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For people of forty-five or younger low back pain syndromes are the major cause of activity limitation in the industrialised societies of the west. Defining what a chronic syndrome has been agreed that any condition lasting longer than the expected time of healing of the soft tissues could be classed as chronic, a period of approximately three months. The soft tissues of the body should heal in this time and pain has a useful survival function for us in these cases, making us remove the injuring forces and look after the damaged part as it heals. There appears to be no useful biological function for the chronic pain syndromes.

Overall back pain is very common and up to 20 percent of the population may have long term and recurring problems but they are not continually severe. A small group of 5-7 percent of back pain suffers develop a chronic pain problem which is disabling and prevents work. It is a relatively common cause of undergoing a surgical procedure and because much of the structure of the intervertebral discs is avascular this may slow the healing period significantly and make resolution of the problem less likely.

Injuries occurring to the spine and the onset of degenerative changes in the joints and the discs may explain many of the back pain problems which arise but there is a poor relationship between the amount of pathological changes in the spine and the level of pain suffered by a patient. MRI scanning reveals many disc changes such as protrusions or prolapses in individuals who are not complaining of significant pain. The causes are not well understood but may include inflammatory and neurological influences.

If imaging and other diagnostic studies do not reveal a plausible pathological reason for a person’s back pain then it is very easy to question whether psychological factors are responsible. Although psychological factors combine in a complex way in the progress from acute back pain towards a disabling condition there is no good evidence that psychological factors can produce pain. The cause of the pain may just not be amenable to the forms of investigation now prevalent. Once the condition is present or developing however, and arguably even in the acute stage, it is vital to identify and deal with all the non-physical factors to attain the best outcome.

Heavy workers make up the greatest preponderance of claims for low back pain, with high risk categories being truck drivers, operators of heavy equipment and construction workers. The lifetime prevalence of back pain and sciatica appears to be very high in heavy workers such as those working on road construction. Sciatica is much less common than back pain (around five percent) and typically resolves without interventions, but is still an important cause of surgical management with most surgery occurring at the L4/5 level, closely followed by L5/S1. Levels of surgical management are low in the United Kingdom but can be much higher elsewhere, such as in the United States.

The levels of chronic disability from low back pain problems has reached crisis proportions predominantly in western and industrial countries, causing both economic and social side effects. The underlying degenerative changes in the spine have not been shown to have any different genetic origin between races. Back pain problems present in equal numbers in both women and men with middle age being the prime time for these complaints to surface due to the likely presence of spinal changes by this time. Sciatica mostly occurs in a person’s forties or thirties and the average age for operative disc surgery is 42.

The last and more flexible part of the spine is the lumbar spine which is specialised in supporting the weight of the body above it and in transmitting it to the legs. For its size the lumbar spine is able to manage heavy loads and pass them on through the sacroiliac joints to the pelvis and the legs. There is considerable mobility in the lumbar vertebrae and they function to transmit loads by the internal bony structure of the cancellous struts forming stronger areas called trabeculae which are aligned with the lines of forces taken by the spine in activities.

Patient sometimes report than they wish their arm could be cut off when they are unlucky enough to suffer from the agonising pain of a nerve root impingement. Patients presenting with nerve root lesions look very tired as they have not slept for several nights, are not in the mood for jokes and hold their arm protected in a typical position. Depending on which nerve root is responsible the area of the pain in the arm varies, with pain running in severe waves down the limb and also feeling exceptionally sharp in nature. An immediate increase in pain severity follows any tension or stretch applied to the affected nerve root.

Patients typically find there are only one or two comfortable positions for the arm and maintain these carefully to ease the pain. They may hold the arm against the tummy or place the hand on top of the head to achieve relief. Countering the pain and the inflammation is very important in the early stages and patients should take maximum permitted doses of strong analgesics and anti-inflammatory drugs to prevent the escalation of pain mechanisms in the nervous system. Manual treatment is risky due to the condition’s highly irritable nature but some input can be given to ease the joint movement and increase circulation.

Much of the management of nerve root lesions consists of not aggravating the condition at all as the results can be very unpleasant if the therapist goes in too hard. Wearing a collar, joint mobilisations, maintaining the least painful position and cervical traction are all possible treatments for this problem as we wait for nature to gradually settle down. As the disc, nerve or joint settles the patient breathes a sigh of relief as the pain reduces, they can get some sleep and start moving their head and doing normal activities again.

Once the pain is settling the focus can change to some extent but still needs to be kept on how easy it would be to re-aggravate the pain back towards its previous levels. A collar may still be useful at night to minimise the excursion of the neck joints during sleep and gentle mobilising movements taught in small ranges for the neck to put some mechanical input in to affect the pain systems. Analgesic support should be kept up for longer than the person feels they need to as control of the pain is important and they need some cover as they begin to do normal things again with the neck.

The arm pain should start resolving within six weeks and if it does not then a referral to an orthopaedic spinal surgeon might be indicated. While nerve root pains almost always settle on their own the period of severe pain can be too long in some cases to just wait until it resolves. The surgeon will want to know the history of previous neck pain and the reason, if known, for this episode, where the pain is and the worsening and easing factors. Examining this kind of patient physically is restricted by their pain levels but movements, sensation, reflexes and muscle power are typically assessed.

