Chronic Back Pain – Long Lasting Or Recurring Episodes of Pain In The Lower Back
Low back pain is very common. During our lifetime, 80% of us will experience an episode of back pain that will be severe enough to seek medical attention. Back pain ranges from mild to severe, with most of us suffering a mild form of back pain.
Dealing with back pain is very expensive when it comes to treatment, sick leave and disability. It is the most expensive disease, the only other condition that comes close is coronary heart disease. All other diseases conditions combined, other than coronary heart disease, do not add up to the expense incurred with chronic back pain.
What Is The Problem With Back Pain
In general, out of 100 people that seek professional health care for back pain, only 20% will be given a specific diagnosis. About 10% will be given a disc related diagnosis like disc herniation, the other 10% will be given a non-disc related diagnosis like stenosis. The remaining 80% is unknown, however, various professions have come up with different diseases comparing different theories. The 80% of back pain is called non-specific back pain. This is a confusing term, because nobody wants to hear they have non-specific cancer. Therefore, the various professions come up with terms to try and define this according to different methods of treatment:
- Displaced annulus
- Lack of core stability
- Vertebral instability
- Locked Facet Joints
- Functional Scoliosis
If you go to one doctor you will get a diagnosis, a physical therapist and you will get another, a chiropractor and you will get yet another diagnosis for the same symptoms.
About 10% of new back pain episodes will still remain after 6 months. That seems good; 90% are better after 6 months, however, so many of us will have an episode of low back pain that it adds up to a lot who will have chronic back pain, which is lasting and forms a cycle of recurrent pain.
A normal disc has an outer layer called the annulus and an inner part called the nucleus. The annulus has around 20 – 25 layers, built like an onion. In typical degeneration, the disc looses water and dries out, so when you bend over or lift and some parts of the nucleus will come out and sit in between the layers of the annulus. The annulus does not like to have the layers separated, and when you get some of the nucleus to come out and sit between the layers, it is painful. Just like you can get a small seed or piece of food caught between your teeth that is painful or uncomfortable, having the nucleus of the disc caught between the layers of the annulus is painful.
So, you go to your doctor, therapist or chiropractor, and you may have therapies or medications that help with the pain, but from doing special exercises or manipulations, the nucleus goes back in slowly and you have a normal disc again.
Then life continues and you have problems at work, at home and stressful situations and you stop your exercises or stop going to the chiropractor; the muscles weaken and stress accumulates, and then you bend, twist or lift and the annulus tears and nucleus material comes out again. This is typical of recurrent back pain and some have 2 months between episodes and some have 2 years or 20 years between episodes. This is what we call “normal back pain”.
According to years lost to disability, a measure of which diseases cause the most suffering, it was found that the leading cause is low back pain, followed by depression, iron-deficiency anemia and neck pain. These causes of disability have not decreased over the years and show no sign of decreasing, so we are not very good at dealing with these chronic back problems.
What are good treatments for non-specific chronic back pain?
Most studies do not show a significant difference between treatment types. In general more patients are satisfied with exercise programs which include; cardiovascular training, strength and flexibility exercises, body awareness and relaxation. However, these were essentially no more effective than care by a general practitioner for pain and disability. Manipulation was shown to have better effects than no treatment for pain, however, the pain relief was only 0.4 on a scale of 1 through 10. It is difficult to imagine being satisfied with such minimal improvement. There were similar minimal improvements in disability, however, over the long term, these improvements did not last. Similarly, studies were done using acupuncture, therapeutic massage and self-care education. After 4 weeks and 1 year – no difference.
Therefore, a major clinical guideline organization has concluded that there is no clinical entity or disease called non-specific chronic back pain – it is a symptom. There is very limited evidence for any positive diagnostic assessment or and therapy, and no single intervention that is likely to be efficient in terms of back pain relief and back disability levels.
It is important to identify specific sub-groups in the category of non-specific low back pain. One of these are related to modic type 1 changes, which are findings on MRI that indicate a rapid progressing, inflammatory and unstable form of degenerative disc disease related to chronic back pain. Studies are showing this group of back pain sufferers are responding to antibiotic treatment. It is wrong to say that antibiotics are being prescribed to treat back pain; it is more correct to say that people with back pain, who have Modic changes are responding to antibiotic therapy (specifically type 1 Modic changes). Indications are that this group of individuals may compromise up to 40% of those suffering from non-specific chronic back pain that is not responsive to other treatments. The results, so far, are impressive and may offer significant benefits, both in terms of human suffering as well as disability impacts on society.