The Basics of Back Pain
Evaluation and Treatment
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:
of joint movement
tissue (fascia, ligament, joint capsule,
patterns of movement
proprioceptor and nociceptor input and
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
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
ABNORMALITIES OF JOINT MOVEMENT
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
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
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
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
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
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.