Low back pain can be experienced as follows:

1. Discomfort in the lower back.
2. Severe pain localised in the lower back. This may occur suddenly and is called acute lumbago. When it comes gradually and persists for a long time, it is called chronic lumbago.
3. Pain radiating from the lower back to the buttocks, or it may radiate to the anterior aspect of the thigh when the higher lumber area is involved. This is called sciatica.

It is quit spectacular to see a patient who is bent over as a result of pain, recover instantaneously following manipulation. These manoeuvres appear to be very simple; only the click sound is often heard during manipulation. It is generally considered that lumbago occurring in young people is the most obvious symptom for manipulation. However such cases sometimes recover after simple bedrest. But more severe cases of sciatica, persisting for years, and with no obvious sign of subsiding, improve with manipulation.
Let us examine the case of a patient with a typical history of acute lumbago. The patient probably felt pain and heard a clicking sound while lifting a heavy object from the ground. (This may also happen while pushing a heavy objects like an almirah). The pain became severe and the patient was unable to move. A few days later, the pain became less severe, but radiated to the buttocks, the back of the calf and foot. Tingling and numbness were felt in the leg. There was severe pain while sneezing or coughing.
A patient with these symptoms and acute back pain adopts a peculiar posture. Muscles in the lower part of the back look prominent as they are contracted in an effort to immobilise the painful spine. The patient tries to assume a posture of maximum comfort. He may develop a lateral curve. The curve may also get obliterated and become straight. The patient finds it difficult to bend forward or backward. Lateral bending is not so painful. He is not able to raise the painful leg high while lying on his back. A careful examination may reveal that there is wasting of the muscles. The corresponding tendonous jerks are impaired or absent.
In a few cases the pain can start without any history of injury, and the onset may be gradual. It may be confined to the back only and not travel to the legs. Sometimes a patient does not feel any pain in the lower back. He may feel it only in the legs and calf muscles. In cases where a higher lumbar disc is involved, the pain radiates to the groin or to the front of the thigh.
Patients with a prominent belly have increased anterior convexity of the lumbar spine. They have more prominent buttocks and a belly. They feel pain while standing and while bending backwards, and experience relief when they sit or bend forward, or when they lie on one side with the knee and hip bent upwards. In such cases more weight is carried by the posterior arches than by the vertebral body and disc. These arches are not meant to bear weight, hence wear and tear in the facet joints starts. This may affect the intervertebral foramen, and put consequent pressure upon the nerves.

Treatment
It is most important to ascertain that the pain is of vertebral origin. Pain due to infection, inflammation, tuberculosis, tumour of the spine, osteomyelitis, cancer or other diseases should be excluded.
A sudden dramatic pain is most likely due to a derangement of the spine. Pain which increases relentlessly without any intermission suggests that it may be due to inflammation or malignancy. In such cases, an X-ray has to be done to check out the condition of the spine and the disc. However if there is an acute prolapse, the X-ray may not show any abnormality, but may show the extent of osteoarthritis as being extensive or mild. It may be remembered that there are many patients with the same radiological changes who do not experience pain, and they continue to show the same changes even after they obtain complete relief.
An injury or strain may indicate the time when the annulus fibrosus of the disc was torn. The nucleus pulposus will bulge from this torn annulus. As the nucleus pulposus is gelatinous, there is a time gap between the injury and the advent of acute pain. If this bulging material lies behind the posterior longitudinal ligament, the patient suffers from acute lumbago; if the nucleus pulposus herniates through the weakened ligament, it impinges on the nerves and there is radiation of pain in the lower limb.
Acute lumbago may also be due to other mechanical disorders of the spine: the sudden nipping of the synovial membrane in one of the fact joints; or subluxation due to constant ligamentous strain, bad posture, disc degeneration or osteoarthritis.
There is great controversy among doctors and orthopaedic surgeons regarding the treatment of lumbago. Some may not allow their patients to be manipulated at all, while others may manipulate each and every case under general anaesthesia. At a meeting of the World Orthopaedic Association, a panel of seven experts under the chairmanship of Professor Mc Farland discussed the problem: even though thirty-three per cent of all orthopaedic outpatients complained of low back pain, the panel had no unanimous suggestions for coping with such a vast number.
Treatment of low back pain is controversial. There is no other condition where treatment varies so much from doctor to doctor. Moreover, treatment depends more on the severity of the symptoms rather than on the severity of the lesion. The arbiter of the result is the patient himself, and different patients have varying sensitivities towards pain.
Backache, lumbago and sciatica result largely from disc lesion, and so the correct mode of treatment should be manipulative reduction, rather than vitamins, heat, diathermy, massage and exercise.