The examination finding will likely be that a specific area of the arm is troubled by the pain and this is accompanied by specific sensory, reflex and muscle power abnormalities, all of which fit the pattern of being supplied by the one affected nerve. It is most common for only one nerve to be affected in this way and if more than one is suspected it should be reported back to the referrer.

A magnetic resonance imaging scan is typically ordered once the surgeon feels a nerve root lesion is the likely diagnosis, in order to indicate the nature of the compression. If a disc protrusion consistent with the examination findings is found on the MRI scan then a cervical discectomy is an option although this is more commonly performed in the lumbar spine. Management after operation is straightforward and patients should return to normal. Maintenance of physical fitness over the long term and a speedy return to normal activities is the best management of this problem and may protect against complications.

It is very difficult to deal with the reality of acceptance whilst easy to talk about it. Pain sufferers find it very challenging that they cannot any longer manage an important ability they feel they should perform with ease. People with a chronic pain disability show no outward signs of their restrictions and others treat them as normal, expecting them to be able to do things normally too. Coping with the loss of usual functioning is difficult as can be the attitudes and beliefs of other people towards pain conditions. However, the conflict which exists cannot usefully be continued and sufferers benefit from working on acceptance of the situation.

In most things we have to accept the reality of what we are and what the present situation is. We can in many cases make changes to our situation to improve things and get closer to what we want to be. However, in some cases we are stuck with the situation we are in and we have no option but the accept it or fight against it. Fighting it generates, as we have seen, conflict which has undesirable consequences. Gradually moving towards acceptance can free us from this conflict and allow us, finally, to work at our difficulties in a productive manner.

Not accepting the situation means we cannot release ourselves from the conflict and can’t take on our or others’ suggestions for improvement. If I won’t give in to the pain or let people down by admitting I can’t do something then I won’t see why I should do things any differently or accept a lower standard of performance of the job. This way the route to making the necessary changes can be blocked, getting in the way of our progress towards where we want to be. If we say This is the reality of the situation and I have to work with that we can step forward and begin change.

The scripts we use, the words which we say to ourselves about our abilities or our desires, are important in how we act. They are often unconscious, these specific interpretations and ideas about ourselves. We might say My fitness is at a good level and I can manage social activities, sports and my life all together, which would be a good position to be in. If a person has a pain syndrome or low back problem their scripts will run in different ways such as My pain disables me and I don’t think it is ever going to improve so I won’t be enjoying any activities in the future. This is the underlying message a resigned person might have constructed for themselves.

However, very negative scripts, constantly going round and round in our minds, lead to negative thinking and depression. One approach is to consciously generate new scripts and an example of this might be Even though I do have a pain condition which limits my ability, if I manage my situation well I will be able to do many of the things I want to in a modified manner. This is a realistic description of the situation and more likely to lead to a realistic assessment of our situation and a more positive approach to any action which could be taken to improve it.

When our scripts describing ourselves are more realistic they are also more positive, though it is important not to generate unrealistic, rose-tinted scripts as they will be found out by us when we realise where we think we are is so far from reality. More positive scripts allow us to participate in the changes that we might want or that a health professional might suggest, ideas that previously were unacceptable due to our inability to recognise where we really were in terms of our physical or mental state.

So if we can accept the situation to some extent it is much more likely we will adopt adaptive measures to improve our condition. The typical behaviour we adopt when we have a chronic pain problem, to push through the pain until the job’s done can be altered.

Having a herniated disc in and of itself can be a very painful condition. When sciatica is a by product of the problem it is even worse. Not only do you have the pain from the disc,but you also have the pain from the swollen and irritated sciatic nerve.

First a herniated disc occurs when the central portion of the disc called the nucleus pulposis migrates outwards and breaks through the outer portion of the disc called the annulus fibrosis.

In research studies only the outer 1/3 of the disc has been shown to contain pain sensitive fibers. Therefore damage can accumulate over time before the person ever feels any pain.

Repetitive activities, incorrect sitting postures and trauma are usually to blame when it comes to herniated disc pain. These activities weaken the outer annulus allowing migration of the inner portion of the disc.

As the migration occurs and the outer fibers become contacted the pain sensitive nerves begin to become activated resulting in local back pain at first.

After the initial bout of back pain from a disc problem occurs a short period of relief or lessened pain may come about. This is usually due to the fact that the activities that caused the problem have been modified or stopped.

Many people make the false assumption that the pain is gone for good, however the medical literature shows a very different scenario. People are almost always destined to have another bout of back pain within a year, unless proper treatment is applied.

With the return of the pain there is also a corresponding increase the the area involved. This usually starts with a movement of the pain into the arm and leg depending on where the disc problem is.

Once pain begins to move into the leg it is often called sciatica. This condition is associated with involvement of the sciatic nerve.

The pain from sciatica can be a consequence of either pressure from the disc itself on the nerve or from inflammation caused by the injured disc irritating the sciatic nerve.

In either case proper treatment is a must. This means actually working to fix the disc problem through proactive means. The best treatment I have come across is for this is spinal decompression.

The outer fibers of the disc are able to scar over due to the negative pressures inside the disc, created with spinal decompression pulling back in the herniated material

Spinal decompression is the best treatment to actually heal a herniated disc relieving sciatica pain.