Consultations and investigations
With an attack of backpain it is important to consult a specialist in the first instance before starting any treatment.On examination alone he can come to a working diagnosis so that appropriate treatment can be started. Certain investigations are mandatory for pin pointing the diagnosis. With the advent of MRI it is possible to diagnose most conditions without doing any other investigation. An MRI Scan on th lumbar spine will give information regarding the presence of prolapsed disc, degeneration in the spine, anatomical defects in the spine or presence of any other pathology in the spine.Instability in the spine cannot be well defined and needs plain X rays of lumbar spine in dynamic positions.Certain pathologies like narrow lateral rescesses or root outlet obstruction can be better defined by CT Myelography investigation

Conservative treatment: Drugs
With acute pain the patient is keen to have some medicines to get relief. Anti-inflammatory drugs are very useful and Ibuprofen is the most effective in relieving pain specially when it is combined with paracetamol.Valim or calmpose (diazepam) in smaller doses helps relieving spasm in the muscles and stiffness. For the first two or three days enzymes like Chymotripsin is very useful in resolving any contusion or swelling in the muscles.Nitrazepam gives good sleep at night and antacids keep the stomack free from irritation due to drugs and pain

Conservative treatment: Fomentations and massage
Fomentation is extremely useful to give a soothing feeling to the painful muscles.
To start with when the muscles are swollen Ice fomentation for 48 hours is of choice.
Once the swelling has subsided hot fomentation is more useful to relax the spasm in the muscles.There are innumerable home and hospital ways of giving hot fomentation like hot water bottle,hot brick, short wave diathermy, microwave diathermy etc.All modalities are useful but infra red light is not very useful in acute pain.The fomentation can be given for a period of ten days.It helps to increase the circulation to the part and relax the muscles.

Gentle massage helps to loosen the tight muscles in spasm.Massage should not be used during the first 48 hours when there is acute inflammation.Massage has several other advantages.

1. With the relief of pain the anxiety of the patient is relieved.
2. Gentle massage gives the feeling of general well being.
3. It also helps to satisfy the ego of the patient.

Therapist’s fingers are good for massage.Several massagers and vibrators are available in the market.They are useful.Oil should not be used in the massage.

Conservative treatment: Rest
The part which is paining or aching has to be rested during the acute phase.However Sports medicine principle should be used. Rest should be taken to a bare minimum absolute essential period.May be two of three days.No sooner the pain is on the decline passive exercises should be started.Rest does relieve pain but when over extended it produces stiffness which in turn brings in weakness in the muscles and prolongs convalescence.Recovery then may not be full and complete.

Mobilisation: Exercises and physiotherapy
Acute pain last from 12 to 72 hours.Once this period is over early mobilization exercises to be started on the 3rd day.The principles of exercises in order are: passive mobilisation; stretching and active muscle strengthening exercises.If these principles are followed active life can be resumed within three to four weeks. Physiotherapist has a significant role to play in backpain.They can start the right exercises for mobility, help the patient with massage of tight muscles in spasm and even do manipulation to mobilize the facet joints.

Conservative treatment: Traction and belts

Traction: Rescent studies have shown that lumbar traction has not produced any beneficial effects except restricting the patient to bed and imposing rest forcefully.I am not very much in favour of lumbar traction. In broad principle the traction is supposed to pull joints apart and thus relax muscles, reduce pressure within the disc and produce stretch on facet joints.

Belts: In the acute phase they are useful.The belt helps to restrict any abnormal movements like twisting specially during sleep in acute phase.Belt also prevent painful movements.Most patients get addicted to belts and addiction is directly related to age.But it should not be used for more than two or three weeks. Overuse of belts cause spinal musculature to be weak and perpetuate backpain causing addiction to belt.

