joint Locking or Strain
The spine is a segmental structure, permitting considerable flexibility. At every level there are two small joints. If a joint moves too far, or movement is poorly controlled by the muscles, a joint may strain or even lock, giving sudden, severe back pain. The back muscles may go in to spasm and movement becomes almost impossible. This problem can be quite frightening, but can be very simple for an Osteopath to sort out, by manipulating a joint so that its mobility is restored, the muscle spasm eases, and the pain goes as soon as any inflammation present has subsided.
However, patients problems are often more complicated than the paragraphs above suggest. It is more common for a combination of structures to be involved - say a facet joint lock, together with strain of the surrounding ligaments which try to support the spine. There may also be irritation of a nerve root emerging close to the joint, which then sends messages to the muscle group it supplies to over-contract, givng cramp-like symptoms. An Osteopath must also be looking for the underlying causes of the problem. For example, a disc may have become abnormally worn, and eventually prolapse, because another area of the back is too stiff and does not carry out its share of movement - this may be for reasons associated with the posture one has learned over the years, or even problems of development back in one's teenage years (known as osteochondritis of the spine or Scheurmann's Disease).
Stiffness and inflexibility of the spine are a common cause of recurring low back strain and pain. This may in part be genetic, it may be to do with previous damage to the area causing the ligaments and muscles to become shortened and tight, or may be to do with arthritic (degenerative) changes in the spine. Arthritis (sometimes called spondylitis) in the spinal joints, associated with abnormal or early wear, commonly causes significant stiffness and this decreased flexibility often leads to recurrent strains in the back. The resulting pain can, however, by successfully treated by Osteopathy, and mobility exercises will often help. Arthritis of the spine rarely leads to significant disablity, and patients who have been given this diagnosis should not be unduly worried (talk to an Osteopath about it!).
Over-flexibility or instability of the spine can give rise to just as many problems. Many patients will remember being very gymnastic as a child, but, over the years, leaving physical activity behind them as the demands of daily life required more and more time. People like this often have rather elastic ligaments, permitting a big range of movement at joints, which is a bonus whilst the muscular strength is there to support the spine. But if activity decreases, adequate muscular support may also be lost, and repeated back injuries may result.
Research over the last few years has focussed more attention on sufferers of long-standing (chronic) or recurrent back pain and its causes. It has been found that patients like this often have an imbalance in the strength of the deep muscles of the back ("multifidus"), which stabilise one bone on another, and the longer, more superficial muscles (Erector Spinae"), which bring about the big movements of the spine. Correct co-ordination between the two may also be lost, so that the stability of one bone on top of another is poorly controlled, whilst the spine as a whole is being moved about - resulting in injury and further loss of strength in Multifidus and co-ordination. Rehabilitative exercise, such as Pilates, can be very useful in addressing this kind of damaging imbalance.
The causes - or rather the combination of causes which adds up to low back pain - are so varied - as varied as people themselves. In addition to considering tissue damage, an Osteopath must also consider a patient's ability to heal - do they, for example, suffer from other pathologies such as Diabetes which makes recovery less rapid, - the occupation they are undertaking, the physical demands of their home-life, their emotional stress which can affect the state of their muscles, and so on and so forth - the list is almost endless. This is why an Osteopath needs to take such a detailed history and undertake a thorough examination of the patient in the first instance, but also needs to re-evaluate and explore a patient's structure more thoroughly at each treatment session, adapting trreatment if necessary as changes begin to occur.