Back Pain

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Back pain and herniated disc



Back pain is everywhere. The so-called key date prevalence, ie the frequency of back pain on a certain day (“today”), is - depending on the region - between 32 - 49% [1] , which is also confirmed by other sources [2] . If one examines whether someone has had back pain at least once in their life, case numbers of 74-85% come together. Conversely, only around 20% of all people examined or interviewed have never had to deal with back pain.


If you compare the figures with literature from other countries, the frequency in developing countries is significantly lower than in countries with a high gross national product [3] . The risk of becoming a back pain patient is highest between the ages of 40 and 60 and then decreases again [4] . It is largely unclear why older people have less "backs" than younger people [5] . Children can also suffer from back pain. In a survey of schoolchildren in Switzerland, 74% of the schoolchildren already reported their own experiences with back pain [6] , whereby this was more common in children whose parents also had back problems.


The intervertebral disc is often mentioned as the reason for back pain. However, it can definitely only be identified to a very small extent as the cause. For example, only approx. 10% of back pain can be attributed to specific causes such as degenerative disease, intervertebral discs, spinal stenoses, etc. [7] , which is comparable to a study that found a value of 9.3% [8] , It is therefore not surprising if there is no real connection between a nuclear spin / MRI finding and the actual cause [9] .


To prove this, a previous study divided symptom-free people who had never had back problems into three age groups (I: 20-39 years / II: 40-59 years / and III. 60-80 years) and x-rayed using MRI. As a result, a herniated disc was found in Group I in a fifth of the subjects. Bulging of the intervertebral disc (a clear sign that the intervertebral disc has changed degeneratively) even in well over half. Apart from that, at this age a third already had degenerative changes in the spine [10] .


A well-known scenario develops from this: The back pain is so severe or lasts until the patient ends up with the orthopedic surgeon. From there it goes on to the radiologist, because there is the principle that only an MRI can provide information about the real cause of the pain. With a high probability (see study Boden SD et al.) Around three quarters of all examined come home with a spinal disc diagnosis and the rest have "degenerative changes" in the spine. Orthopaedists feel confirmed in the suspicious diagnosis they had previously given. And the patient is also happy to be taken seriously at last. But despite all the criticism, the question remains of where the back pain starts from.



The intervertebral disc consists of a connective tissue fiber ring (anulus fibrosus) and an inner, gelatinous core (nucleus pulposus), which is a kind of "water cushion". The intervertebral disc is the largest avascular tissue in the body. This means that it is dependent on an exchange with vessels outside the intervertebral disc both in terms of its nutrition and in the disposal of metabolic waste products. The fluid is transported mainly by diffusion [11] , which originates from the muscle and ligament compartments that result from the respective “sandwich connections” (vertebral body - intervertebral disc - vertebral body, etc.), some of which come from the blood vessels through small blood vessels Outermost peripheral areas of the annulus fibrosus received inflow [12] . The annulus fibrosus is anatomically connected to the marginal ridges of the vertebral bodies.


The intervertebral disc also has no nerve supply [13] , [14] . Other indications that a sensation of pain might be possible [15] ignore the reality of life, since otherwise every normal movement would have to be noticed.


Disc prolapse

With increasing age - with aging in the spine already beginning in adolescence [16] - and also with nutritional disorders, which are usually caused by insufficient exercise [17] , but sometimes also by inflammation [18] , the intervertebral disc loses its flexibility and Shock absorbers function. Since movement promotes diffusion in particular, the intervertebral disc dries out slowly when there is little movement, so that cracks form in the annulus fibrosus. After a violent movement, the viscous gelatinous nucleus can either bulge outwards (protrusion) or push outwards through this gap, which corresponds to a herniated disc (prolapse). Most often (95%) this happens in the area of ​​the lumbar vertebrae (L4 / L5 or L5 / S1). When intervertebral disc material (sequester) presses on the passing spinal cord, it causes severe pain. Loss of reflexes, emotional disorders or even paralysis can also be the result.


Surgery is inevitable or should be regarded as an emergency if bowel movements and urination can no longer be controlled, there are sudden sensory disorders in the buttocks and thighs and paralysis also spreads to the leg (Cauda-Equina syndrome). However, this is only to be expected in 5% of all herniated discs [19] .


After only approx. 10% of all back pain can be attributed to an injured intervertebral disc, spinal stenosis, osteoporosis (“cover plate collapse”) or a tumor, it is surprising why the ritualized diagnostic procedure (“radiology”) has not long since given way to more pragmatic evidence. This is mainly due to the ever-increasing "risk minimization" and, of course, the convenience with which orthopedics fulfills a pseudo standard in order to avoid a possible liability issue. And then also on the uncertain and time-consuming terrain of finding the truth, since the wide area of ​​muscular causes is not really tangible.


