What is back pain? This question is more complicated than it sounds. Back pain is a recognized entity in health care. Low-back pain is an even more commonly used term. But these labels do not identify the types of pain, the sources of the pain, the persistence or contributing factors of the pain, or any of the myriad variables that influence how a person goes from feeling healthy and strong to feeling weak, fearful, and protective of their back. “Back pain” doesn’t delineate between muscle spasm, ligament sprain, osteophytes putting pressure on nerve roots, cracked bones, or bulging discs.
Furthermore, enormous controversy exists over what truly contributes to back pain or back injury. Traditional posture-related recommendations and ergonomic guidelines might not be as helpful as we thought. Small wonder then, that most research about treatment options for back pain are inconclusive.
A rich discussion that has recently entered the world of manual therapies explores the distinction between biomedical causes of pain (specific structural entities that damage tissues) and a biopsychosocial model of pain that suggests pain is a response—not a stimulus—and that response is informed by many factors, including tissue damage, stress, personal history, social settings, and a host of other variables.
This becomes especially interesting in the context of back pain: a condition that affects most American adults at some point and a situation that drives many people to seek massage therapy. Sometimes this happens at the beginning of a journey toward wellness, and sometimes massage becomes a last resort when all other options have failed.
This column focuses on a small part of the broad spectrum of potential contributors to back pain: bone-related problems. We will look at a couple types of inflammation (spondylosis and ankylosing spondylitis) and a bony anomaly (spondylolisthesis). This is not meant to be a comprehensive discussion of all the contributors to back pain; it leaves out disc and ligamentous injuries, for starters, and we won’t consider postural issues. Further, it is important to remember that while tissue damage can initiate pain, for many people chronic pain is less related to a structural problem than it is to other pain-promoting factors like anxiety, depression, social support, eating and sleeping habits, exercise, and many others. This understanding has big implications for treatment options.
Anatomy Review
Readers will remember that the vertebrae are irregularly shaped bones with about a bazillion special landmarks. Each vertebra forms both synovial joints and cartilaginous joints with the vertebrae above and below. The cartilaginous joints between vertebral bodies are formed around intervertebral discs: complex structures that help us adapt to vertical, twisting, and shearing forces on the spine. The synovial joints join the postero-lateral aspects of the vertebrae at surfaces called facets. Additional synovial joints connect each thoracic vertebra to a pair of ribs.
Many ligaments help to stabilize the vertebrae to allow a wide range of motion without danger of nerve damage. Most of the spinal ligaments are short, running from spinous to spinous process, or from transverse to transverse process. However, three long ligaments help stabilize the spine on its vertical axis. They are the anterior longitudinal ligament, which runs up the anterior side of the vertebral bodies; the posterior longitudinal ligament, which runs along the posterior aspect of the vertebral bodies, on the anterior side of the vertebral canal; and the ligamentum flavum, which also runs inside the vertebral canal, on the posterior aspect.
Together, the bones, discs, and connecting ligaments give our spine tremendous adaptability: we can jump, twist, flex, extend, torque, and roll without damaging our spinal cord. However, it is possible for things to go wrong. When that happens, some of the consequences include the following conditions.
Spondylosis
Spondylosis is a form of degenerative arthritis. It involves age-related changes in the vertebrae, as well as the discs, joints, and ligaments of the spine. Unlike many other spinal conditions, spondylosis tends to impact the neck more than the low back. Neck pain is common, but while the majority of people over 60 years old have some indication of spondylosis, this condition is not always associated with pain.
Spondylosis has two features that distinguish it from other forms of degenerative arthritis: bone spurs and ossification of the longitudinal spinal ligaments.
• Bone spurs or osteophytes are common signs of spondylosis. These protrusions usually grow on the anterior or lateral aspects of the cervical vertebral bodies (where they may never produce symptoms), but they can also grow on facets or near enough to the transverse foramina to put pressure on nerve roots where they exit the spine.
