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A large percentage of patients being treated
by general practitioners and being referred to various
specialists suffer from back pain. Such patients
constitute one-third of the total attendance in the
orthopaedic out-patient departments, excluding accident
cases. X-rays, electrocardiograms and other
investigations are carried out and these patients are
then informed that they do not have any serious problem.
They are only able to give a vague description of their
pain. Unable to find any abnormality in these conditions,
the physician treats the problem as a psychological one
and often refers them to a psychiatrist.
The pain is mostly in the upper back between the two
shoulder blades. It is a postural problem: a wrong way of
sitting, standing, or doing home or office work. A
majority of sufferers are typists, secretaries and
housewives, more commonly females than males. According
to our own findings too, such problems occur almost four
times more in females than in males. The pain is usually
only on one side of the spine. In a few cases it may
radiate to the lateral border of the shoulder blade or
upwards to the neck. The patient may feel a deep-seated
chest pain. Sometimes the pain is excruciating as if
somebody is piercing a nail in the back or an abscess is
present in the back. At other times it is diffused and a
certain heaviness is felt in the back. A few patients
describe their pain as a burning sensation or painful
tension. Sometimes they point to a specific point on
their backs which hurts them the most.
The pain is common in people who use their hands at the
level of the chest without providing any support to the
elbows. A farm girl doing strenous work in the field may
not get any pain, but when she starts knitting, she may
develop a severe pain in the upper back. Among those who
have to do work with a stooping posture or where the
posture is not correct, the pain may start – as in
the case of a typist sitting and stooping for hours over
her typewriter. Housewives who either have a low kitchen
platform and have to stoop and work, or sit on the ground
stooping and working for hours to cook food, complain
that when they roll chapatis, they experience pain
in the upper back. The pain may be absent while they are
engaged in other activities. This pain is common among
ladies who use a hand-operated sewing machine or those
who iron clothes. Carrying a heavy shopping bag may
increase pain. Sometimes the pain occur at night when the
head is in an odd position or when using too high a
pillow.
Even wearing a heavy overcoat for a long time may bring
about pain. The pain is sometimes so severe that the
patient cannot carry on with his work. Pain may also be
felt after a sudden twist or turn. It can be severe and
excruciating; a deep breath may hurt but coughing may not
be painful. This is just the opposite of lumbago (lower
back pain) where coughing hurts but deep breathing does
not have any effect. A few days of rest may relieve it.
While bending the trunk forward, it may recur due to
compression on the intervertebral joints. The pain may be
felt on one side of the upper back on one occasion, and
on the other side on another occasion.
A clicking sound may be felt during manipulation and
following this, the pain may change its side. This is a
clear indication that thoracic pain is caused by a disc
lesion. The pain often radiates to the front at the level
of the lower ribs. Sometimes the whole chest may be
involved and the pain may travel down to the upper part
of the abdomen.
This when confusion starts. Since the pain starts
suddenly, for example, while lying down, the symptom may
suggest a heart problem like coronary thrombosis or even
a myocardial infraction. In the case of a real heart
attack occurring at middle age, the patient may have a
similar history.
Differentiation between these two chest pains, namely, a
prolapse of the intervertebral disc of the dorsal spine
or a real heart attack may be made by asking the patient
to take a deep breath. If there is pain during deep
breathing, it is most likely that the heart is not
involved and the cause of pain is the dorsal spine. An
electrocardiogram should also be taken to exclude cardiac
involvement. The slipped disc of the dorsal spine is
self-curing It is common among patients like typists, who
have to sit for long hours every day. The patient feels
comfortable when he wakes up from sleep and for a few
hours thereafter; then after sitting for some hours, the
pain starts playing up. It goes on increasing as the day
wears on. Standing or lying removes the pain in a few
minutes. The cause of the pain is the posterior bulging
of the disc, which recedes as soon as the forward stoop
is no longer there.
When the nerve roots are compressed, the pain may be felt
in the lower part of the abdomen or may radiate to the
testicles. Sometimes symptoms may appear as in cases of
gastritis or cholecystitis, depending on the dorsal
involvement. In such cases we should examine the chest
and abdomen very thoroughly and any pathological
disturbances involving the chest or abdominal organs must
be excluded first.
Generally the chest and abdominal symptoms which arise
due to pressure on the dorsal nerve root are forgotten
while diagnosing different diseases of the chest and
abdomen. Most chest or Abdominal pains are due to disease
of the local organs, but when the pain is in front of the
trunk, and gets aggravated by exertion and bad posture,
then you may conclude that it is due to pressure on the
dorsal nerve root.Treatment: Postural Correction
If a straight
posture is maintained while working in the office or at
home, the pain may not occur. For example, a clerk may
raise the height of his table so that he may sit more
erect than usual. This can even be done by cutting the
legs of the chair to lower its height. A typist may put
his or her papers just above the typewriter on an
inclined board, or keep them vertically tagged on the
wall on a drawing board. Housewives may raise the kitchen
platform if it is too low. They may use a chapati
maker which involves pushing down rather than rolling.
