The new approaches to back pain

Ann Finlayson April 22 1985

The new approaches to back pain

Ann Finlayson April 22 1985

The new approaches to back pain


Ann Finlayson

Putting out the garbage or even dusting furniture—simple tasks that most people take for granted —can be agonizing for Elaine Drew. The 38-year-old Toronto housewife was in a car accident in 1968 and, although she did not sustain any major injuries, she regularly suffers severe back pains, confining her to bed for several days at a time. As well, the trials of labor were short compared to the sustained back pain she endured both during and after her two pregnancies. Then, when she learned last month that a friend had died, Drew suffered her worst attack ever and she spent a week in bed with shooting pains in her back and legs. Said Drew: “It was the most painful thing I had ever experienced. It was excruciating—I was flat out.”

At some point in their lives, eight out of 10 Canadians suffer at least one spell of back pain that incapacitates them for a week or more. For most, the agony is short-lived. But backache is a leading cause of worker absenteeism and a major drain on health insurance and workers’ compensation plans. Last year back problems accounted for one-quarter of all compensation claims in Canada. In Ontario alone the Workers’ Compensation Board awarded $336 million in 1983 in compensation and medical payments

for back injuries sustained in the workplace, and the province’s workers lost about 2.8 million days on the job due to back injuries.

The near-inevitability of backache ensures steady employment for an army of specialists, which maintains a long tradition of often acrimonious disagreement about both its causes and the best way to alleviate it. But significant advances in diagnostics and a growing

understanding of how the mind and the body can conspire to torment backache sufferers have opened new avenues of relief. Said Dr. Stanley Gertzbein, a consulting orthopedic surgeon at Toronto’s Sunnybrook Medical Centre: “As we understand more, we are all better able to educate our patients about what has happened to them. That alone can make a dramatic difference.”

Back pain usually afflicts men in their early 30s and women a few years later. But it can strike anyone at any time. Currently, specialists agree that a sedentary lifestyle and an unfit body are most likely to lead to back pain. Said Maureen Hunt, a physiotherapist and program director at the Canadian Back Institute in Toronto, a private clinic which specializes in the management of spinal disorders: “I used to refer to the problem as homo sapiens distress because it really began when man first stood upright. But now I think that it is more a case of homo sedentarius.” Indeed, the incidence of back pain is closely tied to the rise of desk-bound or routine jobs, although the recent fitness boom has shown that overly vigorous exercise can also cause it. But the agony often strikes for no obvious reason. And when it does, the severity of the pain usually does not indicate an equally serious problem. Despite such possibilities as rheumatoid arthritis and spinal

tumors, the causes of even the most severe backaches are usually much less threatening.

Specialists estimate that 80 per cent of lower back pain victims suffer from one or more of three identifiable syndromes. The pain usually strikes the lower back, which supports the most weight. Facet-jointed degeneration, the first syndrome, occurs when one of the leathery oval discs that cushion the vertebrae, usually as the result of aging, lose some of their moisture and shrink. With age, this natural drying-out process actually stabilizes the spine and reduces back pain. But it can also cause one or more facets—the bony spurs that link vertebrae —to become misaligned. That can create additional stress on joints, which can cause pinched nerves, muscle spasm and excruciating pain.

A second syndrome is the familiar but misnamed “slipped disc.” That occurs when a disc ruptures as a result of age or inj ury, causing its j elly-like interior to bulge or even to break through the ligaments that surround it, sometimes putting pressure on sensitive spinal nerves. More commonly, the same pressure occurs when worn and dried-out discs flatten and push out beyond the spine, causing the third type of backache, the pinched nerve. All three syndromes can cause muscle spasm, the contraction into a hard mass of one or more of the many small muscles that support the back.

The pain from muscle spasms in the lower back can travel up the spine or as far down as the knees, which makes it difficult, if not impossible, for the sufferer to pinpoint the actual location of the spasm and for his doctor to treat it.

Research has dispelled many of the myths that traditionally surrounded back pain, and most medical practitioners have abandoned some outdated medical terminology. It is no longer precise enough to call lower back pain lumbago nor are the sacroiliac joints at the top of the pelvis blamed for every twitch and cramp. Discs no longer “slip” and athletes no longer “throw their backs out.” But the most dangerous myth—that most back pain cannot be prevented by exercise, posture and relaxation techniques—has proven hardier. Said Hunt: “Part of the blame for that can be laid on doctors. They are a slow bunch to convert.”

For her part, Hunt works closely with Toronto orthopedic surgeon Hamilton Hall, whose 1980 best seller, The Back Doctor, will appear in bookstores across

Canada this fall in a revised and expanded edition. In the book Hall criticized his colleagues for confusing and frightening their patients. Declared Hall: “In many instances, I’m sure, it’s purely unintentional—simply a matter of their being less sensitive or less adept at interpersonal communications than they might be.” He added that family doctors “are uneasy with back pain because they find it tricky to diagnose and unsatisfying to treat,” and surgeons find it “a bore” because the treatment needed is likely to be nonsurgical.

Many medical officials say that Hall’s book sparked a minor revolution in the way doctors deal with their long-suffering patients and in the way patients themselves view their aching backs. Hall also confirmed a widely held suspicion: that chronic back pain is rarely just a physical problem. Indeed, some specialists claim that in 80 per cent of all back pain cases such elusive factors as stress, depression and mental attitude play a magnifying role. Said Dr. John Basmajian, professor of medicine and anatomy at McMaster University: “It is not so much in your head as it is in your behavior—societal stresses and strains, overeating, weak abdominal muscles, corpulence. Without question, back pain has reached epidemic proportions in North America. It is not a major problem, for example, behind the Iron Curtain.” Similarly, most experts agree

that the mainstream approach to back pain has changed substantially over the past decade. Said Hunt: “If you went to a convention of spine people 10 years ago, all you heard was talk about surgery. Now, all the talk is about exercise and how to avoid surgery.”

Still, surgery is sometimes unavoidable. The most common surgical procedure for the relief of back pain is a discectomy—the removal of a ruptured disc, which is occasionally followed by a second operation, called a fusion, to join two vertebrae and stop movement at the joints. The procedure is often effective, but there is an alternative: the injection of an enzyme from the papaya plant into the disc, called chemopapain, which dissolves its gelatinous core and reduces pressure on the surrounding tissue. A controversial procedure, it was banned in the United States in 1975 after a study questioned its safety, but Canadian surgeons have continued to use it successfully, and the U.S. Food and Drug Administration recently revoked its ban on the substance.

Back researchers have also made progress in developing diagnostic procedures that are less potentially harmful to back pain sufferers mostly by reducing the amount of radiation aimed at patients who in the past were subjected to frequent X-rays. Doctors also rely less on myelograms, complicated and painful radiological procedures that require the injection of dye into the spinal canal. Said Dr. Stephen Tredwell, pediatric orthopedic surgeon and director of the § spinal clinic at British Colum5 bia’s Children’s Hospital in Van5 couver: “There has been enor° mous progress in making diagnostic procedures safer. Even the dye used in the myelograms is much safer than it was 10 years ago.”

As researchers learn more about how to diagnose and treat the malfunctions of one of the body’s most complex mechanisms, the medical community as a whole is learning how to understand and treat the even more complex relationship between the back and the brain. As a result, treatment is likely to improve. But the prospect of miracle cures is more distant than ever. For one, recent research in Sweden into artificial discs proved disappointing. Still, the route to a cure through prevention is better marked than ever before—for every homo sedentarius willing to forsake the easy chair in front of the television for the exercise mat on the floor.

Marsha Boulton