The whole procedure of treatment can be divided as follows:

1. Postural prophylaxis
2. Manipulative reduction
3. Maintenance of reduction

Prophylaxis. Back extension exercises should be a part of the school gymnastics curriculum. Students should be taught to lift weights by using their knees and not with their backs arched. The medical officer in an industrial unit should teach workers how to lift weights safely. They should also see to it that manipulative reduction is available to their workers. An architect should see that the sink is placed at a proper height, a little higher than customary. The car seat too should be designed in a way that the right posture is maintained.
Patients must be instructed not to do toe-touching exercises. It is much better to do extension exercises so as to keep the muscles strong. If a patient is engaged in heavy work and has had several relapses, the employer must be asked to give him a lighter job.

Manipulation
If the pain is of recent origin and started after bending down or lifting a weight or pushing an almirah, why should it not be cured in an equally short time? The treatment of a slipped disc by manipulative treatment is logical and ethical. Treatment should be by manipulative reduction. But before manipulation, a definite diagnosis should be made and all contraindications for manipulation excluded through the patient’s history, clinical examination, X-ray and laboratory tests. If there is any doubt about the diagnosis, it is better to postpone manipulative treatment.
Manipulation should not be done if a patient has acute pain and is not able to move in bed. A few day’s bedrest and formentation should follow manipulation. Different variations of manipulative procedure are adopted to suit each individual case. In the case of sciatica, a mechanical irritation of the nerve by the disc after intermittent pressure, produces inflammation and swelling of the move. This leads to pain and an abnormal sensitivity in the area distributed by the nerve. Adhesions around the nerve roots are formed and often remain even after the inflammation has completely subsided; then the pain is felt only when the nerve is stretched.
The secondary effect of nerve root irritation or compression arises when the patient tries to escape pain by adopting a position of comfort. In this process different curvatures in the spine, called scoliosis, may occur. If there is no inflammation, the patient is able to adopt a pain-free position. If the nerves are inflamed and swollen, the pain increases during the night. Once mechanical irritation leads to inflammatory change, the rate of recovery is slow and the pain is prolonged.

The treatment in such cases is as follows:

1. Removal of pressure from the nerve through manipulation
2. Avoidance of further irritation
3. Treatment of residual muscle weakness, if any
4. Precaution against recurrence

Here is a very recent report which should be used as a guide before deciding whether we should resort to surgical interference in disc cases or not. The Karolinska Institute, USA, made a study of 583 patients after their first attack of sciatica. Surgery was performed on twenty-eight per cent of them. A close watch was kept on the groups of both operative and non-operative patients for seven years. The study showed that an acute attack of sciatica ran a relatively similar brief course in most cases, regardless of whether the treatment has been conservative or surgical.
There is a noteworthy reduction in the number of disc operations being performed the world over. This is due to the poor results obtained and complications following such operations. A neurological deficit including muscle and motor weakness, is not a compelling factor for surgical interference. Uncontrolled urine and bowel movement which occurs in a small number of cases, however, does call for surgical interference. Surgery should not be done if the pain is severe. It is much better to wait. It should only be considered in cases where manipulative manoeuvres have been tried and failed. When the Pain is severe, a pillow can be put under the knee. A few patients may find a sitting position more comfortable.
Complete bedrest and traction should be given and continued till the pain is reduced. But if the pain persists after two weeks of bedrest, manipulative reduction to shift the pressure upon the nerve can be attempted. If there is a deformity in the spine, sustained traction is often effective at the acute stage. Bedrest and traction should be continued till the pain subsides. Patients may need the support of a corset, but it should not be used for more than 3-4 weeks, otherwise, the lower back muscles become weak, and strengthening them later on becomes a problem.
When the pain has subsided, exercises should be started. If a particular exercise causes pain, it should be avoided. The aim should be to increase muscle strength. A soft bed and low chairs should also be avoided.

Posture
The patient should be taught how to use his knee joints so as to avoid over-bending. He should be made to sit and rise again with the object being lifted.
When turning, the patient should avoid twisting his body. It is much better to change the position of the feet instead and change direction.
Lumbar and abdominal exercises must be demonstrated. It is better to do one simple exercise than a set of exercises.

Exercises

1. Lie on your tummy. Place your hands flat on the ground in front with shoulders back, and lift your shoulders and head up as far as you can. Hold the position for 20 seconds, return to rest for 5 seconds, then repeat the exercise again. Repeat it 20 times morning and evening. If it hurts, do it a less number of times and increase the number by one every day.
2. If the tummy is big, it also pulls forward the lumbar spine, causing a constant strain. Reduce your tummy by lying on your back. Keep your arms on your side; lift your leg upto about 45 to 70 , or even to 90 , and bring it down again. Repeat this 20 times. Do it morning and evening.
3. Correction of lordosis is important. The patient should lie on his back. He should pull in his abdomen and hold his buttocks close together to push his lower back against the floor, and then relax and start it over again. This may be done for 2-3 minutes at a time and 3-4 times a day. It must be done on the floor or on a wooden plank with a rug over it. It should not be done on a mattress.

