Principles of Osteopathy
4th Edition
Dain L. Tasker, D. O.

CHAPTER XV - The Diagnostic Value of Backache

    Elasticity. - It is frequently said that "a man is as old as his arteries." It may with equal significance be said that a man is as old as his spinal column.  In either case a loss of elasticity lessens one's youthfulness out of all proportion to one's actual years.

    A Field for Study. - The use of the back and the spinal column as a field for initiating an effort to diagnose the physical condition of human beings, has many advantages, both for eliciting objective and subjective information.  Probably few physicians realize how much of physical distress is mirrored in symptoms consciously or unconsciously referred to the back.

    Objective and Subjective Symptoms. - In order that we may have something for reference we will pass a few facts in review.  As diagnosticians we are always desirous of knowing whether the structure of the back is normal and whether there is any distress, i. e., pain of any character, in the tissues of the back.  Here we have the old division of objective and subjective symptoms.

    Pain. - Pain is the symptom which usually leads a patient to seek relief or advice, hence we are interested in seeking the cause of the pain.  The simplest possible cause of the pain should naturally be the first thing considered.  Since many localized peripheral and visceral pains either are caused by conditions in the structures of the back, or at least reflexly produce areas of associated hyperaesthesia there, we seek to discover what structural fault or referred sensitiveness may exist.

    Poise. - The first observation should be addressed to determining the poise of the body, i. e., statics.  It is very important to note the poise of the body.  There are many deviations from normal which are only slightly apparent but nevertheless give rise to bodily distress.  Postural faults in adults lead to distress due to fatigue of the tissues and as the bones are not plastic, pain is felt.  The child's bones are plastic, hence the same force that produces distress in mature persons causes structural distortion in children, i. e., the static conditions which in children produce spinal deformity produce in mature persons spinal distress.

    Structural Defects. - Pain in the back is of such frequent occurrence that it is advisable for us to consider some of the general and special conditions which may be more or less characterized by backache.  Since we are exponents of a system of corrective manipulation we naturally look first for possible structural defects.  The simplest structural defect would be a bad posture with its consequent imbalance in the muscle groups which maintain the body erect.

    Statics. - 1. Statics.  Under this head we must consider backache as a possible result of any change in structural support.  The muscles of the back must compensate, by altered tension, for any change in the length of a leg, such as that present in flat-foot, slightly flexed knee, knock-knee, or a sacro-iliac lesion.  The pain due to flat-foot is one of the most common complaints.  Many cases of so-called "innominate lesions" are nothing more than backache caused by the effort to compensate for a weak arch.  Manipulation of the muscles of the back gives relief but does not remove the cause.  The longer such a condition exists, i. e., flat-foot, the more widespread will be the back pains.  Segments above the lumbar are gradually involved until it is hard to recognize where the vicious cycle began.  Backache due to disturbed statics is a fatigue pain, i. e., is evidence of tired muscles or strained ligaments.  All such backaches are relieved by manipulation.  They disappear under the influence of tonic exercise, such as mountain climbing, because the unevenness of the ground necessitates constant variation in muscular tension.  Walking on pavement rapidly produces fatigue, because each movement is a replica of the preceding one.

    General Debility. - General debility may lead to static errors with consequent distress.  Many static errors make their appearance during a slow convalescence and then persist in spite of improved muscle tone; in fact are never recognized until such time as they force special attention because of the distress they cause.

    Sacro-iliac Subluxation. - Since backache is one of the most prominent symptoms in cases of sacroiliac subluxation, no examination would be complete without taking the possibility of such a lesion under consideration.

    Spinal Rotation. - Practically all static conditions of long standing are characterized by slight spinal rotation.  This is the natural result of the body's effort to transmit its weight through its strongest side.  This compensatory rotation can not be corrected without taking into consideration that condition for which the rotation is itself a correction.

    Spinal Curvature. - Curvature of the spinal column is not always characterized by local or general backache.  As a general rule structural scolioses are not painful.  This is probably because the shape of the bones has become adapted to the weight of the body in the new position.  Pain is apt to be associated with a functional curve, because such a curve puts muscles and ligaments on a stretch.  As the bones and intervertebral discs gradually yield to the unequal pressure of a functional curve, rotation takes place, according to the laws which govern rotation in the dorsal and lumbar regions, and a compensatory condition results, which we recognize as a right dorsal left lumbar scoliosis, or the reverse.

