Back and neck pain
Back and neck pain
This section doesn’t set out to be on the scale of ‘Wikipedia’, but more to give a brief overview of the key points that relate to the assessment, diagnosis and treatment of back and neck pain.
Those interested will certainly be able to tap into the enormous wealth of information that can be found elsewhere on the internet (but see cautionary note below) or may want to direct specific questions to us via the ‘Ask a Physio’ section on our Home Page.
After a brief outline of spinal anatomy I’m going to keep to the conditions that come under the heading of ‘mechanical neck and back pain’. There are other conditions that can lead to back and neck pain such as inflammatory conditions, e.g. rheumatoid arthritis, fractures (broken bones), lung and circulatory problems, and some cancers, but these are rare and one of our roles in assessing patients is to identify those things that aren’t suitable for our treatment and need to be referred back to the GP.
It can be misleading – and even scary – to go too far into the signs and symptoms of these other conditions and internet searches can be a mixed blessing in providing information. Experienced physiotherapists are experts at clinical assessment and are very willing to explain and discuss their findings and plans before treatment. Most back and neck pain can be treated without needing further investigations but sometimes these are necessary and sensible before proceeding.
The spine is a curved structure consisting of separate bones, called vertebrae, which are stacked on top of each other in a column – the spinal column.
Each vertebra has a larger bony ‘body’ with backward projections that join in the middle to enclose a hole through which the spinal cord passes from the brain. The holes align in the spinal column to form a tunnel that is called the spinal canal.
There are joints on either side between the backward projections of two neighbouring vertebrae, called the facet (zygapophyseal or apophyseal) joints, and a cartilage disc is placed between the bodies of most of the vertebrae – except at the top and bottom levels of the column. The facet joints are surrounded by a small bag or ‘capsule’, lined with a membrane that secretes lubricant fluid into the joint, and the whole column is supported by elastic ligaments, muscles and connecting inelastic tissue called fascia. Any of the structures mentioned above can be a cause of back pain.
As the spinal cord passes through the central spinal canal, pairs of nerves leave at each level on either side, to pass through small holes on each side of the column and then to provide a nerve supply to structures within the head and neck, mid and lower back, arms and legs. The ‘roots’ of the nerves, where they leave the spinal cord, can become inflamed, sometimes by being irritated by a neighbouring bulging (prolapsed or herniated) disc; this can also be a cause of pain that can travel into the arm and to the hand (brachialgia) or into the leg to the foot (sciatica). This condition can also cause pins and needles, numbness and weakness and is sometimes known as a ‘slipped disc’ or ‘trapped nerve’ – but neither term really describes the situation well.
The spinal column is divided into regions: cervical spine, thoracic spine, lumbar spine, sacrum and coccyx. The sacroiliac joints lie alongside the sacrum and are also an important consideration in low back pain.
cervical spine consists of seven vertebra that are distinctive as they have additional holes in their sideways projections, which provide a tunnel for the important vertebral arteries that provide much of the blood supply to the brain. The upper two vertebrae are a little unusual. The uppermost vertebra is called the atlas, a wide bone that sits under the globe of the skull. If you run your fingers downwards from the base of the ears to the level of the corners of the jaw bone you can feel a tender bony point on each side of the neck. This is the edge of the atlas and gives you an idea of the width of the bone. The small ‘yes’ nodding movement of the head happens at this level. The atlas does not have a bony body but instead has a large hole that receives the upward pointing peg of the vertebra below, the axis, that provides a pivot for the rotating ‘no’ movement of the head. The peg is held in place by a ligament that spans the hole within the bony ring of the atlas.
There are twelve vertebrae in the thoracic spine, which is easily distinguishable as the part of the column that provides attachment for the rib cage. If you drop your head forwards and slide your fingers lightly downwards from the centre of your skull you’ll come across a bony lump that marks the junction between the cervical and thoracic spine. If we adopt a persistent slumped posture with a poking chin, this area can become more pronounced as a fleshy so-called ‘Dowager’s hump’. The thoracic spine is the stiffest part of the spine and problems tend to arise more from the small joints where the ribs attach, and the facet joints, than from the thoracic discs between each pair of vertebrae.
