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Medical Wellness Archives

The Basics of Back Pain Evaluation and Treatment

2004: Volume 1, Number 1


Craig Steingraber, DC


Back pain is the second most common patient complaint in general medical practice. (1) Leading researchers state that up to 80 percent of patients who see physicians for back pain have conditions for which no physiological or organic cause is found through routine investigation. (2,3) Further, since back pain has a well-documented negative impact on society, there is a critical need for a deeper understanding of the most probable causes, treatments, and prevention.

Identifying Functional Deficits
Most back pain patients need to improve functional deficits of the neuromusculoskeletal system. Although this includes those individuals with structural deficits found through advanced imaging, it is documented in respected literature that structural changes in the back are not the primary
cause of back pain. (4,5) With this in mind, we will discuss the components of functional deficits in the neuromusculoskeletal system. Waddell (6) states that neuromusculoskeletal dysfunction has many components including:

  • Abnormalities of posture

  • Abnormalities of joint movement

  • Acute joint locking

  • Muscular dysfunction

  • Fatigue

  • Weakness

  • Tension

  • Reflex muscle spasm

  • Connective tissue (fascia, ligament, joint capsule, muscle)

  • Adhesions

  • Scarring

  • Trigger points

  • Fibrositis

  • Neuromuscular dysfunction

  • Muscle imbalance

  • Abnormal patterns of movement

  • Altered proprioceptor and nociceptor input and neurophysiologic processing

These alterations are caused, simply, by gravity. However, factors such as poor diet, lack of appropriate exercise, psychosocial behaviors, and constrained postures can contribute to developing this dysfunction.  In some cases, developmental changes such as a structural short leg or pes planus can contribute as well.

Waddell states that a more complete approach to rehabilitating neuromusculoskeletal dysfunction is to evaluate each component, analyze how it relates to, affects—and is affected by—the others, and in most cases, treat them as one compound component.

Improving Function
First, a proper evaluation based on symptoms, pattern, and history will rule out structural abnormalities, identify functional deficits, and any contraindications to the proposed protocols. Then, an appropriate combination of the following interventions are more likely to improve function of affected anatomical components and relieve back pain successfully:

Chiropractic manipulation, specifically high-velocity/low-amplitude thrust, is been highly effective in stretching the soft tissue attached to the spinal joint complex and improving flexibility in that soft tissue.

Massage techniques, stretching, injections into the muscle belly, or other physical medicine techniques can be effective in reducing adhesions in other muscle groups. Once these applications have been introduced at the correct frequency and duration, the next phase of rehabilitation can begin.

Exercise and balance work—ideally with instruction from a specialist— can improve nervous system function, which, in turn, produces additional beneficial sensorimotor reflexes.

Patient Education Is Important
Educating the patient about proper diet, exercise, posture, and movement is an important part of the overall rehabilitation and management process. I


In addition, periodic checkups to detect returning loss of joint play, soft tissue adhesions, and altered movement patterns may be beneficial for fighting any negative anatomical soft tissue changes and nervous system responses to the strains of daily life. Ultimately, it is important for the patient to learn how to access well-trained specialists to implement the evaluative and therapeutic processes of the components of back pain.

Use an Interdisciplinary Approach
Ultimately, the primary health care provider must be able to identify the member of the health care team who is most qualified to evaluate and analyze all components of back pain. Back pain is a complex condition involving not only neuromusculoskeletal elements, but also psychosocial and occupational practices that influence treatment approaches and outcomes. Each case should be evaluated using all clinical elements, and an appropriate treatment team recommended. This team may include chiropractors, ergonomic/occupational specialists, neurologists, massage therapists, and/or acupuncture practitioners.

To facilitate this interdisciplinary approach further, employers or other payers should consider offering expanded benefits packages that include complementary care in addition to conventional approaches for back pain. This will allow each discipline to focus on those components of the patient’s back pain that are best served by its particular specialty. The common goal of the entire team is to return the patient to normal, pain-free function, with the least possible likelihood of recurrence of symptoms.


1. Vlahos K, Broadhurst NA et al. Knowledge of Musculoskeletal Medicine at Undergraduate and Postgraduate Levels, Australian Musculoskeletal Medicine, May 2002: 28-32.
2. Wilson IB, Cleary PD. Journal of the American Medical Association. 1995; Jan 4: 59-65.
3. Deyo RA. Low Back Pain. Scientific American. 1998; August: 48-53.
4. Stadnik, et al. Radiology. 1998; 206:49-55.
5. Wiesel MD. Spine. 1984;9(6):49-51.
6. Waddell G. The Back Pain Revolution. Churchill Livingstone. 1998.


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