Back Pain

The four secret causes of back pain (story from WDDTY)

Chronic back pain is a mystery to medicine, and doctors invariably blame it on poor posture and lack of exercise. But it could be an indicator of a more serious problem that doctors almost never suspect, as Bryan Hubbard reports.

Most of us will suffer pain in our lower back at some time in our life; it could be constant and niggling, or it could be so excruciating that we can’t move. And although it affects 80 per cent of the adult population and results in millions of days of lost work, medicine is at a loss to explain why chronic back pain happens, other than to blame our sedentary lifestyle, poor posture and the fact that we now spend hours crouched over a computer or mobile phone.
While all of these reasons may be to blame for some cases and might be helped by exercise and remedial therapies like osteopathy and chiropractic, the ‘standard response’ masks four other causes of back pain that are rarely suspected; in these cases, back pain is a symptom of something far deeper and will never improve until the real cause is treated.
So, if you suffer from constant back pain, and exercise, osteopathy and chiropractic haven’t helped, suspect one of these four causes.

What’s causing your back pain?

Type of pain:
In the middle of the back on one side
It could be:
Kidney stones (especially if you are overweight, and aged between 20 and 40)
Pain relief, fluids—and wait. Shock waves (lithotripsy) can be used on larger stones

Type of pain:
Abdominal pain (just below the ribs) radiating to the back
It could be:
Pancreatitis (inflammation of the pancreas) especially if you’re feeling sick or vomiting
Hospital care, with intravenous (IV) fluids, pain relief and oxygen

Type of pain:
On one side of the lower back
It could be:
A kidney infection (especially if you’re a woman)

Type of pain:
Dull pain in pelvis and back (and urgency to urinate)
It could be:
Cystitis (inflammation of the bladder), caused by infection or irritation such as a tampon, diaphragm, clothing or chemicals

Type of pain:
Chronic back pain that radiates to the abdomen and thighs
It could be:
Pancreatic cancer, especially if you’re aged over 40 or have a history of cancer
Cancer therapy

The idea that chronic back pain is a symptom of an infection treatable by antibiotics suddenly hit the headlines last year, although it’s a theory that’s been mooted for more than a decade. The media hype was sparked by two new studies. In the first, researchers said that people who have suffered intervertebral disc herniation—bulging of the disc contents through a tear in the disc ring—are most likely to develop an infection of the spinal disc that then causes their long-term back pain.1
Turning the theory into practice, researchers at the Spine Centre in Denmark put 162 back-pain sufferers on a 100-day course of Bioclavid (amoxicillin–clavulanate) antibiotics. The participants had suffered from chronic back pain for at least six months following an operation for a herniated disc. Half were given the antibiotic and the rest were given a sugar pill, or placebo. After a year, those given the antibiotic reported significant improvements in pain and mobility—and these results weren’t just ‘in the head’. MRI scans showed that the antibiotics had shrunk swelling of the bones, a sign of infection, around the disc.2
The infection around the herniated disc was due to Propionibacterium acnes bacteria—that bane of many a teenager’s life, as it causes acne and pimples—which are usually found in the hair follicles, but which can enter the bloodstream and so end up in disc material. One of the researchers, rheumatologist Claus Manniche, said: “Our studies show that at least 40 per cent of the herniated patients lying on the operating table are infected with P. acnes bacteria. It is possible that early intervention with antibiotics may prevent the infection from becoming chronic pain.”
This wasn’t the first team of Danish researchers to discover a link between infection and back pain. Five years earlier, a group also led by Manniche had successfully treated 29 back-pain sufferers with amoxicillin–clavulanate antibiotics.3
It’s a therapy that is also being used as part of day-to-day care. Peter Hamlyn, a consultant neurospinal surgeon at the Institute of Sports Exercise and Health at University College Hospital in London, has successfully treated more than a dozen back-pain sufferers with antibiotics instead of surgery. Hamlyn has even set up a web-based training company, The MAST Medical Academy, to help specialists understand the new antibiotic therapy, and how and when to apply it.
The worry, says Hamlyn and the other Academy members, is that consultants will start using antibiotics for every sort of back problem—especially as the current tools available seem to be so ineffective—when the drugs should be reserved only for those who have had disc-herniation surgery, which may represent only around 20 per cent of all back-pain cases.
They are also concerned that the antibiotics come with their own side-effects—some of those in the earlier Danish study had diarrhoea and other gastrointestinal problems bad enough to cause them to drop out of the study—and the discovery adds to the overuse of these drugs, so hastening the emergence of antibiotic-resistant ‘superbugs’.

