Principles of Osteopathy
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
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
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
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
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
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.