    Caries. - 2.  Actual disease of vertebrae may be the cause of backache.  Such a condition is usually a localized caries due to tuberculosis.  Caries is characterized by angular deformity, great sensitiveness to digital pressure and especially to vertical pressure; i. e., any addition to the weight of the body above the involved vertebrae.  Localized backache associated with a prominent spinous process and sensitiveness to vertical pressure should be sufficient to cause any physician to suspicion the existence of caries.

    Rigidity. - Even these conditions without apparent deformity should make one hesitate before using any leverage through that area.  One of the characteristics of localized backache in disease of the structure of the spinal column is rigidity, i. e., the body protects itself by muscular tension sufficient to limit or prevent movement in the inflamed area.  Whenever this protective phenomenon is observed it should be a warning against interference, until one is convinced that more is to be gained than lost by interfering with nature's protective mechanism.

    Arthropathies. - Cases of paresis and tabes dorsalis are subject to arthropathies and hence heavy manipulation, of a leverage or thrusting type, should be avoided.  There is danger that an arthropathy may exist, and as such conditions are not characterized by pain, the normal protective mechanism does not assert itself.  Fig. 135 shows an angular deformity in a case of paresis.  The deformity was caused by severe manipulation by one who had no knowledge of pathology or, in fact, any of the basic medical sciences.  This woman had a comparatively straight spinal column which exhibited some stiffness and sensitiveness, eighth to twelfth dorsal.  The woman was placed on her back, knees doubled under her chin, then rolled on to her shoulders and a heavy downward thrust given so as to strongly flex the lower dorsal.  The sharp kyphosis was instantly produced, with resulting pressure on the spinal cord.

    Spondylitis Deformans. - A general posterior curve with ankylosis, or diminished flexibility, thickened spinous processes, tenderness to digital pressure, localized pains, not markedly sensitive to vertical pressure, is recognized as spondylitis deformans.  Other joints of the body are usually similarly affected.

    Rachitis. - The changes due to malnutrition, rachitis, are frequently recognized.  The fact that changes elsewhere are apt to more positively indicate the previous existence of rachitis makes diagnosis comparatively easy.

    Malignant Growths. - When localized backache is complained of and no deformity is evident, thorough tests should be made to determine the effects of positions and movements.  The protective contraction of the muscles should be carefully analyzed, so as to judge whether the pain is due to any inflammatory process involving the vertebrae, or any of their joints.  Nearly all pains in the lumbar region are called "lumbago," but one must always be on guard lest a persistent lumbago-like pain be not given its true value.  Pains of a sharp, lancinating character which persistently appear in a definite spinal area or along nerve trunks originating from that area, usually have a sinister significance.  A definite diagnosis is practically impossible, but the persistence of the pains, in spite of all efforts to relieve with heat, positions of rest, or manipulations, is pretty good evidence that some malignant process is at work which involves these spinal tissues.  If no fever exists, or other constitutional sign, it may be that the pain is due involvement of the spinal column by a growth within the body.  As example, a man, 44 years old, complained bitterly of sharp lancinating pains in the lumbar region and extending down branches of the lumbar and sacral plexuses.  All efforts at relief were unavailing.  There was no deformity of the spinal column, but the patient held himself rigid.  Many attempts were made by many physicians to make a diagnosis.  One of them used heavy manipulation of a leverage character.  In order to test the effect of vertical pressure he used a concussing blow on the top of the head and then on the heels.  This latter produced agonizing pain which was followed rapidly by paraplegia.  The case ran a tedious course of many months.  Autopsy showed cancer involving left kidney and the spinal area under it.  The progress of the disease was exceedingly slow and hence his body was able to bring many compensatory mechanisms into action, which made it difficult for even the most skillful to recognize the true condition.

    Typhoid Spine. - The so-called "typhoid spine" is another form of spinal trouble, without deformity, which may be a spondylitis but probably is a pure neurosis.

    Lumbago. -  3.  Under this head we may collect a variety of conditions which are characterized by pain which is particularly aggravated by voluntary movement.  It is ofttimes difficult to determine what the structural change is which gives rise to this pain.  Each case will show peculiarities as to the exact location of the pain and the amount of possible voluntary movement.  There may be involvement of muscle, ligament, fascia, or periosteum.  The cause of the trouble may be fatigue as result of posture, strain from lifting, or may be due to a toxemia.

    Posture. - Backache, due to posture, is commonly produced in any one who attempts to do work which compels bending of the back forward.  Until such time as the individual develops adaptation to this position there will be sensitiveness at those points in the spinal column which endure the greatest strain.  The strain thus produced may affect the extensor muscles of the back, or in case the posture is such as puts strain on ligaments, there will be hyperaesthetic points directly on the vertebral spinous processes where the supraspinous ligaments attach.  Backache due to strain is not characterized by fever.  The recumbent position gives relief.

