Magnetic Resonance Imaging (MRI) is a diagnostic modality utilizing magnetic fields and radio frequency fields to produce high-contrast images of the body.

When is an MRI necessary for back-pain?

While a good clinical history and detailed physical examination by a skilled doctor is often sufficient for an initial diagnosis and treatment of a patient with back pain, it is sometimes preferable to proceed to imaging.

Compared to X-rays, an MRI will produce a much better image , especially when it is necessary to see the soft tissues more clearly. These may include:

• Para-vertebral muscles
• Inter-vertebral disc
• Epidural spaces
• Spinal cord

Some special situations in which your doctor may order an MRI for back pain would include cases where it is associated with:

• Unexplained fever
• Weakness of any limb or an unexplained difficulty in walking
• Loss of defecation and/or urinary control
• Sensory loss
• Unexplained weight loss or loss of appetite
• Signs of spine arthritis on X-Rays
• X-Rays showing decreased inter-vertebral space or collapse of vertebral bodies

In such situations, the MRI could help make a diagnosis of, or exclude:

• Spinal cord problems:
  • Spinal cord trauma
  • Spinal cord abscess (infection)
  • Cauda equina syndrome
    
  • Spinal cord tumor
  • Tethered cord syndrome
• Disc problems:
  • Slipped disc
  • Discitis (infection of the intervertebral disc)
  • Disc degeneration
• Spinal canal diseases:
  • Spinal canal stenosis
  • Hypertrophy of longitudinal ligaments
• Vertebrae problems:
  • Compression fractures

If in doubt, always discuss with your doctor on whether you should have an MRI done.

• Medial tibio-femoral compartment (the “inner part” of the knee)
  
• Lateral tibio-femoral compartment (the “outer part” of the knee)
  
• Patello-femoral compartment (the “front part” of the knee)
  

There are many possible causes of knee pain but usually with a good medical history and clinical examination, together with selective investigations by a doctor, it is possible to narrow down the cause of knee pain to one of the following:

Arthritis

Arthritis (from Greek “arthro”-meaning “joint” , and “itis”-referring to “inflammation”) is a form of joint disorder that involves inflammation of one or more joints. It could cause generalized knee pain, and present as a painful knee, or limping on prolonged walking. Some types of arthritis include:

• Osteoarthritis (“commonly known as wear and tear”)
  
• Rheumatoid arthritis
• Septic arthritis (due to infection)
  
• Tuberculous arthritis
• Crystal-induced arthritis (Gout or pseudogout)
• Psoriatic arthritis
• Reactive arthritis (an autoimmune reaction to an infection in another part of the body)
  
• Haemophilic arthritis
• Neuropathic arthropathy
• Ankylosing spondylitis

Trauma

Trauma (commonly sustained through sports injuries, accidental falls, and traffic accidents) to various structures in knee may cause pain. It could affect any of the following structures:

• Bone – Injury to bone leading to fracture of the patella or femoral condyles or tibial plateau.
• Ligaments – Either the intra-articular ligaments (Anterior cruciate & posterior cruciate ligament) or extra-articular ligaments (Medial collateral & lateral collateral ligament)
• Menisci – Structures between the femoral condyles and tibial articular surface (medial and lateral menisci)
• Strains and Sprains – Quadriceps (including 4 muscles), hamstring and patellar ligament (Patellar tendinitis – Jumper’s knee) may be injured causing knee pain.
• Patellar dislocation

Bursitis

Inflammation of the fluid filled sacs between various tendinous structures. There are around 13 bursae around knee which can be affected by chronic pressure and repetitive injuries. Some better known types of bursitis include:

• Housemaid’s knee – Prepatellar bursitis
• Clergyman’s knee – Infrapatellar bursitis
• Pes Anserinus bursitis
• Baker’s cyst – Synovial bursitis behind the knee (also known as a popliteal cyst)

Referred Pain

Some causes of knee pain are not caused by actual problems in the knee, but rather by other structures like hip joint. Pain may be referred to the knee joint in following conditions:

• Hip arthritis
• Lumbar disk herniations (Prolapsed vertebral disk)
• Slipped capital femoral epiphysis (SCFE –a condition in children where there is slipping of the femoral head from its normal position)
• Legg-Calve-Perthes disease (avascular necrosis of the femoral head in children)

Articular Cartilage Abnormalities

• Osteochondritis dissecans
• Chondromalacia

Miscellaneous Conditions

• Osgood-Schlatters’ disease (Epiphysitis of tibial tubercle)
• Sinding-Larsen-Johanssen syndrome (inflammation of patellar attachment of patellar ligament)

Almost everyone suffers from at least an episode or two of back pain during their life-time. Some of the backaches are acute (short duration), while others are chronic (long duration). It is important to differentiate serious causes from the less-serious causes of back pain.

