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Back pain
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Back pain (also known "dorsalgia") is pain felt in the back that may originate from the muscles, nerves, bones, joints or other structures in the spine.

The pain may have a sudden onset or it can be a chronic pain, it can be felt constantly or intermittently, 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.

Associated conditions

Back pain can be a sign of a serious medical problem, although this is not most frequently the underlying cause:

  • Typical warning signs of a potentially life-threatening problem are bowel and/or bladder incontinence or progressive weakness in the legs.
  • Severe back pain (such as pain that is bad enough to interrupt sleep) that occurs with other signs of severe illness (e.g. fever, unexplained weight loss) may also indicate a serious underlying medical condition.
  • Back pain that occurs after a trauma, such as a car accident or fall may indicate a bone 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.

A few observational studies suggest that two conditions to which back pain is often attributed, lumbar disc herniation and degenerative disc disease may not be more prevalent among those in pain than among the general population and that the mechanisms by which these conditions might cause pain are not known.[2][3][4][5] Other studies suggest that for as many as 85% of cases, no physiological cause can be shown.[6][7]

A few studies suggest that psychosocial factors such as on-the-job stress and dysfunctional family relationships may correlate more closely with back pain than structural abnormalities revealed in x-rays and other medical imaging scans.[8][9][10][11]

Underlying causes

Transient back pain is likely one of the first symptoms of influenza.

Muscle strains (pulled muscles) are commonly identified as the cause of back pain, as are muscle imbalances. Pain from such an injury often remains as long as the muscle imbalances persist. The muscle imbalances cause a mechanical problem with the skeleton, building up pressure at points along the spine, which causes the pain.

Another cause of acute low back pain is a Meniscoid Occlusion. The more mobile regions of the spine, such as the facet joints, have invaginations of their synovial membranes that act as a cushion to help the bones move over each other smoothly. The synovial membrane is well supplied with blood and nerves. When these become pinched or trapped sudden severe pain may result. The pinching causes the membrane to become inflamed, causing greater pressure and ongoing pain. Symptoms include severe low back pain that may be accompanied by muscle spasm, pain with walking, concentration of pain to one side, but no radiculopathy (radiating pain down buttock and leg). Relief should be felt with flexion (bending forward),and exacerbated with extension (bending backward).

When back pain lasts more than three months, or if there is more radicular pain (sciatica) than back pain, a more specific diagnosis can usually be made. There are several common causes of back pain: for adults under age 50, these include spinal disc herniation and degenerative disc disease or isthmic spondylolisthesis; in adults over age 50, common causes also include osteoarthritis (degenerative joint disease) and spinal stenosis,trauma, cancer, infection, fractures, and inflammatory disease[1]. Non-anatomical factors can also contribute to or cause back pain, such as stress,[12] repressed anger,[13] or depression. Even if there is an anatomical cause for the pain, if depression is present it should also be treated concurrently.

New attention has been focused on non-discogenic back pain, where patients have normal or near-normal MRI and CT scans. One of the newer investigations looks into the role of the dorsal ramus in patient's pain that have normal radiographic evidence. See Posterior Rami Syndrome.

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. For many, the goal is to keep the pain to a manageable level to progress with rehabilitation, which then can lead to long term pain relief. Also, for some people the goal is to use non-surgical therapies to manage the pain and avoid major surgery, while for others surgery may be the quickest way to feel better.

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 of back pain patients (most estimates are 1% - 10%) require surgery.

Conservative treatment

  • Heat therapy is useful for back spasms or other conditions. A meta-analysis of studies by the Cochrane Collaboration concluded that heat therapy can reduce symptoms of acute and sub-acute low-back pain.[14] Some patients find that moist heat works best (e.g. a hot bath or whirlpool) or continuous low-level heat (e.g. a heat wrap that stays warm for 4 to 6 hours). Cold compression therapy (e.g. ice or cold pack application) may be effective at relieving back pain in some cases.
  • Exercises can be an effective approach, particularly when done 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, one study found that exercise is also effective for chronic back pain, but not for acute pain.[19] Another study found that back-mobilizing exercises in acute settings are less effective than continuation of ordinary activities as tolerated.[20]
  • 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 may be especially effective when part of a 'work hardening' program, or 'back school'.[21]
  • Massage therapy, especially from an experienced therapist, may help. Acupressure or pressure point massage may be more beneficial than classic (Swedish) massage.[22]
  • Body Awareness Therapy such as the Feldenkrais Method has been studied in relation to Fibromyalgia and chronic pain and studies have indicated positive effects.[23]. Organized exercise programs using these therapies have been developed.
  • 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."[26]. More recently, a randomized controlled trial found a small benefit after 1 to 2 years.[27]
  • Education, and attitude adjustment to focus on psychological or emotional causes - respondent-cognitive therapy and progressive relaxation therapy can reduce chronic pain.[28]
  • 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 mattress or office chair, etc. Although this recommendation has not been tested, this intervention is a part of many 'back schools' which do help.[21]

Surgery

Surgery may sometimes be appropriate for patients with:

Emerging Treatments

  • Vertebroplasty involves the percutaneous injection of surgical cement into vertebral bodies that have collapsed due to compression fractures. This new procedure is far less invasive than surgery, but may be complicated by the entry of cement into Batson's plexus with subsequent spread to the lungs or into the spinal canal. Ideally this procedure can result in rapid pain relief.
  • The use of specific biologic inhibitors of the inflammatory cytokine tumor necrosis factor-alpha may result in rapid relief of disc-related back pain. [29]

Treatments with uncertain or doubtful benefit

  • Injections, such as epidural steroid injections and facet joint injections, may be effective when the cause of the pain is accurately localized to particular sites. The benefit of prolotherapy has not been well-documented.[17][30]
  • 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"[14]
  • Bed rest is rarely recommended as it can exacerbate symptoms,[31] and when necessary is usually limited to one or two days. Prolonged bed rest or inactivity is actually counterproductive, as the resulting stiffness leads to more pain.
  • Inversion therapy is useful for temporary back relief due to the traction method or spreading of the back vertebres through (in this case) gravity. The patient hangs in an upside down position for a period of time from ankles or knees until this separation occurs. The effect can be achieved without a complete vertical hang ( 90 degree) and noticeable benefits can be observed at angles as low as 10 to 45 degrees.[citation needed]

