Understanding And Management Of Back Pain

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The symptom of pain in the back is the common link between the ordinary backache that most people have at some time in their life, a number of serious spinal diseases, and low back disability. We should try to keep these different perspectives in mind as we look at the history of back pain.

The oldest surviving text about back pain is the Edwin Smith papyrus from about 1500 bc (Fig. 4.1). It is a series of 48 case histories, the last of which is an acute back strain (Breasted 1930):

Examination. If thou examinest a man having a sprain in a vertebra of his spinal column, thou shouldst say to him: extend now thy two legs and contract them both again. When he extends them both he contracts them both immediately because of the pain he causes in a vertebra of the spinal column in which he suffers.

Diagnosis. Thou shouldst say to him: One having a sprain in the vertebra of his spinal column. An ailment I shall treat.

Treatment. Thou shouldst place him prostrate on his back; thou shouldst make for him...

Edwin Smith 3500 Monografia
Figure 4.1 The oldest surviving description of back pain. The Edwin Smith papyrus (c. 1500 bc). From Breasted (1930), with permission.

At this tantalizing point the unknown Egyptian scribe died and the papyrus lay in his tomb for almost 3500 years. This is an early 20th-century translation that reflects thinking at that time, but the accuracy of the clinical description only adds to our frustration. We do not know what the ancient Egyptians thought about back pain or how they treated it. The ambiguity of the last sentence is particularly frustrating when we look at the recent debate about rest or staying active. From the contemporary evidence, however, it is unlikely this was a prescription of rest. It is more likely to have been the start of some form of local application or manual therapy.

The Corpus Hippocraticus (c. 400 bc) was the collected writings of the Greek library at Cos and Cnidus. It included reports of spinal deformities and fractures, and described pain in the back in that context. Back pain itself received little attention.

The writings of Galen (c. 150 ad) and his disciples dominated medicine for the next 1200 years. Galen thought that disease was due to disturbed "humors" and treatment was empiric. Back pain was a symptom of many illnesses but also one of the "fleeting" pains affecting joints and muscles. Treatment was symptomatic with spas, soothing local applications, and counterirritants. Galen was the original source of the oft-repeated saying that "The physician is but nature's assistant."

When the Graeco-Roman empire fell, exiled Christians took medical learning to Persia. The Arab world preserved that knowledge and reintroduced it to Europe after the Dark Ages, but Islamic laws largely limited them to the preservation of the ancient writings. Medical thought almost ceased during the Dark Ages as patient care moved into the hands of the church. Monks saved the ancient writings but only in degenerate forms. Back pain was a matter for folk medicine. The Welsh "shot of the elf" and the German "witch's shot" reflected beliefs that pain was due to external influences.

Modern western medicine began with the European Renaissance. The scientific method used careful observation to unlock nature's secrets by the power of human reason rather than by religious revelation. Studies of anatomy, physiology, and pathology laid the foundation. Paracelsus (14931541) rebelled against the ancient writings and began clinical freedom by treating each patient on the basis of his own observation and diagnosis. Sydenham (1624-1689) made a clear distinction between illness and underlying disease and introduced our present concept of clinical syndromes. They should be "reduced to certain and determinate kinds with the same exactness as we see it done by botanic writers in the treatises of plants." Diagnosis depends on "certain distinguishing signs, which Nature has particularly affixed to every species." Sydenham classified back pain or lumbago with the rheumatic diseases. The word rheumatism came from the Greek rheuma, a watery discharge or evil humor that flowed from the brain to cause pain in the joints or other parts of the body.

Modern use of the term rheumatism started in the 17th century. At that time it included what we now recognize as many musculoskeletal disorders ranging from acute rheumatic fever to arthritis. The only common feature was pain in the joints or muscles. Doctors at that time thought that rheumatism was due to cold and damp. They did not relate it to trauma. Gradually, different workers identified a number of diseases within this group. Sydenham, who himself suffered from gout, distinguished gout from acute rheumatism and described lumbago as a third form of rheumatism.

By 1800, physicians began to look for the cause of back pain. They suggested that it was due to a buildup of rheumatic phlegm in the muscles, so they used both local and systemic treatment to remove the phlegm. Scudamore (1816) published the first systematic treatise on chronic rheumatism. He blamed inflammation of the white fibrous tissue of the body "unaccompanied by fever but aggravated by motion." The inflammation was attributed to cold and damp. Through the 19th century, treatment of back pain was by general measures against rheumatism such as relief of constipation, counterirritants, blistering, and cupping. The theory was to remove the rheumatic exudi from the affected area, and surgeons removed septic foci in the teeth, toenails, and bowel.

Two key ideas in the 19th century laid the foundations for our modern approach to back pain: that it comes from the spine and that it is due to trauma. In 1828 a physician called Brown in Glasgow Royal Infirmary published a paper on spinal irritation (Fig. 4.2). Brown suggested for the first time that the vertebral column and the nervous system could be the source of back pain. He also described local spinal tenderness. The concept of spinal irritation swept the US and Europe, and held sway for nearly 30 years. For a time, nervous "irritability" got a kind of false legitimacy because it was compared with inflammation. However, inflammation was a local condition with objective features; irritation was only a hypothesis based on distant, subjective complaints. The concept of spinal irritation had a profound influence. Neither Brown nor his followers ever demonstrated its pathology and the diagnosis gradually fell into disrepute. But spinal irritation introduced the idea that the spine is the source of back pain; and the idea that a painful spine must somehow be irritable lingers in our thinking to this day.

It is difficult for us to believe that all through history neither doctors nor patients thought that back pain was due to injury. This idea only came in the latter half of the 19th century. The industrial revolution, and particularly the building of the railways, led to a spate of serious injuries. Violent trauma could cause spinal fractures and paralysis, so perhaps less serious injuries to the spine might be the cause of lumbago. There might be cumulative or repetitive trauma. Some people even thought the speed and nature of railway travel could damage human health.

Erichsen (1866) described what he called railway spine (Fig. 4.3; Keller & Chappell 1996). He suggested that severe jarring or shaking of the spine and nervous system could disturb spinal cord

Figure 4.2 Spinal irritation. The copperplate minutes of Brown's original presentation to the Glasgow Medical Society in January 1923. With thanks to the Royal College of Physicians and Surgeons of Glasgow.



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Figure 4.3 Erichsen's classic description of railway spine. With thanks to the Royal College of Physicians and Surgeons of Glasgow.

function, and compared it to disturbed mental function after concussion of the brain. It might be a form of molecular derangement, so was impossible to demonstrate. Alternatively, there might be an insidious and even more ominous disorder. A slight blow to the spine could lead to meningitis or myelitis with back pain, motor or sensory disturbance in the arms or legs, and mental symptoms of confusion and lassitude. Railway spine was a syndrome of subjective weakness and disability. As you might expect, no one ever confirmed its pathology and this diagnosis also eventually fell into disrepute. Railway spine, like spinal irritation, was a key act in this story that we will see again. Suffice to say that, for the first time, it linked back pain to trauma. Most health professionals and patients still regard back pain as an injury.

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