• Diffuse idiopathic skeletal hyperostosis (DISH) is a situation in which the anterior longitudinal ligament, the posterior longitudinal ligament, and the ligamentum flavum can become thickened, calcified, or even buckled with age. When these ligaments degenerate, two problems can develop: progressive, painless loss of range of motion and impingement of the nerves, spinal cord, and/or blood supply to the central nervous system.
Spondylosis may not have major symptoms outside of a progressive loss of range of motion. When symptoms are present, they are related to bone spurs or DISH putting mechanical pressure on the spinal cord or nerve roots. Nerve root irritation leads to numbness, tingling, pins and needles, and muscle weakness on the affected side. Spondylitic myelopathy—spinal cord damage from spondylosis—is an especially alarming possibility; this may be marked by bilateral nerve symptoms, loss of balance, trouble with walking, and loss of bowel or bladder control. Left untreated, it could lead to paralysis.
Spondylitis
Spondylitis is technically “inflammation of the spine,” but this term is usually reserved for a group of autoimmune conditions, the most common of which is called ankylosing spondylitis (AS).
Ankylosing means “stiffening.” Ankylosing spondylitis usually starts with an acute inflammatory episode at one or both sacroiliac joints, and then moves upward with episodes of flare and remission. In its wake, the vertebrae, cartilage, ligaments, and even nearby tendons ossify and fuse together. Further, the spine may fuse in a flexed position. The ribs may fuse with the vertebrae, resulting in a locked rib cage and a high risk of fractures, pneumonia, and heart failure. In rare cases, this process may also affect joints of the axial skeleton.
AS usually starts as an experience of low-back pain. It is often confused for disc injuries or spondylosis in early stages. Each episode leaves permanent damage behind as the disease progresses up the spine.
Spondylolisthesis
Spondylolisthesis (say that three times fast!) is a condition in which the pars interarticularis, which is the anterior portion of the lamina, degrades. This allows the vertebral body to slip forward, while the posterior part of the vertebral arch stays in place. Spondylolisthesis usually happens in the lumbar spine, where the intervertebral facet joints are on a coronal plane.
Several different types of spondylolisthesis have been identified:
• Congenital spondylolisthesis occurs when a person’s lumbar facet joints are not vertical enough to prevent slippage.
• Isthmic spondylolisthesis happens when the pars interarticularis is weak and activity causes multiple microfractures. This type is usually seen in athletic adolescents.
• Degenerative spondylolisthesis is the most common type in adults. In this case, the pars may be fine, but thinning discs and arthritis at the facets allow the vertebrae to shift anteriorly, stretching the joint capsules.
• Traumatic or pathologic spondylolisthesis occurs when an accident or a situation like cancer or infection damages the affected vertebrae at the pars interarticularis.
Spondylolisthesis occurs on a continuum of severity, so mild cases may not present major symptoms, but more severe cases may create serious complications. Most patients with mild to moderate slippage experience central low-back pain, tight hamstrings, muscle spasms, and possible pain radiating into the leg. More severe cases can compress the distal end of the spinal canal, where the extensions from the spinal cord, resembling a horse’s tail, may be injured. This is called cauda equine syndrome, and it can cause long-term problems with bladder and bowel control as well as many other problems.
Typical Treatment Options
When we consider the fact that most adults will experience back pain at some point, and many will be temporarily or permanently limited by this problem, it is surprising that we have so few possible interventions, and many of those interventions are, overall, not well supported by research.
Noninvasive options for managing back pain include medication, physical therapy, and other manual therapies, including chiropractic and massage. Medication, ranging from NSAIDs to opioids, tends to be effective in reducing the severity of pain, but the risks and possible complications make their long-term use problematic. Manual therapies vary in their effectiveness, but large-scale comparative effectiveness studies suggest low levels of evidence for most interventions, especially when compared to placebo or no intervention. Carefully gauged exercise (at a level that a client can and will do reliably) is an outlier here: pain-free movement is consistently helpful for back pain—if a person can get to the point of being able to engage in this kind of activity.