    Toxemia. - Backache due to toxemia is nearly always of sudden appearance.  The fact that the patient first becomes conscious of its existence when some movement is made such as quickly sitting up in bed, or bending forward to pick up something, or putting on clothing, always leads to the belief that the pain is due to strain.  Nearly all such cases show a coated tongue, bad breath, constipation, headache, and general physical depression.  The pain is not necessarily located in the erector spinae muscles.  It is frequently localized around the fifth lumbar spinous process, which is exceedingly sensitive to digital pressure.  There may be some fever in the cases for twenty-four hours.  Thorough catharsis is indicated and usually is followed by rapid decrease in pain.  The pain in most of these cases is only present during voluntary movement.  The physician can usually give quite extensive passive movement without causing severe pain.

    Trauma. - A genuine trauma of the extensor muscles or ligaments of the back usually has enough of positive history to classify it with sprains of other joints.  Rest, heat and gentle manipulation are indicated.  In these cases the protective mechanism heretofore mentioned, that is, muscular tension to prevent movement, is very apparent.  Relief from pain is usually quickly attained by a position of rest which makes no demand on the strained tissues.  There may be localized swelling under the aponeurosis covering the erector spinae.  Fig. 136 shows such a swelling caused by a severe lift.  The patient was a lumber shover.  He was assisting in handling a heavy timber when the greater portion of the weight came suddenly upon him.  Another case, whose back had a swelling of similar character and history of repeated attacks of "lumbago," but no history of trauma, proved to be sarcoma involving both muscle and bone in this area.

    "Crick in the Back." - The so-called "crick in the back" is characterized by a sudden onset and excruciating pain.  It appears to be due to some sudden movement which ordinarily puts no strain upon any tissue.  They are not limited to any particular area of the back, but are as apt to appear in the neck or interscapular area as in the lumbar area.  All such attacks are rather severe during the first day but usually subside under heat and manipulation.  These attacks seem to be associated with a constitutional state and hence tend to recur at certain seasons or under certain conditions of the atmosphere, especially cold, dry, electrical winds.  Although these cases show some signs of indigestion they do not seem to be of the same character as those we have previously mentioned.

    Involvement of the Spinal Cord. 4.  Pain in the back may be due to some involvement of the spinal cord or its membranes.  As a general rule there are enough other symptoms such as motor or sensory phenomena to direct one's attention to the real seat of disease.  The pain in these cases is likely to be symmetrical or at least definitely located with respect to certain spinal nerve trunks.  Furthermore, pain due to involvement of the cord, or its meninges, does not call forth the protective reflexes which are so evident when any structural tissue of the spinal column is involved.  There is no necessity for rigidity to protect supporting tissues. (We are not including spinal meningitis in this group.) When the nerve roots are involved the pain is intense and definitely located.  When the root ganglia are involved we have the well known condition called herpes zoster.

    Infectious Fevers.  5.  Many of the acute infectious fevers are characterized, in part, by severe backache.  Influenza, tonsilitis, smallpox, typhoid, diphtheria and dengue all have severe backaches as an incident in their course.  It is not known what produces the pain in these fevers.

    Referred Visceral Pains.  6.  Probably the great proportion of backaches are referred pains due to involvement of thoracic, abdominal or pelvic viscera.  Attention has already been called to Head's law of referred pain, and to the existence of the receptor fields for sensory impressions for certain segments of the spinal cord.  The intero-ceptive field is an area of low sensibility, so far as our conscious recognition of this field is concerned.  Not all segments of the spinal cord receive sensory fibers from this field, hence visceral reflexes are found only in those portions of the back associated with those segments having intero-ceptive sensory communication.  Disturbances in hollow viscera such as the stomach and intestines are due to overloading the digestive apparatus.  Fatigue and consequent failure of digestion leads to distention with gas, absorption of toxins, faulty elimination.  Distention causes pressure on nerve endings in the walls of the viscera and thus initiates reflex backache.  Exaggeration of physiological activity of the liver, or spleen, causes tension on the capsules of those organs and hence irritation of their sensory nerves with reflex back pains.  The same is true of the kidney.  Disturbances in the blood supply to any organ, such as occurs in arteriosclerosis, or as result of aneurism, usually cause referred pains.  The referred pains that are due to functional fatigue are usually of a somewhat different character from those due to inflammation in visceral organs.  Acute inflammatory states in the viscera give rise in many instances, to cutaneous hypersensitiveness in their segmentally associated areas.  These cutaneous areas are hypersensitive to a slight touch but not especially so to pressure.  States of functional strain and fatigue, whether acute or chronic, are more apt to produce a reflex, in the spinal area, which is characterized by tenderness to pressure over the extensor muscles at some point between the spinous processes of the vertebrae and the angles of the ribs.  Cutaneous and deep tissue hypersensibility may be associated in the same case.  The deep hypersensibility is the more constant form discovered by palpation.

