Low back strains.
Subject: Exercise (Physiological aspects)
Low back pain (Care and treatment)
Low back pain (Research)
Author: MacDonald, Allan
Pub Date: 11/01/2010
Publication: Name: New Zealand Journal of Physiotherapy Publisher: New Zealand Society of Physiotherapists Audience: Academic Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2010 New Zealand Society of Physiotherapists ISSN: 0303-7193
Issue: Date: Nov, 2010 Source Volume: 38 Source Issue: 3
Topic: Event Code: 310 Science & research
Geographic: Geographic Scope: New Zealand Geographic Code: 8NEWZ New Zealand
Accession Number: 263880351
Full Text: A low back strain, myo-fascial or ligamentous, is one of the commonest injuries of the back. An acute postero-lateral prolapse of a low lumbar intervertebral disc is relatively rare. Yet is has become commonplace for the public and the profession lazily to label them all with the one glib phrase of a "slipped disc". This is a diagnosis which is often fear-inspiring and psychologically damaging to the patient. It may bring temporary mana to the doctor for his alleged ability to make a quick diagnosis, even if a wrong one, and possibly benefit his reputation because the strained back, which it has been all along, gets better in a few days or a few weeks, as it nearly always does, provided that it is not over treated. A truly prolapsed disc all too often does not.

Muscle strains are found with great frequency near all the joints of the extremities. They vary from the rupture of a few fibres, as in the pulled hamstring of the footballer, and the partial tear of the gastrocnemius or the tennis elbow to the more serious frank tendon and muscle ruptures in the rotator cuff of the shoulder, the arms and the leg. Yet some doctors appear to believe that they do not occur in the low back, where the greatest muscular strains in the body are centred, or, at all events, to gloss over their common occurrence there. Ligamentous sprains of almost all of the peripheral joints are well recognised and treated for the most part successfully by strapping in a relaxed position or by splinting them in various ways until they have healed themselves in nature's own good time. The same lesions occur in the low back. The signs and symptoms are the same, and so, too, should be the treatment. When a patient sprains his ankle badly he feels immediate pain, followed a little later by stiffening of the joint, which is held in an abnormal position by muscle spasm and which hurts him when he walks on it. Under proper treatment it clears up in from ten days to three weeks' time. So, too, when he hurts his back he feels the same pain, usually more severely because larger joints and muscles are involved. His back stiffens up in just the same way and for the same reason as in the ankle--namely, to hold the affected area in as relaxed--and, therefore, as comfortable--a position as can be obtained. Hence the scoliosis or sciatic list, which does not, of itself alone, prove the presence of a prolapsed disc, but only that of low back strain. Much more certain signs of nerve-root pressure must be elicited before the term "slipped disc" can truthfully be allowed to slip out. A pain down the buttock or the back of the thigh is not sciatica from nerve-root pressure but merely a referred pain from a low back joint injury, in exactly the same way that pain about the region of the deltoid insertion is a referred pain in the case of a shoulder injury, and not a brachial neuritis from a cervical disc protrusion.

How do you treat torn muscles and ligaments in arms and legs? Do you keep manipulating them and tearing them apart, or do you put them on racks and stretch them apart? Surely you treat them all by resting the strained or partially torn part, in one way or another, in as much relaxation as you can get, until you believe that it will have had time to join up sufficiently strongly, and only then do you start to mobilise it and, if necessary, to redevelop weakened muscles with exercises. Rest, sedation and, perhaps, mild warmth, are still the sheet anchors of the successful treatment of low back strain in its early stages, though heat may, because of the vasodilation it produces, temporarily increase local swelling and so make the pain worse, in which case it should be stopped. There is absolutely no inherent healing power in infra-red or diathermy, and surely none in ultra-sonic radiation. The humble hot-water bottle, one-quarter filled, is still a worthwhile bed-fellow in the acute stage, but the ray lamp may certainly prove handy. As healing progresses acute symptoms will subside, and when they have abated is the time to start gentle active exercises. Really light massage to back and buttocks--and I emphasise the word "light"-is, in my opinion, helpful to the patient; but any sort of deep massage, kneading or rolling causes totally unnecessary suffering, and may well be harmful. The return to full activity must not be too hurried. Muscles waste in a few days after a strain, but take many days--perhaps weeks-to recover. They must not be rushed. Many of our physiotherapists, especially the younger ones, tend to try to take their patients along far too quickly, with the result that they relapse. Exercises must be carefully graduated in type and in vigour. Above all, do not manipulate these backs and tear them apart when they are bravely trying to join themselves up. That is one of the ways in which an initial simple acute back strain, misdiagnosed as a "slipped disc", can be turned into a chronic back strain, and a normal patient into a neurasthenic.

