One of the biggest challenges for physicians is the diagnosis and treatment of chronic back pain. Some estimates claim that up to 85% of these common cases are initially misdiagnosed. There are a bewildering number of conditions that can cause pain in the back. The fortunate news is that in many cases of back pain resolve without a doctor’s intervention. However, when back pain lingers it becomes more difficult to treat. Chronic back pain rarely exists without compensation and changes in other body parts related to long term pain. Successful treatment requires a specialist who can diagnose not only the back, but can look and recognize when posture, gait and other biomechanical abnormalities may be contributing. Successful treatment is contingent in dealing with each of these areas if lasting relief is to be expected. A simple four step program to diagnose the “big picture” of back is often utilized.

Step one in the evaluation of chronic back pain is to make sure that the pain is actually biomechanical in nature. Although this may sound simplistic, many cases of chronic back pain are related to abdominal or other organic disorders. Gallbladder or stomach disorders well often refer pain to the back. In addition, more insidious and life threatening problems such as cancer or abdominal aneurysm need to be ruled out. Fortunately these conditions are rare. An experienced manual therapist can quickly rule out most of these conditions.

Step two in the evaluation of chronic pain is the analysis of standing and seated posture. A simple tool that is utilized is the bilateral scale measurement. This device measures the amount of weight that is placed on each leg and provides valuable information about balance and weight distribution. Many chronic back pain sufferers will compensate by placing weight on one leg or another. This is similar to having your suspension out of line in your car. Problems develop over time in response to uneven wear. Many postural disorders are obvious without measurement. Office workers who sit for extended periods of time are likely to have “hunched” postures that result in chronic neck, back pain and even carpal tunnel syndrome. Overweight individuals will have both postural and gait compensations that are more deleterious than the effect of the weight alone. Postural analysis in all of these cases is critical in effective long term pain relief.

Step three in the evaluation of chronic back pain is the determination of whether sufficient range of motion and strength is available for daily activities. Pain typically leads individuals to abstain from the motion that causes pain. Unfortunately the human body is governed by the “use it or lose it” principle. If you don’t fully use a joint or muscle you will gradually and predictably lose function in that joint or muscle. This applies to muscular strength, flexibility and the movement of the joints themselves. Think of what happens to a joint or muscle after it has been put in a cast for 6 weeks and you will get an idea of what happens on a more subtle level when and individual is compensating for chronic back pain. Adaptations resulting joint dysfunction are very common in the spine, but the effects can reach above and below to the knee, ankles, hips and shoulders. All of the areas must be evaluated and often need treated for chronic pain to be elevated.

The final step in the evaluation of chronic back pain is the analysis of the gait. Gait is simply how a person walks. Most patients with chronic back pain will have some gait abnormalities. The trick lies in evaluating whether the gait abnormalities are contributing to the pain or are a result of the pain. Many individuals will alter their gait in response to an acute episode of pain and will then acquire the new walk as a habit to avoid future exacerbations. This is a sure recipe for chronic, lingering back pain. A large percentage of people have a short leg that may cause pain that takes years to develop. Others may have gait alterations related to recent weight gain or even weight loss. For example, the rapid weight loss associated with gastric bypass surgery may cause postural changes too quickly for the body to compensate. This typically leads to back pain. Gait analysis is critical in the evaluation process in all of these cases.

Treatment of chronic back pain cannot follow a simple formula to be successful. Most individuals will require a multitude of treatments and therapies, but the key is to have a thorough analysis of the cause of pain and all the factors and compensations that may be contributing. Some cases require strengthening exercises and stretching. Other cases require spinal manipulation and therapy. Others may need a simple intervention such as an orthotic of heel lift. The best results come from combining all of these elements and treating the whole person, not individual parts.