Heart problems or cancer
A bad back could be a symptom of something more serious, such as heart problems or even cancer. Researchers in Finland stumbled upon an association between heart disease and a bad back 20 years ago when they tracked the lives of 8,816 farmers, aged 30 to 66, for 13 years. At the start of the study, none of the farmers had heart problems—but those suffering from back pain, including sciatica, before starting the study were far more likely to have died of heart disease before the study ended. This was also the one association that persisted after the researchers had ruled out all the usual suspects for heart disease, such as smoking, body weight and social status.4
But an association doesn’t necessarily mean a cause, although a little understanding of biology gives more credence to the Finnish researchers’ findings. The muscles in our back play an important role in helping to pump blood back to the heart. As they contract, they squeeze blood out of the surrounding tissues, but in a back that has been injured, the muscles may remain in a continuous state of spasm with no symptoms. An inability to pump efficiently over years means that damage could build up and affect healthy heart function.
It can work vice versa too. A poorly functioning heart could cause chronic back pain. If the veins that supply blood and nutrients to the spine aren’t working properly, it can lead to degeneration of spinal tissue.
Although rare, back pain may be a symptom of cancer, as actor Andy Whitfield, who starred in the TV series Spartacus: Blood and Sand, discovered. He started to suffer from back pain during rehearsals, but assumed it was because of the rigorous training he was going through in preparation for the role. It was only after filming had finished and the pain had become more severe that he had it checked out and was diagnosed with non-Hodgkin’s lymphoma. He died 18 months later, aged just 39.
Low back pain is sometimes a symptom of cancer of the spine or breast cancer and should always be considered a ‘red flag’, especially among the over-50s, say researchers at the Institute of Public Health in Heidelberg, Germany. In a review of eight large-scale studies of back pain involving a total of 6,622 patients, the researchers say the chances of being a spinal malignancy are very small—just 0.66 per cent of the cases reviewed turned out to be cancer—but being aware of the possibility does mean the cancer can be caught early.5 Doctors should particularly suspect cancer if the pain radiates from the lower back to the abdomen and to the fronts of the thighs, one specialist reported, or if the patient has a history of cancer.6
Back pain can also be a symptom of pancreatic cancer. Around half the patients with cancer in the head of the pancreas suffer abdominal or back pain. And anyone over the age of 40 who has unexplained weight loss along with upper abdominal or back pain, or late-onset diabetes, should be checked out for pancreatic cancer, one study says.7

Bladder dysfunction
Chronic back pain may be a symptom of bladder problems.8 Interstitial cystitis (bladder pain syndrome), which is chronic, recurring and doesn’t respond to treatment, can cause long-term back pain, as Michelle Law discovered.
Michelle had suffered chronic back pain since childhood, but it was only when she was 35 that a doctor thought to have her kidneys checked out. Eventually it was discovered that the cause of her back problems was interstitial cystitis, which attacks the lining of the bladder. But by the time it was discovered, the bladder was so badly damaged that it had to be replaced by bowel tissue, and Michelle now has to use a catheter.9
Women seem to be especially vulnerable to bladder problems masked as back pain, says urologist Dr Zaki Almallah, at the Birmingham Bladder Clinic. As the spine connects most parts of the body, it is often the target of referred pain from organs like the kidneys, bladder and gallbladder.
A survey of 629 interstitial cystitis sufferers asking participants to describe their pain revealed that lower abdominal and lower back pain were among the most common areas where pain was experienced. Most said the pain was intermittent and moderate.10

Chronic back pain may be a complex problem that doesn’t always have a physical cause, as psychological issues, including stressful life events and anxiety, can be involved too.11 Factors like stress can cause pain by increasing muscle tension around the spine, which eventually becomes painful because of the accumulation of waste products like lactic acid in
the muscles.
Although it’s difficult to prove that stress can cause chronic back pain, the fact that relaxation therapies ease the problem suggests a connection. Meditation, hypnosis, biofeedback and cognitive behavioural therapy have all been successfully used for back-pain management, so much so that they have been endorsed by America’s National Institutes of Health. In one study, these non-conventional therapies reduced stress levels and resulted in a reduction in back pain of around 47 per cent, a drop of 37 per cent in visits to the doctor and a rise of 73 per cent in the ability to cope with pain. There was also a 47 per cent increase in activity levels within the group as a whole.12
And as possible further proof of the mind–body connection when it comes to back pain, three Japanese researchers took 23 back-pain sufferers to an amusement park. Their pain levels, as assessed by a visual analogue scale and saliva tests, were measured after 10 minutes, one hour and three hours after arriving. From the start, these volunteers forgot about their pain, and the physical checks confirmed that their pain was dramatically reduced just by having fun.13