The lumbar spine consists of five large vertebrae designed for weight-bearing. It starts at approximately the lower edge of the rib cage and runs to just below the brim of the pelvis. The discs between the lumbar vertebrae act as shock absorbers and also help to distribute forces during movement. The stability in this region comes from the size and shape of the joints, strong ligaments that span the joints and core abdominal and small muscles that pass across the lumbar joints, together forming long pillars of muscles on either side of the spine. Low back pain is very common, especially arising from the lower levels of the lumbar spine where the more flexible region meets with the fused sacrum below.
The sacrum is a triangular shaped bone that sits at the bottom of the lumbar spine as a wedge between the two wings of the pelvis. Use a fist to punch yourself lightly at the bottom of the spine and you’ll feel it as solid bone. It is formed by five fused sacral vertebrae. In its position within the ring of the pelvis, it supports and transmits bodyweight between the trunk and the lower limbs.
The final part of the spinal column is known as the coccyx (pronounced ‘cock-six’) and it is often referred to as the tailbone. It may consist of between three or five vertebrae that literally tail off in size; they may be separate bones or fused together. You can feel it as a tender bony point by pressing inwards and upwards towards the top of the buttock crease. A small disc usually exists between the bottom end of the sacrum and the top of the coccyx that does allow a small amount of movement between the two parts. Landing directly onto the coccyx may give rise to localised pain, known as coccydynia, but pain can also be referred to this region from problems in the lumbar spine.
The sacroiliac joints sit between each side of the sacrum and the posterior wings of the pelvis, which are known as the ilia. If you put your hands onto the sharp upper edge of the pelvis (hands on hips) and sweep your fingers backwards you will feel a bony prominence on each side of the solid sacrum at the base of the spine, and fall into a dimple just beyond. This is the position of the sacroiliac joint – you won’t be able to feel the joint itself though, as it is supported by a thick mass of ligaments within and over the joint that are the strongest in the body. The sacroiliac joints transmit bodyweight to the lower limbs. They are solid interlocking joints that normally allow just a shuffle of movement while walking and moving between standing, sitting and lying. In pregnancy particularly, the softening of the ligaments can lead to excessive movement at the sacroiliac joints that can lead to pain. Some inflammatory conditions can also affect these joints.
The spine is meant to be curved and is mechanically stronger with two hollow curves at the cervical and lumbar regions that are balanced by the curve in the opposite direction at the thoracic spine. Problems may arise when the curves are too pronounced or too flattened however and attention to posture and the stability of the spine is bound to form part of the general management of neck and back pain.
Let’s talk about the ‘discs’, since they tend to get a lot of bad press as a cause of back and neck pain. The intervertebral (i.e. between two vertebrae) discs vary in size and structure at the different levels of the spine. Particularly in the lumbar spine, they are thick, almost oval structures formed of ring-like layers of cartilage (rather like an onion) that both allow and provide constraint to the movements of the spine. The centre of the disc is gel-like up to the late teens/early twenties but then gradually becomes more tough, or fibrous. The centre of the disc acts as a ball bearing, allowing the spine as a whole to pitch and roll in all directions.
The trouble is that the disc doesn’t have a blood supply and relies on movement of the spine to squeeze the disc and spread nutrients to all parts of it, like a sponge. The nutrients seep through into the disc from the blood vessels in the vertebrae above and below the disc. That’s why it’s so important to keep moving to keep the disc healthy – sometimes the advice to avoid all bending has possibly gone a little too far.
Over time, the discs tend to dry out, or degenerate, but you can still have healthy discs in your eighties or degenerate discs in your thirties and forties, so it’s not just down to ageing. This degeneration can lead to the formation of splits or ‘fissures’ in the disc substance, which can be a cause of pain in themselves, as there is a nerve supply in the outer layers of the disc that may transmit pain in this situation. Pain can also result if the weakened wall bulges, known as a disc protrusion.
Sometimes the splits in the outer layers will allow the material in the inner part of the disc to push completely through the outer wall; this is known as a disc prolapse, disc herniation or ‘slipped disc’. The disc itself doesn’t move or ‘slip’ though, so the description isn’t quite accurate. In this situation, the extruded material may irritate the neighbouring emerging nerve root, leading to inflammation and pain that may extend into the arm or leg and be associated with pins and needles, numbness and/or weakness. ‘Trapped nerve’ is another term used here but although the nerve may be pressed against by the disc prolapse it can still move.
