The musculoskeletal system is responsible for movement of the body and any disease or dysfunction of it will therefore affect the bones, muscles, tendons and ligaments. Some conditions that present in clinic will be superficial and acute, others chronic and deep rooted with dysfunction from organs and internal disharmonies.
Musculoskeletal disorders are classified in western medicine as inflammatory and non-inflammatory disorders. The inflammatory diseases are further classified as autoimmune conditions at their origin, meaning the body’s own immune system attacks itself. The most commonly seen ones in clinic being Rheumatoid arthritis, Polymyalgia reheumatica, Ankylosing spondylitis and Gout. Non-inflammatory conditions you will likely see are Osteoporosis, Osteoarthritis, nerve impingements (Sciatica) low back pain sometimes referred to as lumbago, tennis elbow etc.
Chinese medicine refers to the above conditions as either Bi syndromes (obstruction syndromes), or Kidney deficiencies and are separately categorized into several different sub sections. The patterns or syndromes of pain are all the result of obstructions of qi and blood in the meridians and collaterals. The differentiations being, wandering bi, painful bi, fixed bi and hot bi are all based on the origin of outside pathogenic influences, such as Heat, Cold, Damp and Wind entering the body due to a deficiency Wei Qi which protects the body from invasion. Other forms of pain are internal in origin from disharmonies of the Zang Fu used to either move or govern the flow of blood and qi.
The number one non-inflammatory musculoskeletal condition seen in clinic is easily Low Back Pain, affecting 80% of the population in their life time and costing millions of pounds in lost revenue from days off work. The majority of low back pain cases originate from the spine in the intervertebral joints and the local back muscles. Due to wear and tear and the natural ageing process the fluid content in the disc begins to diminish resulting in a thinning of the intervertebral disc itself.
As the disc thins the back loses its ability to absorb shock, thus resulting in instability of the spine. This instability can now lead to inflammation of the joints from lack of disc thickness and the occurrence of bony outgrowths know as Osteophytes, may result in nerve impingements, this degeneration of the intervertebral discs is referred to as Spondylosis.
The intervertebral discs can herniate or rupture leaking out internal fluid. This is often mistakenly referred to as a slipped disc, although this is totally untrue as the disc does not slip, it tears, often due to extreme pressure placed on it by lifting heavy weights with movement. Because of this disc rupture the fluid may exert pressure on the spinal nerve or cause a chemical irritation resulting in pain. If this radiates now down the leg, we can ascertain where the pain is to what disc is being affected. If pain only reaches the knee level, l4 is the possible origin and if the ankle and foot is affected L5 S1 has likely been affected.
If the pain arising from disc herniation is severe the patient’s bladder and bowel maybe affected. By losing control of it known as Cauda equina syndrome, this is classed as a medical emergency requiring immediate surgery to relive the spinal column compression by removing the disc. If this is not done permanent paralysis may occur from the affected disc down.
Pain can also occur from what’s known as vertebral fractures or Osteoporotic fractures, this is when through osteoporosis or diminished bone density fractures of the bone occur as body’s weight compresses resulting in a crush fracture.
The back muscles also play an intrinsic relationship with skeletal structure of the body and many situations can cause pain in the lower back, usually but not always if the back is painful there is often some form of contraction. Through correct postural assessment you may notice one hip is higher than the other, this is referred to as a pelvic up slip causing contraction to the quadratus lumborum or spinal erector muscles. This may be occurring from a spinal nerve compression and the proximal muscle tissue tension.
Other conditions known to cause low back pain are from weak abdominal muscles failing to work in their pairing of extension and flexion of the spine working in unison with the back muscles. Over tight psoas muscle connected by shortened hip flexors also can have a major effect on back pain causing instability.
This is seen frequently in modern society as more people become seated and sedentary, working predominantly desk based or driving jobs spending many hours seated thus shortening the hip flexor as a result. The muscles of the back are also prone to tearing if the load placed on it is greater than it can withstand so physical exercise such as weight lifting and sudden movement especially with rotation e.g. as a car accident may all cause tears in its structure.
Common treatment strategies that will be offered to patients via their G.P range from no intervention at all as 90% of all acute back pain will resolve itself within one month, to advising rest and gentle exercise and to take the over counter medication e.g. paracetamol and ibuprofen for pain management. In more serious or chronic conditions a varying degree of drug options can be administered such as (please see below).