This can best be illustrated using the example of a clinical facility that patients with a diagnosed intervertebral disc prolapse do not consider as future “surgical intervertebral disc customers”, but rather go through the trouble of getting to the bottom of the pain through physiotherapeutic measures in a diagnostic-therapeutic manner. Unless there are neurological failures such as paralysis, conservative therapies for herniated discs are the method of first choice. At least that is how the guidelines of the German Society for Neurosurgery determine it [20] .


However, the reality is quite different: the number of intervertebral disc surgeries has increased by more than 58% since 2005 and the TU Berlin counted 278 531 spinal surgeries in Germany alone in 2011 [21] , of which 92 508 related to excisions of intervertebral disc tissue. The differences with other countries and regional clusters are also striking. In England, for example, the number of intervertebral disc operations per 100,000 inhabitants per year is 100, in France 250 and 450 in Germany. Germany, however, excluding Munich, because there are 1,000 in Munich alone, which is probably due to the fact that there the number of intervertebral disc surgeons rose from 54 to 140 within a few years [22] .


Real cause of back pain

Although the scientific literature on the "true cause" of 85 - 90% of back pain is largely silent and there is obviously satisfied with the reason "non-specific low back pain" [23] , it is quite clear that so-called myofascial syndromes are behind it [24] . Already at a pain congress it was denounced that unspecific back pain describes a frequently neglected differential diagnosis because this takes time and does not bring the doctor appropriate remuneration [25] . Since 90% of back pain is myofascial, effective analgesia (pain treatment) and above all the normalization of muscle tone have top priority. Anti-inflammatory drugs are only indicated for classic signs of inflammation, because these occur in only 5% of all cases [26] .


Myofascial pain syndrome

These are “hardening” in the course of the muscle fibers, which can be easily palpated by experienced physiotherapists and cause local or transmitted muscle pain. The term “myofascial” was first coined in the 1940s [27]> , and also refers to pressure-sensitive trigger points, which, however, can be distinguished from fibromyalgia syndrome, where they are predominantly close to the tendon and have neither a hard cord nor transmitted pain. The "myofascial pain syndrome" [28] , which describes strand-like hardening in over 130 relevant muscles and pain radiating from trigger points [29] , has since been proven by a number of clinical and experimental studies [30] , [31] , [32] , [ 33] , [34] , [35] .


The pathophysiological cause is hypersensitivity of the muscle tissue, which is caused by muscle overload. This causes local hypoxia (oxygen undersaturation) with the consequence of a reduced absorption of calcium in the sarcoplasmic reticulum (cell organelle), which promotes a permanent contraction of the muscle fibers.


The sarcoplasmic reticulum only occurs in myocytes (muscle cells) and “envelops” the fibrils of the muscle cell. It serves to store calcium ions, which are released after a motor nerve stimulus (action potential) and thus trigger a contraction of the muscle fibers.


Measurements in a motor skills laboratory, for example, have shown [36] that when the heel is put on (while walking), the back muscles tense in order to absorb the impact. In back pain patients, this exact interplay of muscles no longer works properly, ie the back muscles only tighten when the heel is already on. The impact hits the spine unchecked. The most important cause is likely to be a lack of movement in modern workplaces or permanent stress. When muscles are no longer active or fail even under permanent stress, coordination disorders are inevitable. The underlying muscles in the abdominal, back and buttocks areas were identified as possible causes [37] .


Myofascial pain syndrome is one of the most common pain disorders. It does not only refer to the back, but also, for example, to arthrosis [38] , [39] , [40] , abdominal pain [41] , shoulder pain [42] , orofascial pain [43] , tension headache [44] and migraine [45 ] .

Based on new findings on the myofascial syndrome, the old thesis that humans were not made for upright walking and that this leads to increased stress and increased wear on the spine can no longer be maintained. As already explained above, the real reason is a deficit in the exact interaction of the back muscles [46] . In the case of back pain patients, coordination deficits [47] as well as deficits in the strength and endurance area of ​​the trunk muscles can be demonstrated [48] . A kind of "protective mechanism" develops an over-sensitive, tightened muscle fiber bundle ("taut band").

Taut band + trigger point

The "taut band" is a group of tightened muscle fibers that thicken like a strand and consist of several contraction nodes in individual zones. These seem to be responsible for tightening the muscle fibers. This can lead to transmitted pain, ie the place of pain is not the point of origin. Insertion trigger points are created on each side of the taut band in the attachment area of ​​the tense fiber bundle. The central trigger point is thought to transmit the reference pain and the attachment trigger points to transmit the local pain [49] . Taut band and trigger areas lead to a shortening of the sarcomere (“smallest contractile unit of the muscle”), which results in compression of the blood vessels passing through and an ischemia (anemia) [50] . With the reduced blood flow, there is an oxygen deficiency in the trigger point area with a pO2 close to zero [51] . The decreased pO2 is associated with an ATP deficiency so that the contraction nodes cannot loosen on their own.