    Inflammation of Serous Membranes. - Wherever the necessity for friction of one organ, or structure, on another is necessary, we find serous tissue in the form of a bursa, tendon, sheath, synovial membrane, tunica vaginalis testis, pleura, pericardium or peritoneum.  Inflammation of a serous membrane is accompanied by muscular fixation of the structures which depend on that membrane for free movement.  This is a protective action required to prevent friction of the inflamed surfaces.  Inflammation of a pleural surface calls forth a protective contraction of all the muscles which are concerned in producing movements which require the co-operation of that pleural surface.  If pleural effusion occurs there is still an increased muscular tension, although not so spasmodic as when no effusion exists.

    Colicy Pain. - Gall stone colic, intestinal colic, renal colic and appendicitis all cause severe reflexes, deep muscular as well as cutaneous, in the areas innervated from the same segments of the cord.  These reflexes are found in areas of greater extent than those properly associated with these visceral structures.  The severity of these colicy pains undoubtedly excites an overflow of stimuli into segments above and below those which directly innervate these structures.

    Summary. - For the purpose of bringing some of the various causes of reflex pain into orderly arrangement we may classify them as follows:

1. Due to functional strain of viscera, e. g., digestion of a very rich meal.

 2. Due to distension of a hollow viscus, or stretching of the fibrous capsule of an organ.

 3. Due to inflammation of the serous investment of a  viscus.

 4. Due to disturbance of circulation in visceral blood vessels caused by disturbed mental condition, or on account of a pathological change in the walls of the arteries, arteriosclerosis.

5. Due to excessive effort to overcome obstruction of the lumen of hollow organs as in spasms of the muscular coats of the intestines, common bile duct, ureter or fallopian tube.

    Pluri-Segmental Control of Viscera. - It should be remembered that, as a general rule, the reflexes due to these causes are not definitely limited in extent, either as to skin areas, or groups of extensor spinal muscles. just as no skin area, or single muscle, other than a rudimentary one of the fifth layer of the back, is completely innervated from a single segment of the cord, we find also that no viscus is wholly controlled by fibers from one segment.

    Reflex Subluxations. - The continuous action of a reflex, such as that due to inflammation of a serous surface, or to long continued functional strain, or to continued circulatory disturbance, usually results in a change in the character of the back, i. e., a certain degree of static alteration takes place as a compensatory adaptation to varying degrees of muscular ankylosis.  This muscular ankylosis is the expression of the visceral reflex.  It produces changes in bony alignment which we recognize as subluxations when only three or four vertebrae are affected; or as curvatures, when greater numbers are involved.

    Intensity of Reaction. - The extent and complexity, or intensity, of a reflex, or coordinated series of reflexes, is not a criterion by which to estimate the extent of pathological change in a viscus or viscera.  Very serious pathological changes may be present in a viscus without producing intense or even determinable spinal reflexes.  These ,changes may have progressed so slowly and involved such small areas that no intense protective reaction was called forth.

    Location of Reflexes. - Based upon clinical and experimental observations, a considerable amount of data has been secured bearing upon the location of reflexes in connection with various visceral diseases.  The data with respect to the location of cutaneous hyperaesthesia has been well mapped out, but until osteopaths began to plan their manipulative treatment according to the structural changes in spinal alignment, due to muscular hypertension, there was practically no attention paid to the phenomenon of reflex hypertension.  The referred visceral pains and the hypertension of the spinal muscles are expressions of a disturbed segment or segments of the spinal cord.
    Reflex Patterns. - Based on clinical and experimental data, it is possible to outline a series of reflex patterns which are characteristic of certain visceral involvements. The complexity of the patterns depends largely on how great an effort is required by the body to overcome the disease. Some diseases have a spinal reflex pattern apparently out of all proportion to the gravity of the illness. This is especially marked when autotoxemia is a characteristic of the illness. Under such circumstances muscular tension and tenderness extend far outside the limits of the nornial segmental innervation.