Treatment protocols / Common prescribed medications
Pain killers: Paracetamol, Co-Codamol (papacetamol+codeine), Codeine,
Brands names Codipor (co-codamol), Kapake (Codeine). Diazepam, Tramadol hydrochloride, Co-dydramol, Diamorphine, Dihydrocodeine, Fentanyl, Morphine.
Anti-inflammatory: Ibuprofen, Diclofenac Tablet/Suppository, Naproxen-Usually taken with a PPI e.g. Lansoprazole or Esomeprazole, Omeprazole to protect stomach, nausea upset stomach typical side effects.
Nerve blockers: Amitriptyline, Pregabalin (Lyrica), Gabapentin.
Injections such as cortisone, a type of steroid which mimics the naturally occurring substance of cortisol that is released when the body is under stress and produced in the adrenal glands. This is often used and is a highly effective method to reduce inflammation as the injection is directly injected to the area of concern. Typically, the patient feels relief from pain after 5 days as irritated tissue begins to decrease. Known side effects are facial flushing and increased blood pressure and blood sugars levels. Repeated cortisone injections also weeken tendons and softens cartilage therefore doctors limit the amount given.
Physiotherapy is a recognised therapy to treat musculoskeletal disease or injury by manipulation, massage and exercise protocols.
Magnetic resonance imaging may be used to gain better knowledge of a patient’s pain. Used in radiography it allows for pictures of the anatomy along various planes to be formed giving greater detail than a standard X-ray could.
Surgical intervention typically includes procedures such as Spinal fusion, this is where vertebras are joined together. Laminectomy, this is where parts of bone are removed from conditions such as bone spurs. Foraminotomy, this is a procedure where bone is removed from the sides of the vertebra to widen the nerve exit cavity. Discectomy this is the full or partial removal of a ruptured disc which is causing nerve compression. Disk replacement is the removal of the spinal disc and an artificial one put in its place. Interlaminar implant is a procedure where an implant is placed between two vertebrae creating a space easing pressure on the spinal nerve.
The Chinese perspective
Pain in its various guises from the Chinese perspective come from three origins, Trauma, Internal organ and External pathogenic factors or epf’s.
Low back pain of the lumbar region is associated as a disharmony of the Kidneys, as this area is commonly referred to as the “Dwelling house of the Kidneys” as such pain in this region is a result of its disfunction.
Kidneys dominate the bone, produce marrow and store the essence and as such massively influence the structure and stability of the spine, vertebra and discs. The Kidneys are known as the lower source of water of the body as Kidney yin brings nourishment and hydration to the bones which it dominates, failure to do so leads to spinal and disc degeneration, resulting in the western diagnosis of Osteoporosis.
Other forms of back pain may be the result of a trauma related injury, as the meridians and collaterals become injured, obstruction in the flow of Qi and Blood creates pain. As these vital substances are obstructed in their normal flow, skin, muscle and tendons fail to be nourished thus pain occurs. Qi is the commander of blood if it fails to flow neither does the blood resulting in stagnation arises and pain.
And finally, invasion by external pathogenic factors that of cold, damp, heat and wind resulting from exposure to the elements or damp living conditions, even profuse sweating with open pores allowing wind, the spear head of disease to invade the meridians and collaterals creating chaos in the channels. Once inside it now occupies space it shouldn’t and impedes the natural flow of qi in the meridian causing pain through stagnation.
Using the TCM model patterns are now identified and treatment protocols decided.
Typically, these would include some variation of Acupuncture, Tui Na, Herbal medicine Cupping or Moxibustion as these all readdress the fundamental imbalances of the body and to regain harmony and normal flow of qi.
If the back pain has been identified as that of Kidney Qi deficiency general advice should be to rest, as this helps the kidneys to conserve its qi and Essence as overwork, stress and excessive sexual activity are all said to drain its energy. If pain occurs through cold damp invasion a heavy sensation and stiffness to the muscles will occur. A cold sensation to the affected area is typically felt and the condition usually worsens for deterioration in weather conditions. The tongue may show a thick sticky coat with a deep, weak and slow pulse.
If pain is the result of trauma, rigidity and local fixed pain aggravated by pressure and movement. The tongue may show purple colouration and a tight pulse.
Let us now first look at other non-inflammatory conditions commonly seen in clinic and to be aware of allowing you to correctly differentiate what these conditions in to appropriate pattern
Non-inflammatory disorders (in the next article.)