Therapy of myofascial pain syndromes or non-specific back pain

Since myofascial pain syndromes (trigger points and taut bands) are based on reduced blood flow and hypoxia, pain therapy should aim to improve the microcirculation [52] . In addition to physiotherapeutic measures that also apply to deficient muscle coordination, simple heat applications [53] , for example, appear to be rather counterproductive, since a reflex contraction of the vessels occurs after the heat source has been discontinued ("exception: mud baths"). The electrotherapy, which is effective in principle, is also limited, because it does not allow you to reach deeper muscle compartments or an increase in the current intensity due to skin resistance and irritation of the sensitive nerve endings ("pain") fails. So it makes sense to use the principle of electromagnetic pulses (PEMF) for which there is no tissue resistance. PEMF are known to have a microcirculation-increasing potential (see document microcirculation) and at the same time have an anti-inflammatory effect (see document tendopathies).


study location

As expected, only nine studies and one systematic review are indexed for PEMF therapy for acute or chronic back pain. This is also due to the fact that the effect model of a myofascial event as the actual cause of acute or chronic back pain has little liking among orthopedists for the reasons stated. This means that there is very little incentive to treat a herniated disc diagnosed by MRI with PEMF, let alone to raise tuition fees. So it is not surprising that back pain studies almost exclusively refer to the outdated intervertebral disc model.


This is all the more astonishing, since the use of physiotherapeutic measures alone leads to a reduction in pain, so the suspicion should arise that the intervertebral disc cannot be behind it. After the physiotherapeutic treatment of a “herniated disc”, the discharge diagnosis (prolapse) corresponds exactly to the initial diagnosis (prolapse), ie nothing has changed in the prolapse. To put it in a nutshell: About 90% of all back pain is non-specific, i.e. despite diagnosed herniated disc, it is not caused by changes in the spine, but is related to the deep back muscles as well as the abdominal and gluteal muscles.


Study 1

In a randomized, double-blind and placebo-controlled clinical study, 40 patients (without radicular irritation according to MRI) with a pain score of> 4 (11-point scale NRS) were examined 3 times a week for 3 weeks with a magnetic field of high intensity (System CR- 3000 / 1.3 - 2.1 Tesla / 5 + 10 Hz alternating every 5 seconds) treated for 15 minutes each. For this purpose, the applicator was placed 5 cm above the skin in the lumbar area. Result: Although there was a significant reduction in pain in both the verum and placebo groups, the result was significantly better in the active group. 4 weeks after the end of therapy, the percentage change in the NRS score was 38 +/- 11% for verum versus 22 +/- 24% for placebo. In the Oswestry Disability Questionaire, those treated actively improved by 28 +/- 30% and in the placebo group by 8 +/- 32% [54] .


Comment: A flux density of 1 - 2 Tesla is of course not representative of PEMF. This is likely to be rPMS, i.e. repetitive peripheral magnetic stimulation. The study design presented here amazes after a 15-minute application without pausing the risk of muscle fatigue.


The Oswestry Disability Questionnaire or Index (questionnaire) assesses the patient's limitations in ten different functional areas such as pain intensity, personal hygiene, lifting, running, sitting, standing, sleeping, sexual activity, social life, travel. Each of the 10 questions provides 6 possible answers, which the patient rates with 0 - 5 points. With 0 there is no restriction in this area. This means a maximum of 50 points can be achieved. A percentage value is determined from the points. If the patient calculates 16 points, for example, then he has a functional disability of 16/50 x 100 = 32%.

Study 2

In another study, 66 patients ( / 30 - 76 years) with chronic back pain, due to degenerative changes in the spine (spinal), were treated with either PEMF (System Viofor JPS), magnetic stimulation or TENS. The pain score (VAS) was determined at baseline, after 5, 10 and 15 applications. Result: Pain was reduced in all patients. The best results were achieved with PEMF and with TENS. The slightest improvement was achieved by magnetic stimulation (rPMS) [55] . See previous explanation.


Study 3

120 patients diagnosed with lumbar disc herniation without root symptoms. Group A (60 patients) received laser treatment, group B (60 patients) received PEMF (5 mT, 30 Hz, 15 minutes). Result: Both groups benefited from the applications. There was a slight benefit to lasers in terms of pain reduction. PEMF had an advantage in terms of mobility (flexion and extension) [56] .


Study 4

40 patients with nerve root irritation (radiculopathy) after a herniated disc received either PEMF or placebo in a randomized study design. Result: According to the VAS score and ODQ (pain intensity, personal care, lifting, walking, sitting, standing, sleeping, social life and work), there were clear differences compared to the placebo group. Based on the somato-sensory potential of various dermatomes, the authors come to the conclusion that PEMF reduces nerve compression [57]


Dermatome: is the area of ​​the skin that is autonomously supplied by sensitive fibers of a spinal nerve root. Somatosensory potential: Irritation of the sensitive nerve or dermatome. Since the stimulus is switched via the spinal cord, damage to the nerve root can be concluded by changing the stimulus response.

