Back pain diagnosis and treatment
How is back pain diagnosed?
When examining cases of back pain, clinicians will attempt to diagnose the pain into several types of categories. The first categories are aimed at differentiating between mechanical back pain, back pain which is associated with nerve pain and any possible more serious medical causes of back pain. These diagnostic categories are used to guide whether any diagnostic tests may be useful and the most appropriate onward management such as physiotherapy, pain management or surgery.
For patient’s suffering with mechanical back pain the clinician will attempt to find areas of stiffness, weakness or poor movements patterns which may be contributing to the pain.
In some cases of possible nerve pain, and for all cases where there is a possibility of more serious medical causes of back pain, imaging will be requested. In cases of nerve pain, the clinician will be attempting to diagnose the specific structure at fault such as an intervertebral disc or an enlarged facet joint. An evaluation will also be sought as to how severe the compression of the nerve root may be as this will enable the clinician to guide the most appropriate management. In cases of possible serious medical causes of back pain, scans and blood tests will confirm whether there is cause for concern or not. In most cases, these tests will also be immediately helpful for the prognosis of the condition and any immediate surgical planning required.
Treatments for back pain cover a range of disciplines dependent on your diagnosis, and are conducted by spinal rehabilitation professionals, which include spinal consultant surgeons, physiotherapists and osteopaths, in addition to specialist pain management consultants.
What are the best physiotherapy exercises for back pain?
Specific exercises for back pain should be aimed at the individual biomechanical problems which are contributing to the pain. However, some general principles still exist. Individuals with a stiff middle (thoracic) spine will often benefit from some exercises to improve the flexibility of this area. Some common examples are mobilising the spine with a foam roller as well as rotational stretches in lying.
Similarly, stiff structures in the lower limb which place more movement demand on the lower spine may also give some back pain relief if flexibility is improved. The most common examples of these are stiff hip joints which can be stretched in sitting or lying as well as stiff gluteal and hamstring muscle groups which can be stretched most effectively in various standing positions.
Various strengthening programs exist for treating back pain. In general, if the back pain is related to a flexion related activity such as sitting or flexing forwards, increasing spinal strength in to extension may help. Torso raises over a swiss ball and for more advanced progressions exercises such as light deadlifts provide two examples.
For individuals suffering with back pain mainly related to standing and walking, strengthening the abdominal muscles which work to flex the spine may be of benefit. Common examples include plank exercises and pelvic tilts exercises.
Strengthening the muscles of the hips may also help cases of lower back pain and strengthening the muscles which move the shoulder blades outside their normal range of motion may also help relieve middle and upper back pain.
What are the best forms of general exercise for back pain?
When combined with appropriate, specific physiotherapy exercises and ergonomic modifications, increasing general levels of activity has been shown to be one of the most effective ways of managing back pain. The mechanisms behind this are not proven, but may relate to releasing hormones which act as a natural painkiller. Reducing the relative time spent in sedentary seated postures, which is one of the main causes of back pain, is a great way to begin to address the causes of back pain, as well as increasing general fitness levels.
Many forms of exercise are popular with sufferers of back pain. Yoga is an excellent way of improving general flexibility and pilates is often practised to increase spinal strength. There are different forms of these exercises and it is generally recommended to start with beginner classes and build slowly to more advanced routines.
Swimming is an excellent way of taking the load off the spine for prolonged periods of time and, depending on the technique used, can significantly improve middle spinal and shoulder flexibility. It is also an excellent all round exercise which improves cardiovascular fitness.
Studies which have looked at large populations of individuals with back pain have concluded that the type of exercise completed matters less in comparison with completing a consistent program of exercise. Therefore, a brisk walk several times a week may also be of significant benefit especially for individuals who spend significant amounts of time sitting.
Will increasing core stability help back pain?
Previously the term “core stability”, when initially proposed as a treatment, was defined as strengthening muscles called the transversus abdominis and multifidus. These muscles lie deep under the larger muscles next to the spine itself and when contracted may provide stability to individual spinal segments.
In recent years the term core stability has been used widely in healthcare and fitness for a wide variety of strengthening protocols. Therefore, exercises you might find online called “core stability” exercises should not be assumed as being a good exercise for back pain. As with all exercises to treat back pain, there should be a specific underlying biomechanical fault these exercises are trying to correct which a trained physiotherapist can help you with.
Types of spinal surgery
The majority of cases of back pain are termed mechanical, having no obvious structural cause found on diagnostic tests such as blood tests, X-rays and MRI scans. This means there is not an identifiable target for surgery. Yet where there is an identifiable cause, surgery may be appropriate.
Cases of back pain when surgery is considered can be categorised intto three main groups. The first group and by far the most common type of spinal surgery undertaken is termed decompressive surgery. As the name suggests this type of surgery is undertaken to decompressive the spinal cord or spinal nerve roots.
Generally, neural compression results from an intervertebral disc prolapse or general enlargement of the soft tissues and facet joints of the spine. When a disc prolapse needs to be resected this is termed a discectomy operation and when there is a wider soft tissue and bony resection needed this is termed a laminectomy.
The second category is fusions. Fusions are generally more invasive than decompressive operations but in some cases, spinal segments may need both fusion & decompressive operations performed as part of the same procedure.
Fusion operations are performed to stabilise one or more spinal segments which for a variety of reasons may have become unstable. The most common reasons for segmental instability of the spine is a developmental abnormality to the bone supporting the facet joints which is sometimes referred to as a pars defect or pars fracture.
An extremely common cause for spinal instability is due to age-related changes weakening the facet joints and discs. Spinal segmental instability can lead to significant inflammation to the joints and underlying bone and may lead to a secondary condition termed a lysthesis, which describes the forward translation of one segment on another. Depending on the cause, fusions may be achieved with a variety of metal work and bone grafts.
The third category is to remove masses from the spine and surrounding tissues. This operation is needed to treat the underlying cancer but may also be needed for non-malignant masses as these may encroach and compress the spinal cord and nerve roots in some cases.
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