Conservative treatment: Hydrotherapy and Back School Philosophy
Hydrotherapy or just sitting in water or floating in water gives the effect of weightlessness which in turn increases the mobility in the musculature of spine. It has definite role to play in the treatment of backpain. Really there should not be any concerns to the contents of the water.It does not matter if the water is hot or not, whether it contains sulphur or salt or nothing. Back school philosophy.there are centers where one can get very useful advice to keep the spine healthy and agile. Most important is the positional advice so that aberrations of posture can be corrected. Correct exercise keeps the muscles mobile and energetic. Hydroptherapy increases mobility and education helps tremendously to know more about the spine and its care which in turn helps to build the confidence of the patient

Conservative treatment: Home remedies
More has been written and is being written now than in the past about Home remedies.It only proves the importance of home remedies.In a given case of backpain home remedies are extremely useful.Backpain in the acute phase is extremely nagging and home remedies should be tried along with other medicines.Just to give one example it was reported rescently that our famous cricketer of yester years Mr.Dilip Sardesai bruised elbow while playing against New Zealand and the team doctor declared that he will be unable to play the next day.His mother applied a balm containing egg yolk, cashew fenni and some herbal medicines.Mr.sardessai scored 200 runs the next day.

Conservative treatment: Exercises

Basic principles to prevent backpain:
1: Regular exercises.
2: Warm up before active exercises specially lifting weights.
3: Prevent getting fatigued at the end of the day.
4: Not to lift unaccustomed weight or not to do unaccostomes activity like occasional gardening.

Basic principles of exercises:
1: Warm up.
2: Muscle stretching.
3: Muscle strengthening
4: Cool down.

Types of exercises:
1: Passive exercises.
2: Resistive exercises.
3: Active exercises.
4: Functional exercises.

After surgery exercises:
1: Extremely important.
2: Operation produces stiffness.
3: Exercises increase flexibility and ROM.(Range of motion)
4: Exercises must be started as soon as is possible.

Hospitalisation for surgery
When the conservative treatment has not produced satisfactory relief of pain then surgery is advised and hospitalisation is recommended.With advance in surgical technology the operation for prolapsed lumbar intervertebral disc has become extremely simple for the patient with very little time being spent in the hospital.With backache and sciatica the operation is done through microscope(Microlumbar discectomy.)It has least morbidity and the patient is discharged from the hospital in less than 24 hours.

Serious consequences. Must see a doctor
within a day or two. But if the pain gets worse then doctor must be consulted. Difficulty in passing urine and difficulty in opening bowels is of serious consequence.There is no time to be wasted in conservative treatmentThe specialist must be expeditiously consulted who in turn will advise immediate hospitalisation and quich surgery. Foot drop. Dragging of foot because it cannot be elevated due to weakness of paralysis is also a serious neurological problem and must be dealth with immediately by decompressiong the offended nerve root surgically. In all these conditions the nerves are compressed.It is a matter of interest to know that successful decompression of the nerves done late does not much help to recover the function in these nerves.On a number of occasions one sees a patient dragging his foot while walking or using anti dragging device or catheter being permanently placed in his bladder or he is regularly doing self catheterization.

Who should be doing the surgery?
Whenever the subject of treatment of backpain is discussed by Neuro and Orthopaedic surgeons one always finds controversy and disagreement over advisability,indications and necessity of surgery. The reason for this is the fact that many patients remain apparently asymptomatic for a long time and others with exactly the same pathology have incapacitating low back pain.The difference between the two groups has not been simple to define and it really does not matter.Any specialist who is expert at dealing with these problems should be doing the surgery. Many times patients have asked the Orthpaedic surgeon.Doctor, you say the nerve is involved.then it should be Neurosurgeon’s problem.Other patients have asked a Neurosurgeon.Doctor, is the slipped disc a part of bone or nerve.Such questions have no definite answer.Fortunately Spinal Surgery is rapidly evolving as a separate speciality and all such misconceptions will be done away soon.

The surgery
On admission to the hospital for surgery tests are done to find out medical fitness for surgery.The operation is done under general anaesthesia.The incision is just less than one inch.It takes about 2 hours for the procedure.There are no sutures.Patient wakes up from anaesthesia soon after the operation and within hours he is allowed to get out of bed and walk to the toilet. In to- day’s surgery there is no post operative vomiting or feeling drowsiness or giddiness and within six hours he is allowed to eat soft diet. He is discharged from the hospital the next day.