Pain arising from a prolapse with irritation of the nerve root is usually felt first in the back or neck, according to where the problem level is, and can then travel into the leg, chest or arm – usually becoming less in the back or neck as it does so. As mentioned above, in this situation you may also experience pins and needles, numbness or weakness.
This ‘nerve’ pain can be ‘agony’, disabling and frightening. It is often associated with strong muscle spasms in the low back or shooting twinges of pain that can take your breath away and even make you feel hot, nauseous and faint.
Mechanical back and neck pain
Mechanical means that the pain is arising from the joints, discs, ligaments or muscles in the back and neck. It can range from pain caused by faulty posture to a full blown disc prolapse as described above. Mechanical pain accounts for approximately 95% of all back and neck pain and around 75% of people will experience mechanical back and neck pain at some point in their lifetime – some more severely than others. The pain can recur too, sometimes with gaps of years or sometimes every few weeks or so.
Non-mechanical back and neck pain can be caused by infection, some conditions affecting organs or the circulatory system, such as pancreatitis or aortic aneurysm; inflammatory arthritis, bone disease or malignancy (cancer) etc.
Physiotherapists need to be sure that a patient’s pain is mechanical in origin and safe to treat. Before making that decision, a thorough assessment is needed to make sure that there are no so-called contraindications or ‘red flags’ that would either guide the treatment approach to be selected or suggest that further investigation is needed.
Symptoms and signs
It might be helpful here to define what is meant by ‘symptoms’ and ‘signs’. Symptoms are perceived and described by the patient and can include pain, stiffness, pins and needles, numbness etc. Signs are features that can be observed by the examiner and may include bruising, reddening, heat, swelling, muscle spasm, limitation of movement and changes in posture. There are some things that can be both a symptom and a sign; swelling and heat for example.
The assessment will usually begin with taking a thorough history from the patient; i.e. the subjective examination. How old are you, what is your job and what sports and hobbies do you pursue? What is the problem; what and where are the symptoms; when and how did the problem start; how has the problem behaved since it came on; what makes it better; what makes it worse?
What is your past medical history, any serious illnesses or major operations? Have you had this problem before? Did you have any treatment and what was the outcome?
Have you got a problem with any other joints? This will alert the examiner to the possible presence of arthritis that could be inflammatory or degenerative.
What tablets are you taking? This will give important clues to your general health and how much pain relief you might be needing for your problem. The information is also important as some drugs, anticoagulants for example, may be a contra-indication to some treatments, but not all, and will help to guide the selection of the appropriate treatment for you.
According to the level of the spine affected, the assessment will include special questions about your bladder and bowel function, dizziness, headaches, night pain, weight, smoking, past operations and general health.
After the ‘interview’ or subjective part of the assessment, the objective assessment will begin that involves a thorough inspection of the area and observation of particular movements and special tests that will be performed on you by the examiner to be able to get to the root of your problem.
You will be asked to undress so that the physiotherapist can have a good look at the back or neck as a whole, looking at posture, colour changes and any wasting or swelling, which might be muscle spasm.
Then you’ll be asked how you feel as you’re standing or sitting there; that is, can you feel your pain at rest, pins and needles or other sensations, such as numbness or muscle fluttering etc? This allows you and the physiotherapist to compare if movements that follow bring on your symptoms or change them in some way.
Each level of the spine needs different movements to be tested to be able to establish the cause of your symptoms. For all levels you will be asked to bend your back or neck in different directions to see how far you can go and to assess if they are stiff and painful. The pattern of movements can be interpreted to help with diagnosis and treatment selection.
Muscles and reflexes will be checked to see how messages are passing along the nerves, and the nerves may be stretched a little to see if they bring on your symptoms. The most common of these ‘stretches’ is the so called ‘straight leg raise’ test where the physiotherapist will lift your leg upwards with your knee straight to apply some tension to the sciatic nerve, which runs from your low back and into your leg. Don’t worry though – the movement is done very slowly and stops as soon as you report pain. It is helpful in assessing whether you have irritation at one or more of the nerve roots by applying a stretch through the length of the nerve.
You will be asked if you can feel light touch normally, testing for numbness or dulled sensation that can result from pressure on the nerve roots.
At the end of the assessment your physiotherapist will put all your symptoms and signs together to arrive at a clinical diagnosis.
Clinical diagnosis is the act of identifying the cause of symptoms by evaluating the patient’s history and objective examination. It can include evaluation of special tests such as x-rays or blood tests, but doesn’t have to.