Using a hard bed with no pillow or a very low pillow
while sleeping is helpful. Sitting in an ordinary office
chair instead of a low sofa is better. One must keep
reminding oneself to sit straight as the habit of sitting
in a wrong way may be difficult to change. Three
exercises are of advantage:
Dand. This is a well-known
Indian exercise. The patient rests on his arms and legs.
The body is drawn backwards initially, till his hips
reach the highest point. This is the starting position.
Then the head travels slowly down in the direction of the
arms, and after the nose has reached the floor level, the
chin and the chest are gradually brought to the same
level. Now the upward journey of the head and trunk
starts in an arch till the final position of the exercise
is reached where the spine is in full extension. This
exercise is somewhat difficult. To make it easy, hands
should be placed on a higher level than the feet –
perhaps on the side of a table or bed. Six repetitions
done morning and evening will be very useful.
Shoulder
Raise. The patient
stands erect with his hands on the side. Both shoulders
are raised up and without bringing them down, taken
behind as far as possible and then dropped down. This
exercise can be done twelve times in the morning and
evening. This also helps to alleviate upper back pain.
Swimming.
Swimming helps
patients with a postural backache problem. Keeping the
head out of water keeps the body in a posture of
extension. When the body floats, all the compression
strain on the body ceases.
Manipulation
Manipulation is
attempted in all cases unless contraindicated. In quite a
few cases, a tender point can be located 2 cm from the
middle of the spine at the level of the fifth or sixth
dorsal spine. Pressure over this reproduces the exact
pain which the patient is complaining of. Some years ago
Kellagren injected 1 ml of hypertonic saline solution at
the above-mentioned tender point. For a few minutes this
injection produced the habitual dorsal pain which the
patient had been complaining. Of. He proved that there
was an involvement of the dorsal spine in such pain and,
therefore, manipulative manoeuvres were justified for its
treatment.
The lower cervical spine involvement as a causative
factor for upper back pain has already been discussed in
earlier chapters. Manipulation of the lower cervical and
dorsal spine should be done in these cases. Manipulation
can be done without general anaesthesia. It should be
repeated once a week till final recovery takes place.
Case
Histories
- A 41-year-old woman
with a two-year-old child had occasional pain in
the upper back and both shoulders for a year.
Then for three months it became continuous and
severe. She would get severe back pain after
ironing clothes or rolling chapatis. Along
with pain in the upper back, she felt heaviness
in the chest. After resting for 1-2 hours, she
felt somewhat better. She underwent treatment
from her doctors for a few months but this
provided no relief. She then came to me and after
a clinical examination and investigations,
manipulative treatment was started. Her pain
subsided gradually and she was able to do all her
household work without any discomfort. She was
asked to do the upper back and shoulder-raise
exercises.
- A shop-keeper aged
thirty-six, had pain in the chest now and then
and a persisting heaviness in the same region.
After a year, neck pain also started. Though he
had suffered no injury, the pain increased and
became persistent. He would also get occasional
stiffness in the neck and pain in the arms while
lifting heavy objects. However at nights he slept
well. Treatment by general physicians and medical
consultants did not help him. He consulted an
orthopaedic surgeon but to no avail. His chest
X-rays and electrocardiogram were normal. The
X-rays of the cervical spine and dorsal spine
were normal. Laboratory tests were also normal.
The manipulative treatment of the dorsal and
cervical spine was started. He felt better after
the first manipulative manoeuvre. His chest pain
became less frequent and much less intense, and
the pain in the neck did not occur after the
second treatment. The chest pain and heaviness
completely subsided after eight weeks. He was
told to sleep on a hard bed and without a pillow.
He was also told to do exercises.
- An engineer, aged
thirty-three, employed with a large company, used
to get pain in the lower ribs and chest off and
on. This became more prominent when he had to do
any job bending for a long time. This pain
persisted for two to three days. When he lay flat
in bed, the pain subsided slowly. The pain was
incapacitating and allowed him no exertion. He
would also get pain in the upper back and lower
back occasionally. The chest pain followed the
low back pain and with this pain he became
bed-ridden for fifteen days. X-rays of the chest
and electrocardiograms were taken on several
occasions but they were all normal. Laboratory
tests too did not reveal any significant
abnormality.
- Manipulation was done
on his dorsal spine. The pain subsided in six
weeks’ time. He could bend and work for
hours without any pain at all. He was also told
to do exercises for his back for five minutes
every day, and use a hard bed and a low pillow.
- An engineer, aged
twenty-nine, met with a car accident while in the
US. He started getting pain in the upper back
following this accident. The X-ray showed that he
had a compression fracture of the fifth dorsal
vertebra. He was hospitalised for eight days and
later flown to India for treatment. Though he
became better and improved, a mild pain continued
for about a year. His hectic lifestyle also
aggravated the pain.
- He came to me with
the above complaint. His X-ray showed an old
fracture of the dorsal spine. Manipulative
treatment was given to him for the cervical and
dorsal spine. He improved and there was no pain
at all within six weeks. He improved and there
was no pain at all within six weeks. He was
taught exercises and advised to be careful about
his posture as he was in the habit of sitting and
walking with a forward stoop.
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