Activity:
Exercises on the back are started as soon as is possible preferably within a week after Microlumbar discectomy.The aim is to do away with operative stiffness, make the muscles supple and increase the mobility of spine.One can then start rebuilding the strength in the spinal musculature.Rachita Mistry, Olympic athlet from Mumbai was operated upon by me for Microlumbar discectomy in 1999.Net year she participated in Olympics and also in the National Games in Bangalore and succeeded in breaking the 18 years old record of P.T.Usha in 100 meters.She was conferred Arjuna Award. While doing exercises there should be no pain and any exercise which hurts must be stopped.To avoid overdoing one must stop when tiredness sets in. Walking is the best activity after surgery to start with. Within six weeks after surgery all restrictions on his activities are lifted.

Sexual Functions
Indulgence in sex is extremely important during the recuperation phase either after surgery or conservative treatment.As a result of backpain and or surgery the patient is in a depressed mood and is in need of some sort of recreational activity to elevate his mood. Sexual activity is the best recreation. As such sexual activity had taken a back seat as a result of backpain. Patient is in fact looking forward to this type of activity. This need during the healing phase should not be ignored. Sexual activity also helps to overcome anxieties and fears.. It particularly helps in chronic backpain in tense personalities and anxious persons.When nothing more can be done for chronic backpain due to degenerative disorder sexual activity helps to live with satisfaction with chronic backpain.It is advisable for the patient to be in supine position during the activity.

Meditation is extremely important in backpain.
1: It helps to recognize and reduce stress
2: Overcome anxieties and fears
3: Lowers Heart beats and respiratory rate
4: Promotes Alpha rhythm and calm mind
5: In chronic backpain meditation is useful in
a)tense personalities
b)Anxious persons.
6: Helps the patient to live with chronic backpain.

Types of meditations
There are several types of meditations.Important is to learn one technique from the teacher. Following types are known.
1: Transcendental
2: Buddhist
3: Yoga and
4: Active form of meditation of Rajneesh. Which involves various postures and facial contortions along with deep breathing during meditation.
Transcendental Silent rhythmic repetition of a word like “OWM”
Buddhist or Yoga Involves concentrating on a single object.

Principles of meditation
1: Perception of oneself is lost
2: All personal desires are lost and
3: Sense of unity with universe is achieved.

Philosophy
Most people are too bogged down and involved with their own activities and emotions or sufferings like chronic backpain. Mental tranquility does take them away from the path of sufferings and restlessness of the mind. Meditation A simple method.

Choose a quiet room
Sit or lie down
Close eyes and relax muscles
Breathe through nose and be aware
Breathe out slowly and say “ONE” or “OWM”.
Practise to keep away distracting thoughts
Practice from 10 to 20 minutes.
End: Sit or lie quiet for few minutes first with eyes closed and then with eyes open.

Practitioner's attitude to the patient
Involves Orthodox and Western therapies.
Alternative therapies.

Holistic medicine:
It involves diagnosis and treatment of all factors affecting health.
Physical considerations:
Biochemical factors
Mechanical factors

Mental considerations:
Motivation towards recovery
Ability to adapt.
Trust in the therapist heightens the chances of cure.

Improvement is most seen using therapeutic approach preferred by the patient.

Conclusions
In a given case of industrial backpain treated conservatively or surgically, once a proper and scientific approach has been adopted based on sports medicine principle there is every reason to expect that the daily life and activities will have significantly improved as a result of having undergone proper treatment and proper rehabilitation. Hundreds of thousand of surgeries are being carried out on the back for prolapsed lumbar intervertebral discs round the world every year. Wrong concept and wrong fear should not be encouraged.

Rachita Mistry, Olympic athlete, was operated upon by me for prolapsed lumbar intervertebral disc in 1999 In the year 2000 she participated again in Olympics and later in the National Games in Bangalore she broke 18 years old P.T.Usha’s record in 100 meters.

Fitness
Insufficient exercise increases the risk of back problems. Strong and flexible muscles prevent backpain, help in quick recovery and help to grow old in a healthy way. Sports like Golf, Bowling and Cricket which causes twisting and straining of the back has higher incidence of backpain.

SUMMARY OF SUCCESS

No single method is right
Strong Doctor patient relationship
Faith in the therapist is important
Therapist perception, expertise and knowledge has a lot to say in the success of therapy.