PAIN WITHOUT A CAUSE: BACKACHE

An attack of pain in the lower back has caused 60 per cent of the population at some time to take more than a week off work. The number of those who suffer has increased so strikingly that the condition has become a serious economic and social problem to add to the misery of the individual victim. For most attacks, the pain dies down in one to three weeks, although others take months, and some who suffer never fully recover from the first episode. Because the numbers of people having an initial attack are so great (back pain is almost universal), the fraction who never fully recover make up very large numbers of our chronic sick. Everyone, acute or chronic, is convinced that there is damaged tissue in their back and can put a finger on the area that seems to be the origin of their problem. There are tender areas around the apparent centre and the pain often radiates down the leg.

It is commonly believed that the cause of low back pain is a slipped disc, which is believed to extrude from between the vertebrae and to press on the root carrying the sensory fibres. A slipped disc can be seen in X-rays and is present in 1 to 3 per cent of the population. Slipped discs are seen with the same frequency in people in pain as in those who are not. If people in pain with a slipped disc are treated without surgery, the extrusion of the disc may or may not disappear, but this bears no relation to whether or not they are still in pain. The confusion by surgeons over the role of the disc is shown by the large variation between countries of the rate of operations to remove the extruded disc. Ten years ago, the rate per 100,000 was 100 in Great Britain, 200 in Sweden, 350 in Finland and 900 in the United States. These rates are now dropping, and mark the end of a disgraceful period in which a myth was peddled to the profit of a few and the disadvantage of many, some of whom became clearly worse off as a result of surgery.

There are five generally accepted causes of back pain. They are a slipped disc or other types of vertebral disorder, an area of infection, a tumour, a fracture and arthritis. When patients with back pain are carefully examined, a maximum of 10 to 15 per cent of them may be found to have one of these five causes. This leaves 85 per cent with no apparent cause, which produces a very large social, medical and personal problem. There are a number of other causes proposed by practitioners of alternative medicine, including misplaced vertebrae, trapped nerves and disordered joints, but so far there has been no convincing demonstration of these causes. It would seem natural to add injury as a cause, but in the vast majority of low-back-pain victims there is no evidence for injury. In large surveys of companies such as the aircraft manufacturer Boeing, it has been repeatedly shown that the rate of back pain complaints is the same among clerical workers as among shop-floor workers who lift heavy weights. There is therefore no evidence that heavy or unusual exercise leads to low back pain.

It is not true that the nonspecific low back pain patients 'only say' they are in pain. Their posture is abnormal and some muscles are in steady contraction, which tilts the back into an unusual shape. Movement is not free and there is palpable stiffness. These muscle contractions could be secondary to the pain if the muscles are attempting to splint the back to prevent pain-producing movement. These prolonged contractions could spread the pain so it migrates from its early location to settle in new structures.

Fortunately for most patients with sudden-onset back pain, the condition dies down within three to six weeks with minimal treatment. Patients should be permitted a day or two in bed followed by graded activity which speeds recovery, even though it is painful. They are also given minor analgesics, usually of the aspirin family. Depending on the society, they may also receive a variety of types of physiotherapy, acupuncture, yoga, manipulation, osteopathy and chiropracty. These latter therapies have been studied intensively and, although they may produce impressive temporary effects, they have not yet been shown to have a long-lasting effect on recovery.

The abandoned patient whose pain continues but in whom no damaged tissue can be detected is in serious trouble. The doctor may say: 'There is nothing wrong with you. It is all in your head'. The patient is forced to consider that he is the cause of his own suffering and is completely puzzled. If the word spreads to friends, relatives, union organizers, employers and social-security offices, his loneliness is extreme. If the doctor's message spreads to others as 'Don't encourage him. It will only make it worse', the patient exists in a near vacuum. In any Western country, there are considerable numbers of people who identify the major problem of their society as being a huge mass of swindlers and manipulators who are deliberately stealing money from social services to live in luxury and do no work. The patient is now assigned to this pariah status.

People in pain have difficulty coping. Pain monopolizes their world. Anger, fear, rejection and isolation clearly make matters worse. The patients' conflicting sense of shame and dependency adds to their problems. When these have been deliberately triggered by the authority of doctors, the patients are in deep trouble. Very rarely, individuals can diagnose the social situation, stop complaining to others and put on an act that signals to others that they are not in pain despite their continued problems. These rare individuals may appear admirable but their public performance is a sham. For the rest of us in pain, we need comfort, support, recognition and help if we are to make the best of our days in pain. To achieve that effort, we certainly do not need a group of doctors to wash their hands of us and dump the problem entirely on our shoulders.

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Pain Relief