Surgery is reserved for cases that do not respond to other interventions. It can range from implanting pain management devices to procedures designed to restore adequate space for the spine or spinal nerves to full spinal fusions. Frustratingly, the research on spinal surgery effectiveness for back pain has the same limitations as research for other interventions: because back pain varies so greatly from one case to another, it is difficult to predict whether surgery is likely to be successful for an individual just from looking at the data. Overall, the effectiveness of some spinal surgeries does not appear to be dependable; spinal fusions in particular do not show long-term outcomes substantially better than other interventions.
Massage Therapy for Back Pain?
As we have seen, back pain is one of those conditions that defies expectations. It is notoriously difficult to study, and many studies conclude that most treatments are not substantially better than doing nothing over the long term. “Doing nothing” is not always a viable option, however, especially for people who need relief in the short and medium term. (See “Some Relief” at left.)
Back pain is also a difficult condition to study because its precipitators and perpetuating factors may vary greatly from one person to another. One person’s back pain may be specifically tied to a structural anomaly in their lumbar vertebrae; another person’s problem may be related to an initial injury that has subsided, but other pain-promoting factors have not. Each of these individuals may have similar symptoms, but they need different treatment approaches. Massage therapists who specialize in working with clients who have back pain need to be ready to approach it from multiple perspectives: the biomechanical approach that looks for structural problems that may be resolved, but also the biopsychosocial approach that addresses the behaviors and other factors that can contribute to pain.
Since we see that establishing and maintaining pain-free movement is a high priority for almost all people with back pain, it makes sense to think about massage therapy as an adjunct to this goal. The massage itself may or may not have long-lasting impact on the experience of pain, but if massage can help a person be more physically active, then the long-term outcomes are much more likely to be positive.
As with other chronic-pain issues, massage therapists in this situation will set up the best chances for success if they:
1. Work as part of an integrated team with the client’s other health-care providers. This allows them to support what happens for the client in physical therapy, to make appropriate accommodations for medications, or to help prepare for, or recover from, surgery if that becomes necessary.
2. Acknowledge that pain is probably related to both a biomechanical trigger and biopsychosocial factors that prolong it. We can address this through massage by looking at whole-person strategies that offer pain relief, support, and empowerment to the client.
3. Help clients identify specific goals. Maybe it’s to reduce morning pain from a 5/10 to a 2/10. Maybe it’s to be able to play nine holes of golf. Maybe it’s to be able to attend dance classes, or hike five miles, or work in the garden for an hour or two. Client-led functional outcomes help to create a partnership so both clients and therapists are working toward the same objectives.
4. Track progress toward those goals so clients and therapists can determine whether the massage therapy is effective. Then, be prepared to change course if it’s not working.
And the final thing massage therapists can do to improve outcomes and serve both their clients and their profession: share their observations in case reports and let us know what works. I will look forward to reading them.
Ruth Werner, BCTMB, is a former massage therapist, a writer, and an NCBTMB-approved provider of continuing education. She wrote A Massage Therapist’s Guide to Pathology (Lippincott Williams & Wilkins, 2016), now in its sixth edition, which is used in massage schools worldwide. Werner is available at www.ruthwerner.com.
Resources
Chou, R., et al. “Noninvasive Treatments for Low Back Pain.” Comparative Effectiveness Review No. 169. Cochrane Database System Review 1, no. 9 (September 2015). Accessed July 2016. www.ncbi.nlm.nih.gov/pubmed/26329399.
Furlan, K., and L. S. Wieland. “Massage for Low-back Pain.” Explore (NY) 12, no. 3 (May–June 2016): 215–7. Accessed July 2016. www.ncbi.nlm.nih.gov/pubmed/27033320.
Hedlund, R., et al. “The Long-Term Outcome of Lumbar Fusion in the Swedish Lumbar Spine Study.” Spine Journal 16, no. 5 (May 2016): 579–87. Accessed July 2016. www.ncbi.nlm.nih.gov/pubmed/26363250.
Menke, J. “Do Manual Therapies Help Low Back Pain?: A Comparative Effectiveness Meta-Analysis.” Spine Journal 39, no. 7 (January 2014): 463–72. Accessed July 2016. www.researchgate.net/publication/259988037_Do_Manual_Therapies_Help_Low_Back_Pain_A_Comparative_Effectiveness_Meta-Analysis.