Yoga relief

If you suspect your back pain is related to stress, try the mind–body exercise of yoga. There’s plenty of evidence to suggest it could work. When tested against exercise and advice from a self-care book in 101 back-pain sufferers, those who took part in weekly yoga sessions for 12 weeks had greater mobility and flexibility than those in the other two groups, although the exercise group started to report better levels of mobility after 26 weeks.
The take-home message? Yoga gets speedier results.1
Yoga was also tested against stretching, and had a more profound effect by the end of a 12-week programme.2

Taking painkillers?
Try this instead

A daily painkiller is a way of life for many with chronic back pain—but a course of acupuncture works better.
Tested in a group of 1,162 people suffering from back pain for an average of eight years, these people received either 10 sessions of acupuncture twice a week, ‘sham’ acupuncture where the needles were not properly inserted or conventional therapy with painkillers, physical therapy and exercise.
After six months, 48 per cent of those in the acupuncture group reported dramatic reductions in pain compared with only 27 per cent of those receiving conventional care. Interestingly, 44 per cent of those given ‘sham’ acupuncture also reported pain reduction, suggesting the importance of the mind–body connection when it comes to back pain.1

Keep taking the supplements

The most important supplements for the treatment of chronic pain are the B-complex and C vitamins. The spine is surrounded by cerebrospinal fluid which, in healthy individuals, contains a higher concentration of these water-soluble vitamins than is commonly found in blood. A combination of thiamine (B1), vitamin B6 and vitamin B12 has been shown to significantly improve symptoms in those complaining of severe pain.
In one study of back-pain sufferers, a combination of 100 mg of B1, 200 mg of B6 and 0.2 mg of B12, each three times daily, was taken over six months. Only 32 per cent of those taking the vitamins suffered a relapse compared with 60 per cent of those taking a placebo.
Also, adequate vitamin C intake is necessary to maintain the integrity of the intervertebral discs. Being deficient in copper and selenium may also be contributory to chronic pain; 90–100 mcg of selenium alone or in addition to 20 IU of vitamin E, taken daily, has been shown to improve musculoskeletal complaints.
Proteolytic enzymes such as bromelain, papain, trypsin and chymotrypsin can also help heal minor injuries, as they are anti-inflammatory and can be absorbed from the gastrointestinal tract. Several small trials have shown that both bromelain and papain can reduce pain and swelling, and promote faster healing in people suffering from a variety of conditions, including back strain.

Smart talk: know your Modic

How did the specialists know that bone had become infected (see pages 25 and 27)? They used the Modic scale of changes. It’s named after Michael Modic, the radiologist who first detected three stages of degeneration of the vertebrae when looking at MRI (magnetic resonance imaging) scans, now known as Modic type 1, 2 and 3 changes.
When he made the discovery in the late 1980s, Modic didn’t think the degeneration had anything to do with back pain. That happened in 2006 when researchers finally made the connection and, a year later, others found a connection between Modic type 1 and disc herniation. It was not till 2008 that researchers tested the theory that infected discs caused type 1 Modic changes to bone, and successfully treated 29 back-pain sufferers with antibiotics, so proving that infection was a cause of back pain and damage to the lumbar spine.1
Interestingly, all of the back-pain sufferers from the study that grabbed the headlines last year had type 1 Modic degeneration of their vertebrae.
Modic himself seems to be a humble fellow. He won’t allow his students at the Cleveland Clinic in Ohio to refer to the Modic scale; instead, they have to call them ‘marrow changes’.

Eur Spine J, 2013; 22: 689
Eur Spine J, 2013; 22: 697–707
Br J Sports Med, 2008; 42: 969–73
BMJ, 1994; 309: 1267–8
Cochrane Database Syst Rev, 2013; 2: CD008686
Man Ther, 2013; 18: 624–7
Practitioner, 2011; 255: 21–5, 2–3
J Man Manip Ther, 2007; 15: 42–9
Mail Online, November 11, 2013;
Int Urogynecol J Pelvic Floor Dysfunct, 2006; 17: 69–72
Psychosom Med, 1999; 61: 304–10
J South Orthop Assoc, 1998; 7: 81–5
J Pain Res, 2012; 5: 409–13
yoga References
Ann Intern Med, 2005; 143: 849–56
Evid-Based Complement Alternat Med, 2013; 2013: 130818
acupuncture references
Arch Intern Med, 2007; 167: 1892–8
modic references
Br J Sports Med, 2008; 42: 969–73

Published: 28/02/2014 14:32:44 GMT