It may seem strange but with regard to mechanical back or neck pain, it isn’t always possible or helpful to diagnose a problem by labelling a specific structure in the spine; for example facet joint, disc or ligament, as it may be that several structures are affected and contributing to the problem. There may be muscle spasm in the area, that helps to protect the underlying spinal joints, and pain may lead to faulty movements that lead to structures shortening or tightening, muscle imbalance and issues with posture.
It is more appropriate to look at the spine and person as a whole and most of the treatment plans and the techniques applied are devised according to how the pain came on and the pattern of movements that are restricted and increase your pain. The same techniques can be applicable for several disorders. However, this may be different for patients who have pain travelling into the arm or leg and where there may be numbness or muscle weakness.
These models are derived from listening to how the pain came on, where it is and how it has behaved since, as well as the different patterns of movements that may be found on examination. The models guide the physiotherapist in the selection of the appropriate treatment for you, as well as the home exercises that you will be asked to do to help your problem.
Very generally, provided that there are no contraindications, spinal pain that came on suddenly and recently and doesn’t travel too far into the arm or leg is more likely to respond more quickly to treatment, and that treatment may include manipulation.
Pain that came on more gradually and perhaps travelling further into the arm or leg is likely to respond more slowly and may need traction as well as mobilisation and stretching techniques.
Treatment of back and neck pain
With all mechanical back and neck pain you will be advised to ‘keep active’ and the days of bed rest and months in a soft collar are long gone. Research has shown consistently that if you keep moving as normally as possible you will get better sooner. The important message is that although you might be in pain you will not be doing any damage to yourself by moving. Even with back and neck pain that has been there longer than about three months you would do well to gradually build activity into your daily routine; it may be exhausting to start with but if you build a little more general activity into your life day by day you will gradually increase your fitness and your pain will lessen.
It’s important to look at your diet and lifestyle habits too and to lose a bit of weight through sensible eating and to stop smoking can be enormously helpful as part of your general plan towards feeling better.
Physiotherapists are specialists in devising appropriate exercise programmes to help you to get better and to prevent recurrence of your pain. The exercises can include those to improve your movement and flexibility as well as to strengthen key muscles to improve and support your posture. You will be advised to get going with something you really enjoy: swimming and walking – with supportive footwear – Pilates or gym exercise classes, as well as tennis, badminton, golf etc. With appropriate treatment, advice, exercise and pacing, you can return to pretty well anything that you enjoyed before your back and neck pain came on.
As well as keeping active and following exercise programmes you may need specific treatment according to your particular problem. The treatment applied will aim to reduce your pain and to help you to get better more quickly.
The National Institute for Health and Care Excellence (NICE) guidelines recommend the use of manipulation and acupuncture for low back pain and there is a growing body of evidence that early treatment is better than leaving pain to become more chronic, complex and difficult to treat.
Physiotherapists use mobilisations, manipulation, soft tissue massage and stretching techniques to treat neck and back pain, including the use of traction to apply longitudinal stresses to the back or neck to create more movement at the affected levels. Acupuncture may be used for pain relief and some patients respond very well to this, making it easier for them to move about and to keep active. Electrical equipment and TENS (transcutaneous electrical nerve stimulation) may also play an important role in pain relief alongside the treatments applied.
How many treatments?
It’s not possible to be absolutely accurate with how many treatments will be needed as every person and problem is different. Progress will rely on the assessment of the outcome of treatment and patient preferences and the plan will always be discussed and agreed with you. As mentioned above, pain of more recent onset that is fairly local to the back or neck is likely to respond to treatment more quickly, whereas something that has been present for longer is likely to take longer to get better.
It is important to follow the treatment plan through though, as to stop too early may leave you with persistent problems that are hard to resolve. Physiotherapy works – but you may need to stick at it. Sometimes a couple of treatments may be needed every few months to keep you mobile and to review your exercise programme so it’s good to forge a relationship with a physiotherapist or practice that you can trust to help you to maintain your improvement too.
This has been a general run through of the anatomy of the spine, an outline of the possible conditions and presentations of back and neck pain, with what you can expect from our assessment, and a brief account of treatment approaches.
As the web site builds we’ll be able to go into more detail of the treatment approaches that physiotherapists use.
In the meantime, you are always welcome to contact the practice to Ask a physio and we’ll do our best to answer any queries you might have before you choose to come to see us.