Study 5

Study on PEMF treatment of non-specific back pain in combination with conservative therapy measures. Two groups were formed for this. One group was treated conventionally over 6 weeks (physiotherapy), the other group conventionally + 6 PEMF applications. Result: The pain and the degree of disability (mobility) decreased significantly in both intervention groups. However, significantly better results were achieved with the combination therapy [58] .


Study 6

In the US military, back pain is one of the most frequently mentioned complaints that lead to a doctor and both cost working time and can also result in retirement from active service. The aim of this study was to examine the extent to which the use of PEMF affects the symptoms of back pain, quality of life, mental health and incapacity to work. Two groups were formed for this. One group received conservative therapy. The second group conservative therapy + PEMF. Result: The additional use of PEMF improved all examined parameters, whereby the results regarding pain reduction and incapacity for work were not significant. However, it was incomprehensible why more anxiety symptoms appeared in the combination group [59] .


Study 7

For a randomized, double-blind and placebo-controlled study at the School of Physiotherapy at the University of Otago, 40 patients were recruited who had acute back pain <6 weeks (diagnosis: non-specific back pain). The ODQ index was the primary measuring instrument. Secondary assessment scores were the "Patient Specific Functional Scale" and "Numeric Pain Rating Scale". Testing was done at baseline and one week and four weeks after treatment. Result: In the group that received an additional PEMF treatment (30 µT / 27.12 MHz) in addition to the conservative therapy, there was no difference to the group with the exclusively conservative therapy. As a result, additional PEMF therapy does not appear to bring any additional benefit [60] .


Comment: The radiotherapy / diathermy procedure (high frequency 27.12 GHz) performed here is not comparable to an extremely low-frequency PEMF.


Study 8

Prospective, randomized, single-blind, placebo-controlled study on chronic back pain. 40 patients. PEMF with 15 mT. After a baseline period of 2 weeks, 6 treatments of 30 minutes each were carried out over 2 weeks with a subsequent follow-up after 2 weeks. Result: In the follow-up, the PEMF group showed a significantly greater pain reduction (20.5%) than placebo [61] .


Study 9

16 patients with back pain without root irritation. Group A with 8 patients received the standard medication (non-steroidal anti-inflammatory drugs) + PEMF (4 x daily / 9 days). Group B only received the standard medication. Result: The pain decreased faster in the PEMF group. Their active physical functions were also available to them again more quickly - in each case compared to group B [62] .


Review 1

Systematic review of the effectiveness of PEMF in back pain. Publication period January 2005 - August 2015. Result: 6 studies were suitable for a qualitative analysis and 5 studies for a quantitative analysis - corresponding to a total score of 6.8 points on the PEDro scale. PEMF showed a clear tendency to minimize pain. PEMF also improves the functional parameters [63] .


The PEDro scale (Physiotherapy Evidence Database) [64] is a freely accessible, web-based database on evidence relevant to physiotherapy. It contains citations of over 39,000 RCTs (Randomized Controlled Trials), systematic reviews and evidence-based practice guidelines on physiotherapy. This is intended to quickly differentiate between likely valid and interpretable and non-valid RCTs. PEDro takes two aspects of the study quality into account: credibility ("internal validity of the study") and whether the study contains sufficient statistical information. A maximum of 10 points can be achieved: PEDro value 7 - 10 points = high quality. 4 - 6 = average. 1 - 3 = poor quality.


Confidence in the incorruptibility of radiological diagnostics (MRI) and a misinterpreted model of action suggest that herniated discs or degenerative changes in the spine are always the cause of acute and chronic back pain. This confirms critics and doubters in their supposed logic that a PEMF application is relatively useless after pulsating electromagnetic fields cannot repair a spinal disc.


However, there is no lack of clear evidence that around 90% of all acute and chronic back pain - regardless of whether a spinal disc diagnosis is made - is caused by a myofascial syndrome. Muscle strand hardening and fiber knots, which are very painful due to the “squeezing” of sensitive nerves, are also related to an interruption in the microcirculation, which results in hypoxia (undersaturation of oxygen). Therapeutic interventions therefore benefit from measures that increase microcirculation.


In addition to physiotherapeutic applications, PEMF is particularly recommended here, since PEMF has a microcirculation-increasing and anti-inflammatory effect. The latter should not be decisive, however, since only 5% of all myofascial syndromes have an inflammatory origin. Compared to electrotherapy, which is of considerable importance in myofascial syndromes, PEMF therapy is characterized by a greater depth effect.


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