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Low Back Pain – a Disability of Modern Civilization?

The significant increase in the low back pain occurrences in the recent years, as well as the economical, medical, and social impacts on our society, prompted scientists to investigate issues surrounding disability resulting from lower back disorders. It is estimated that the annual direct cost of treating back pain reached $ 193.9 billion in 2004 in the USA alone (1). One of the frequently asked questions is whether low back pain is a disorder of the contemporary, high industrialized societies or perhaps it has been known for ages. With the increased industrial safety, easier access to medical help, and improved work ergonomics, low back incidences should be on decline. Ironically it is not so.

The low back pain is not a new problem and it has been documented in various medical and non-medical literature throughout the centuries. The earliest description of back problems, later known as sciatica, could be found in an Egyptian manuscript dated circa 2.500 B.C. The term “sciatica” was introduced by Hippocrates, one of the most prominent ancient Greek philosopher, however, the definition and description of this particular back disorder was given by Caelius Aurelianus in his dissertation “Sciatica et Psoadica” in the 3rd century B.C.(2). At that time, very little was known about human anatomy. Although Aurelianus described various back problems and Hippocrates suggested a few methods of treatment, they were unable to provide anatomical or physiological basis for the etiology of low back pain. The Middle Ages represented a decline in the Western medicine. The first speculations regarding the case of low back pains were introduced with the work of Andreueus Versalius, who in 1543 described detailed anatomy of the human body with clear outline of vertebrae and intervertebral disc. In 1579, the famous French surgeon Ambrose Pare introduced first surgical attempt to stabilize the spine utilizing metal plates, setting the standard for future orthopedic surgery (3). A number of scientists and physicians contributed to understanding the causative factors of low back disorders and developing different methods of treatment, ranging from surgical interventions or manual therapies to various medications in 18th and 19th centuries.

The end of the 19th century depicted a significant progress in the medical knowledge. In 1887 Dr Victor Horsley, professor of surgery at the University Collage London performed the first laminectomy, relieving pressure on the spinal cord by trimming the vertebral bone to widen the spinal canal. In 1934, Mixter and Barr provided a scientific explanation of one cause of the low back pain. They concluded that the source of sciatic pain was a herniated disc. Their finding was based on the experiment with nineteen patients, who showed a significant improvement after laminectomy followed by the removal of the herniated disc.(4). Since then, numerous research has been done in attempts to identify the causative factors, appropriate treatments as well as preventive means of low back problems. The fast advancement of diagnostic tools, namely MRI or CAT scan in recent years, shed some light on the low back problems.

Low back pain is a general term indicating the subjective experience of the patient, but not a diagnosis. The patient complaining of back pain needs to be evaluated by a clinician using standard objective clinical tests in order to make a final diagnosis. One of the most widely used classifications of low back pain is based on clinical findings and considers pathology as well as causative factors. In this classification, the causes of low back pain are divided into two groups: vertebral/paravertebral causes and referred causes. The first group includes all disorders pertaining to the spinal column e.g. degenerative joint and disc disease, musculoskeletal disorders, neoplasms, infections, rheumatoid conditions, traumatic and idiopathic conditions. The second group covers diseases that originate in other body systems, such as renal, vascular, and gastrointestinal, that refer pain to low back area.

Since the majority of low back pains are caused by some combination of overuse, misuse, muscle strain or injury to muscle and ligaments supporting the spine, it is crucial to identify the factors that may predispose the spine to possible injury. The numerous research on this issue resulted in the long list of predisposing factors that may not directly cause the pain, but undoubtedly contribute to it. One of the most important factors is the history of previous back pain or injuries. Most people experience low back pain periodically, with every new bout being usually more severe than the previous one. Certain occupations require repetitive bending, lifting, prolonged sitting or standing positions. If the worker demonstrates poor posture or is unaware of proper body mechanics, it certainly puts him or her at risk for developing low back problems. Sedentary life style and obesity can also contribute to weak postural musculature, eventually leading to a back disorder. Conversely, sports or recreational activities involving twisting, excessive extension or bending may result in repetitive trauma of low back region. Even gender or age could be consider risk factors for certain spinal disorders. Younger people present more frequently with intervertebral disc disorders, whereas patients over 60 years old would rather suffer from degenerative diseases. Low back pain is a very common problem related to pregnancy. During pregnancy, the center of gravity shifts forward with a lot of stress being placed on the back. Moreover, in preparation for delivery the body produces the hormone – relaxin, which causes the ligaments between pelvic bones to become more relaxed. Postmenopausal women are more prone to osteoporosis, which may contribute to compression fractures of vertebra. Males, on the other hand, are more inclined to traumatic damages to lower spine. There are also genetic and hereditary predispositions to low back disorders. Psychological and psychosomatic factors influencing low back pain have been increasingly recognized. Research has shown that anxiety, depression, stressful responsibility, job dissatisfaction, mental stress at work, and substance abuse can place people at increased risk for developing chronic low back pain.

Back pain is an impairment, which may lead to disability. According to World Health Organization, impairment is “any loss or abnormality of psychological, physiological, or anatomical structure or function”(5). Conversely, disability is defined as “any restriction or lack of the ability to perform an activity in the manner or within the range considered normal resulting from an impairment” (5).

The high incidence of low back disorders, often resulting in permanent disability, and its effect on our society, necessitated researchers to identify factors that influence patient`s recovery and may be predictive of future disability. Among them, the most important factors recognized by scientists are perception of fault by the patient, possible financial compensations and lawyer involvement, patient`s perception of permanent disability, history and duration of pain, job satisfaction and the relationship with an employer, as well as physical requirements of patient`s job (6). An early recognition of disability predicting factors helps clinicians to develop better treatment plan to avoid future disability and promote patient’s return to work forces.

With the industrial progress, advancements in medical technology, easier access to medical help and improvement of work ergonomics, the incidences of low back problems should be expected to decline. Unfortunately, this is not the case. The twenty first century has not brought any solution to low back problem as one of the most common reasons for epidemy of lower back pain is sedentary lifestyle leading to obesity and deconditioning of the muscles supporting low back.

Maggie Garbiec, PTA

References

1. http://www.aaos.org/news/aaosnow/jan09/research6.asp

2. Deyo, Richard A., and Weinstein, James “Low Back Pain” The New England Journal of Medicine 344.5 (2001): 363-370.

3. Paris, Stanley V., and Loubert, Peter V. FCO Foundation of Clinical Orthopedics. Seminar Manual. 3rd ed. St. Augustine, Institute of Physical Therapy, 1999. 17-24.

4. Latchaw, John P. “A Historical Note on Sciatica” Hardy, Russell W. Lumbar Disc Disease. New York: Raven Press. 1982: 3-22.

5. World Health Organization (WHO). International Classification of Functioning, Disability and Health. Geneva, Switzerland, 2001

6. Frymoyer J. Predicting Disability From Low Back Pain “Clinical Orthopaedics and Related Research”, No. 279, June 1992