Discs may certainly be injured in any low back strain, but unless there are unequivocal signs of nerve-root irritation or compression they have not prolapsed. Then why call them "slipped discs"? To the lay mind, a disc which has slipped out should, theoretically, be capable of being made to slip in again, and this, they are often told nowadays by the soi disant specialists in manipulative surgery, can be made to happen. Those of us, however, who have operated upon and removed prolapsed and sequestrated discs usually find that they are so jammed in position that it is obvious that no power on earth could induce them, by manipulation alone, to go back into their original home in the inter-vertebral joint. They must either stay where they are, lying in uneasy apposition with the nerve root in a narrow bony channel, and wait there until they gradually shrink and so relieve the pressure, or they must be removed surgically. It is probably true that a bulging disc which has not yet burst out completely free may be induced to retract itself during a passive manipulation with or without anaesthesia, but the big -and, I believe, unjustifiable-risk is that the two vertebral bodies, instead of opening up, may come together on the side of the protrusion and do the reverse, nipping the disk free and pushing it out to remain forever sequestrated and a permanent danger to adjacent nerve roots. Once this has happened, the disc is diminished from actual loss of substance, and degenerative changes in it in the future are assured. I just do not believe that anyone can be so omniscient as to be able to tell by a conscious patient's reaction whether any such manipulation is moving in a safe direction or in a dangerous one.

Manipulation of the back for certain complaints localised to it is occasionally a shortcut in treatment and is often undoubtedly beneficial. It is simple and can be done by anyone, but it should be used only in cases deemed suitable by a surgeon of considerable experience, and it should never be done by physiotherapists, unless they have been definitely instructed to do so in a specific case by someone with sufficient knowledge and experience. There are no secrets in how to do it: the only secret is to know when to do it. It is being used far too widely. So uncontrolled has the enthusiasm for manipulation waxed of late that I have actually had an old gentleman of 67 years, bent up with a simple osteoarthritic spine, who had been seized upon by one such enthusiast, manipulated by him by the passive back-to-back method and then, because the pain was not getting better, put on the rack to have his spine stretched. That is an extreme case, as is also the case of the lady in her fifties, treated by a medical practitioner for pains about the left side of her chest by passive manipulation of the dorsal spine, which completely tore the rotator cuff muscles in her left shoulder, but left her angina pains unaltered. The fetish of manipulation has, I believe, gone too far.

Finally, I want to condemn completely a treatment by the injection of a sclerosing fluid, which I heard advocated at a recent general practitioner conference held at Auckland. It would appear that the solution is injected into the interspinous ligaments of the low lumbar spine with the intention of inducing the production of fibrous issue and tightening up "mobile joints". I cannot think of anything which has a less rational basis to commend it, or is fraught with more possible danger. The best that it could do would be to make scar tissue, and scar tissue is our enemy and not our friend. It will contract at first, as it always does, but it will inevitably stretch later on, and, when it does, any laxity which was present before will still be present with the irritation of the scar tissue superadded to it. An injection of a sclerosing solution in this area, ill-judged either as to depth or direction, could give results too dire to bear thinking of.

In conclusion, I suggest again that the phrase "slipped disc" should be avoided in all cases other than those in which it has eventually become reasonable to make a diagnosis of a clear-cut prolapse with acute pain below the knee, an acutely positive Lasegine test and some definite changes in sensation motor power or reflexes in addition to the low back signs. Nearly all cases, for a start at all events, can be fairly called low back strains, a phrase which is not fear-provoking and is just as easily understood by the patient. The majority of them are just that and no more.

By Allan MacDonald (Auckland)

Published in the New Zealand Journal of Physiotherapy, November 1960
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