See also

References

  1. ^ A.T. Patel, A.A. Ogle. "Diagnosis and Management of Acute Low Back Pain". American Academy of Family Physicians. Retrieved March 12, 2007.
  2. ^ Borenstein DG, O'Mara JW, Boden SD; et al. (2001). "The value of magnetic resonance imaging of the lumbar spine to predict low-back pain in asymptomatic subjects : a seven-year follow-up study". The Journal of bone and joint surgery. American volume. 83-A (9): 1306–11. PMID 11568190. {{cite journal}}: Explicit use of et al. in: |author= (help)CS1 maint: multiple names: authors list (link)
  3. ^ Savage RA, Whitehouse GH, Roberts N (1997). "The relationship between the magnetic resonance imaging appearance of the lumbar spine and low back pain, age and occupation in males". European spine journal : official publication of the European Spine Society, the European Spinal Deformity Society, and the European Section of the Cervical Spine Research Society. 6 (2): 106–14. PMID 9209878.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  4. ^ Jensen MC, Brant-Zawadzki MN, Obuchowski N, Modic MT, Malkasian D, Ross JS (1994). "Magnetic resonance imaging of the lumbar spine in people without back pain". N. Engl. J. Med. 331 (2): 69–73. PMID 8208267.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  5. ^ Kleinstück F, Dvorak J, Mannion AF (2006). "Are "structural abnormalities" on magnetic resonance imaging a contraindication to the successful conservative treatment of chronic nonspecific low back pain?". Spine. 31 (19): 2250–7. doi:10.1097/01.brs.0000232802.95773.89. PMID 16946663.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  6. ^ White AA, Gordon SL (1982). "Synopsis: workshop on idiopathic low-back pain". Spine. 7 (2): 141–9. PMID 6211779.
  7. ^ van den Bosch MA, Hollingworth W, Kinmonth AL, Dixon AK (2004). "Evidence against the use of lumbar spine radiography for low back pain". Clinical radiology. 59 (1): 69–76. PMID 14697378.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  8. ^ Burton AK, Tillotson KM, Main CJ, Hollis S (1995). "Psychosocial predictors of outcome in acute and subchronic low back trouble". Spine. 20 (6): 722–8. PMID 7604349.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  9. ^ Carragee EJ, Alamin TF, Miller JL, Carragee JM (2005). "Discographic, MRI and psychosocial determinants of low back pain disability and remission: a prospective study in subjects with benign persistent back pain". The spine journal : official journal of the North American Spine Society. 5 (1): 24–35. doi:10.1016/j.spinee.2004.05.250. PMID 15653082.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  10. ^ Hurwitz EL, Morgenstern H, Yu F (2003). "Cross-sectional and longitudinal associations of low-back pain and related disability with psychological distress among patients enrolled in the UCLA Low-Back Pain Study". Journal of clinical epidemiology. 56 (5): 463–71. PMID 12812821.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  11. ^ Dionne CE (2005). "Psychological distress confirmed as predictor of long-term back-related functional limitations in primary care settings". Journal of clinical epidemiology. 58 (7): 714–8. doi:10.1016/j.jclinepi.2004.12.005. PMID 15939223.
  12. ^ "At the Root of Back Pain". WholeHealthMD.
  13. ^ McGrath, Mike (2004-11-03). "When Back Pain Starts in Your Head: Is repressed anger is causing your back pain?". Prevention.com. Rodale Inc. Retrieved 2007-09-12.
  14. ^ a b French S, Cameron M, Walker B, Reggars J, Esterman A (2006). "A Cochrane review of superficial heat or cold for low back pain". Spine. 31 (9): 998–1006. PMID 16641776.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  15. ^ van Tulder M, Touray T, Furlan A, Solway S, Bouter L. "Muscle relaxants for non-specific low back pain". Cochrane Database Syst Rev: CD004252. PMID 12804507.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  16. ^ van Tulder M, Scholten R, Koes B, Deyo R. "Non-steroidal anti-inflammatory drugs for low back pain". Cochrane Database Syst Rev: CD000396. PMID 10796356.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  17. ^ a b Nelemans P, de Bie R, de Vet H, Sturmans F. "Injection therapy for subacute and chronic benign low back pain". Cochrane Database Syst Rev: CD001824. PMID 10796449.{{cite journal}}: CS1 maint: multiple names: authors list (link) Cite error: The named reference "pmid10796449" was defined multiple times with different content (see the help page).
  18. ^ Friedman B, Holden L, Esses D, Bijur P, Choi H, Solorzano C, Paternoster J, Gallagher E (2006). "Parenteral corticosteroids for Emergency Department patients with non-radicular low back pain". J Emerg Med. 31 (4): 365–70. PMID 17046475.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  19. ^ Hayden J, van Tulder M, Malmivaara A, Koes B. "Exercise therapy for treatment of non-specific low back pain". Cochrane Database Syst Rev: CD000335. PMID 16034851.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  20. ^ Malmivaara A, Häkkinen U, Aro T, Heinrichs M, Koskenniemi L, Kuosma E, Lappi S, Paloheimo R, Servo C, Vaaranen V (1995). "The treatment of acute low back pain--bed rest, exercises, or ordinary activity?". N Engl J Med. 332 (6): 351–5. PMID 7823996.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  21. ^ a b Heymans M, van Tulder M, Esmail R, Bombardier C, Koes B. "Back schools for non-specific low-back pain". Cochrane Database Syst Rev: CD000261. PMID 15494995.{{cite journal}}: CS1 maint: multiple names: authors list (link) Cite error: The named reference "pmid15494995" was defined multiple times with different content (see the help page).
  22. ^ Furlan A, Brosseau L, Imamura M, Irvin E. "Massage for low back pain". Cochrane Database Syst Rev: CD001929. PMID 12076429.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  23. ^ Gard G (2005). "Body awareness therapy for patients with fibromyalgia and chronic pain". Cochrane Database Syst Rev. PMID 16012065.
  24. ^ Assendelft W, Morton S, Yu E, Suttorp M, Shekelle P. "Spinal manipulative therapy for low back pain". Cochrane Database Syst Rev: CD000447. PMID 14973958.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  25. ^ Cherkin D, Sherman K, Deyo R, Shekelle P (2003). "A review of the evidence for the effectiveness, safety, and cost of acupuncture, massage therapy, and spinal manipulation for back pain". Ann Intern Med. 138 (11): 898–906. PMID 12779300.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  26. ^ Furlan A, van Tulder M, Cherkin D, Tsukayama H, Lao L, Koes B, Berman B. "Acupuncture and dry-needling for low back pain". Cochrane Database Syst Rev: CD001351. PMID 15674876.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  27. ^ Thomas K, MacPherson H, Thorpe L, Brazier J, Fitter M, Campbell M, Roman M, Walters S, Nicholl J (2006). "Randomised controlled trial of a short course of traditional acupuncture compared with usual care for persistent non-specific low back pain". BMJ. 333 (7569): 623. PMID 16980316.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  28. ^ Ostelo R, van Tulder M, Vlaeyen J, Linton S, Morley S, Assendelft W. "Behavioural treatment for chronic low-back pain". Cochrane Database Syst Rev: CD002014. PMID 15674889.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  29. ^ Uceyler N, Sommer C. Cytokine-induced Pain: Basic Science and Clinical Implications. Reviews in Analgesia 2007;9(2):87-103.
  30. ^ Yelland M, Mar C, Pirozzo S, Schoene M, Vercoe P. "Prolotherapy injections for chronic low-back pain". Cochrane Database Syst Rev: CD004059. PMID 15106234.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  31. ^ Hagen K, Hilde G, Jamtvedt G, Winnem M. "Bed rest for acute low-back pain and sciatica". Cochrane Database Syst Rev: CD001254. PMID 15495012.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  32. ^ Cheing GL, Hui-Chan CW (1999). "Transcutaneous electrical nerve stimulation: nonparallel antinociceptive effects on chronic clinical pain and acute experimental pain". Archives of physical medicine and rehabilitation. 80 (3): 305–12. PMID 10084439.
  33. ^ Deyo RA, Walsh NE, Martin DC, Schoenfeld LS, Ramamurthy S (1990). "A controlled trial of transcutaneous electrical nerve stimulation (TENS) and exercise for chronic low back pain". N. Engl. J. Med. 322 (23): 1627–34. PMID 2140432.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  34. ^ Khadilkar A, Milne S, Brosseau L; et al. (2005). "Transcutaneous electrical nerve stimulation (TENS) for chronic low-back pain". Cochrane database of systematic reviews (Online) (3): CD003008. doi:10.1002/14651858.CD003008.pub2. PMID 16034883. {{cite journal}}: Explicit use of et al. in: |author= (help)CS1 maint: multiple names: authors list (link)
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