Case Histories

• During a series of test matches played between India and the MCC, the opening batsman was found to be suffering from back pain on the first day of the first test match. As a result, he could not play in the match. He thought that the pain was due to sleeping in an air-conditioned room. His pain persisted in spite of the best possible treatment. All possible investigations were done and X-rays taken. Finally he was diagnosed as having a slipped disc of the lumbar spine, and advised complete bedrest for three weeks. When he did not improve, his bedrest was extended for a further three weeks. Later he was referred to the physiotherapy department for shortwave diathermy and traction. He was also given a belt to wear and asked to do exercises which he did very vigorously since he was keen that his career should not be ruined. He was asked to undergo a disc operation. He refused this fearing that though the operation might rid him of the pain, he would never return to the cricket grounds as he would never be able to reach the required efficiency needed for a world-class batsman. He started treatment with an expert masseur who gave him a massage every day for half an hour, for six weeks. This too did not help much. He still had pain while walking, and the pain would start after sitting for a while in a chair. Then he came to me for osteopathic treatment. I started him on manipulative treatment of the lumbar spine. He was recalled after one week. His anxiety was great as the time for the team selection at Madras for the Australian tour was approaching fast. He began showing improvement within six weeks; started playing inter-club matches every Sunday and doing his Keep-Fit exercises. At the end of eight weeks, he was ready to leave for Madras. His performance was good. There was no end to his joy when he scored the highest number of runs in the semi-finals of the Duleep Trophy match. He was selected for the finals and was grateful to osteopathy, which had put him back on the field.
• For one year a thirty-year-old housewife with a seven-year-old child suffered from low back pain which descended to her right leg. She also experienced pain during her periods. Stiffness of the upper back and neck followed, and lately, she had also started complaining of heaviness in the head. She was a keen sportswoman and used to a great deal of cycling. The pain had started after she had pushed a heavy almirah. She came to me and after being given osteopathic treatment for six weeks, she recovered. Her periods also became free of pain.
• A lady advocate, 28 years old, was bedridden with severe backache. She had no injury preceeding this pain. The pain had started suddenly one day when she got up from bed. Before that she used to get feverish in the evening. The X-rays, ESR and other investigations showed normal results. She did not respond to drug therapy, rest, traction or diathermy. She was also Pregnant. Since she was running a temperature, her case was diagnosed as one of tuberculosis. She was advised antitubercular treatment and an abortion. Her family was upset as it was her first pregnancy. A high sacral belt was given to her. This was the time when she came to me. I examined her. As every investigation and the X-ray were normal, I could not agree with the diagnosis of tuberculosis. I felt that her temperature was due to severe pain and decided on manipulative treatment for her spine. She responded well. The next time she came to me, she did so without a stretcher. She could walk from the portico to my consulting room. By the end of the third treatment she was a lot better and definitely hopeful. At the end of six weeks, she was back to work. Two more sessions of treatment at fortnightly intervals included back extension exercises. No abortion was done, and she delivered a normal healthy baby. It was a painless delivery.
• A man aged 49 complained of low back pain which radiated to the right leg. It began when he tried to lift something heavy from the ground. He took medication, rest and traction, but all these did not help. He took recourse to auto-urine therapy for ten days but this did not seem to help either. He went to Poona and got himself thoroughly examined. An X-ray was taken and his lumbar spine was manipulated three times under general anaesthesia, but this too did not help. Ultimately he was brought to me. He could not even sit. After examination I gave him manipulative treatment. He felt much better after the first session. The third time he came for treatment he was able to travel by train and bus. By his sixth visit, he was able to resume his insurance work. He recovered completely after two months.
• A well-built mechanic, 41 years old, complained of pain in the calf muscles for fifteen years. He had pain in the upper back and both shoulders for eight years. But there was no injury. The pain was present all the time, sometimes a little less, sometimes more. He was better if he rested at home; otherwise, it would start in the morning and increase by evening. There was no numbness or tingling in the legs. He had difficulty even walking short distances. After having tried several types of treatment and undergone other investigations, manipulative treatment was finally started. He felt much better following the first treatment. He showed improvement, and by the end of six weeks he had no pain at all. He was advised to sleep on a hard bed and keep on doing exercises for his back.

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