Back pain

Back pains a condition or symptom that affects 60–80% of people at some time in their lives. Although the prevalence has notincreased, reported disability from back pain has risen significantly in the last 30 years.   Globally, low back pain is thought to affect about 9% of the population.¹

Types of low back pain²

1. Local pain: caused by injury to pain-sensitive structures that compress or irritate sensory nerve endings; pain located near the affected part of the back.
2. Pain associated with muscle spasm: Diverse causes; accompanied by tense paraspinal muscles, dull or aching pain in the paraspinal region, and abnormal posture.
3. Pain referred to the back: abdominal or pelvic origin; back pain unaffected by posture.
4. Pain of spinal origin: restricted to the back or referred to lower limbs or buttock. Diseases of upper lumbar spine refer pain to upper lumbar region, groin, or anterior thighs. Diseases of lower lumbar spine refer pain to buttocks, posterior thighs, calves, or feet.
5. Radicular back pain: radiates from spine to leg in specific nerve root territory. Coughing, sneezing, lifting heavy objects, or straining may elicit pain.

Mechanical backpain is the most common cause of acute back pain in peopleaged 20–55.

Symptoms of mechanical low back pain¹

1. Pain varies with physical activity (many times shows improvement with rest)^{1 and 2}
2. Onset often sudden and precipitated by lifting or bending¹
3. It is usually confined to the lumbar–sacral region, buttockor thigh, is asymmetrical and does not radiate beyond the knee(which would imply nerve root irritation).^{1 and 2}
4. On examination, there maybe asymmetric local paraspinal muscle spasm and tenderness,and painful restriction of some, but not all, movements.
5. This cause is common in manual workers, particularly those inoccupations that involve heavy lifting and twisting.
6. No clear-cut nerve root distribution.
7. The prognosis is generally good.After 2 days, 30% are better and 90% haverecovered by 6 weeks. Recurrences of pain may occur andabout 10–15% of patients go on to develop chronic back painthat may be difficult to treat.¹

Other Causes of low back pain¹

• Intervertebral disc lesions (e.g. prolapse, disc degeneration)
• Facet joint disease (osteoarthritis, psoriatic arthritis)
• Vertebral fracture
• Paget’s disease
• Axial spondyloarthritis
• Spondylodiscitis
• Bone metastases
• Spondylolisthesis
• Scheuermann’s

Spondylolisthesis

Back pain induced by spine movement and associated with stiffness. Increaseswith age; radiologic findings do not correlate with severity of pain. Osteophytes orcombined disc-osteophytes may cause or contribute to central spinal canal stenosis, lateral recess stenosis, or neural foraminal narrowing.²

Vertebral Metastases

Back pain most common neurologic symptom in patients with systemic cancer and maybe presenting complaint (20%); pain typically not relieved by rest and worse atnight. MRI or CT-myelography demonstrates vertebral body metastasis; disk spaceis spared.²

Vertebral Osteomyelitis

Back pain unrelieved by rest; focal spine tenderness, elevated ESR. Primary sourceof infection usually urinary tract, skin, or lung; IV drug abuse a risk factor. Destructionof the vertebral bodies and disk space is common.²

Lumbar spinal epidural abscess

Presents as back pain and fever; examination may be normal or show radicular findings, spinal cord involvement, or cauda equina syndrome. Extent of abscess bestdefined by MRI.²

Lumbar Adhesive Arachnoiditis

May follow inflammation within subarachnoid space; fibrosis results in clumping ofnerve roots, best seen by MRI; treatment is unsatisfactory.²

Immune Disorders

Ankylosing spondylitis, rheumatoid arthritis, reactive arthritis, psoriatic arthritis, and inflammatory bowel disease.²

These need to be treated by treating the base condition.  

Osteoporosis

Loss of bone substance resulting from immobilization, hyperparathyroidism,chronic glucocorticoid use, other medical disorders, or increasing age (particularlyin females). Sole manifestation may be back pain exacerbated by movement. Can alsooccur in the upper back.²

Visceral Diseases

Pelvis refers pain to sacral region, lower abdomen to mid-lumbar region, upperabdomen to lower thoracic or upper lumbar region. Local signs are absent; normalmovements of the spine are painless. Rupture of an abdominal aortic aneurysm mayproduce isolated back pain.²

Investigations

• Patients with persistent pain (>6 weeks) or red flags should undergo further investigation. MRI isthe investigation of choice because it can demonstrate spinalstenosis, cord compression or nerve root compression, as wellas inflammatory changes in spine, malignancy and sepsis.Plain X-rays can be of value in patients suspected of havingvertebral compression fractures, OA and degenerative discdisease. If metastatic disease is suspected, bone scintigraphyshould be considered. Additional investigations that may be required include routine biochemistry and hematology, ESR andCRP.¹
• Include abdomen and rectum to search for visceral sources of pain. Inspection may reveal scoliosis or muscle spasm. Palpation may elicit pain over a diseased spine segment.²
• Pain from hip may be confused with spine pain; manual internal/external rotation of leg at hip (with knee and hip in flexion) reproduces the hip pain.²
• Straight leg raising (SLR) sign—elicited by passive flexion of leg at the hip with pt in supine position; maneuver stretches L5/S1 nerve roots and sciatic nerve passing posterior to the hip; SLR sign is positive if maneuver reproduces the pain.²
• CrossedSLR sign—positive when SLR on one leg reproduces symptoms in opposite leg orbuttocks; nerve/nerve root lesion is on the painful side.²
• Reverse SLR sign—passiveextension of leg backward with pt standing; maneuver stretches L2–L4 nerve roots,lumbosacral plexus, and femoral nerve passing anterior to the hip.²
• Neurologic examination—search for focal atrophy, weakness, reflex loss, diminishedsensation in a dermatomal distribution.²

Management

Itshould emphasizethe self-limiting nature of the condition andthe fact that exercise is helpful rather than damaging. Regularpain relieving medicines may be required to improve mobilityand facilitates exercise. Return to work and normal activity shouldtake place as soon as possible. Bed rest is not helpful and mayincrease the risk of chronic disability. Referral for physical therapyshould is considered if a return to normal activities has not been achieved by 6 weeks.Other treatment modalities should be considered based on cause of the condition.

Homeopathic medicines are available which help relieve muscular spasm and also pain due to nerve irritation. Medicine selection is done by a homeopath based on symptoms and pathology. Physiotherapy and posture correction have an important role to play in management of backache.

Diet recommended avoiding backache

• Plant Based Proteins-lentils, beans, nuts, and chia seeds.
• Dairy Products – Improve your bone health and strength with dairy products that are high in calcium, including cheese, milk, and yogurt.
• Herbs and Spices – Turmeric helps fix damaged tissue.Oregano cinnamon, rosemary, basil, and gingerfight inflammation.
• Deep green vegetables – spinach, broccoli, and kale, can help reduce back pain by reducing inflammation in the spinal column. Vegetables like carrots and peppers also lower a substance in the blood that’s related to inflammation.
• Omega-9 fatty acidsvegetable and seed oils – olive oil, avocado oil, peanut oil
• Nuts– almonds, cashews, walnuts.
• Salmon, flaxseeds, and seaweedare good sources of omega-3 fatty acids, which can help reduce inflammation and benefit bone and tissue health.

Some homeopathic medicines for Back pain³