Three common ways of describing as back pain include:

• Localized (pain located over a specific part of the back)
• Radiating (pain felt from back to other parts of the body, usually one or both legs)
• Referred (pain felt over the back due to disturbances in some other part of the body)

Back Pain Is Not Always Caused By “Back Problems”

It is important to bear in mind that back pain does not necessarily always arise from problems in the vertebral column or spinal structures. Some of the other structures in human body which can give rise to backaches include:

• Uterus
• Kidney
• Aorta
• Urinary bladder
• Retroperitoneal lymph nodes

What Are The Risk Factors For Back Pain?

Some people are more prone to backaches than others. The reasons for this may include:

Non-Modifiable Risk Factors :

• Increased age
• Anthropometric measures of a person

Modifiable Risk Factors:

• Osteoporosis
• Poor Posture
  
• Workplace Ergonomics
  
• Heavy manual labor
  
• Psychosocial Factors
  
• Scoliosis

Causes of back-pain

Some specific pain generators that can cause localized back pain are:

• Muscles causing spasm, myofascial syndrome or fibromyalgia
• Injured ligaments from a back sprain
• Facet joints (articulations of vertebral bone) arthritis.

Radiating pain, Also commonly known as Sciatica, is often described as “current like sensation going down a leg”. It usually indicates nerve root irritation or compression occurring as a result of:

• Lumbar Spondylosis, a degenerative condition of the spine that can cause lumbar canal stenosis
• Prolapsed intervertebral disc (or slipped disc)
• Spinal tumors or infections

As there are many different causes of back pain, and some of these can have serious or urgent implications, it is important to always get your doctor to do a full assessment and to properly diagnose and treat back pain.

• Poor sitting posture
• Poor back support during prolonged sitting
• Improper height of arm rests
• Continuous leaning over the table as in typing on a computer
• Holding a phone between a ear and shrugged shoulders, to free the arms

How Do Trigger Points Affect A  Patient?

Trigger points may manifest as:

• Tension headache
• Tinnitus
• Temporomandibular joint pain
• Arm and hand radiating-pain, tingling and numbness
• Fibromyalgia
• Myofascial pain syndrome
• Low back pain
• Decreased range of motion in the legs

How is Trigger Point Therapy Performed?

The most common approach to trigger point therapy consists of deep pressure application over the taut muscle fibers, in order to induce the relaxation of these muscle fibers and pain relief. The pressure applied tends to increase the discomfort initially, but relief is usually felt soon after.

Trigger points can also be treated using various other modalities:

1. Non-pharmacologic means

a) Massage – Applying pressure over the trigger points

b) Dry-needling – Stimulating the trigger points by needling the taut muscle fibre groups.

c) Bio-stimulation (electrical stimulation, ultrasound) – Low voltage current or imperceptible ultrasound waves are applied over the trigger points.

d) Hydrotherapy, thermotherapy – Using water jets or other media like paraffin wax, infra-red waves to conduct heat and cold sensation to the trigger points

1. Pharmacologic injections

a) Local anaesthetics

b) Steroids

c)  Saline

d) Botulinum toxin

Platelet Rich Plasma Therapy is a novel therapeutic approach using this knowledge. It has recently begun to gain increasing favor as a way to stimulate the repair of damaged tissue.

How is Platelet Rich Plasma harvested?

A small amount of blood is taken from the periphery (eg, the arm, similar to a blood test) and it is centifuged (rotated at high speeds, through an automated rotating machine). The initial process of centrifugation separates heavier blood cells (including RBC, WBC, and platelets) from lighter plasma and gives us Platelet Rich Plasma (PRP).

Clinical Uses of Platelet Rich Plasma

Platelet-Rich Plasma, by providing the growth factors, helps in faster repair of bone and soft-tissues. In a sense it enriches an enriched medium for growth (as it does not supply cells responsible for healing, but provides biological factors required for the differentiation of mesenchymal stem cells into various specialized cells).

PRP may be clinically applied for wound healing, to provide a jump-start in soft tissue (tendon & ligament) and bone healing. It has also been tried for cases of diabetic ulcer (with the aim of encouraging the growth of new blood vessels).
It has become a possible adjunct in dentistry. PRP enhances the platelet quantity from low level of about 5% in normal blood clot, to enhance healing after surgery in oral and maxillo-facial regions by 2-3 times.
Similar results have been shown in healing of chronic elbow tendinosis, not responsive to conventional treatment.
It may be used in cases of non-healing tendon injuries though results are not always conclusive.

In joint replacement surgeries (for e.g. Total Knee Surgery), PRP has been found to be responsible for shorter periods of hospital stay, less blood loss after surgery, and fewer infections.
PRP is also considered for possible cosmetic purposes.

PRP injections have been found to produce significant improvement in pain of osteoarthritic knee, thought to be due to its cartilage healing effects on the joint.
However, being a relatively new treatment approach, larger clinical trials are needed to establish the efficacy of PRP injections.

As a result, electrotherapy has gained increasing favor as a physical therapy modality for various medical conditions. Some of the electrotherapeutic devices currently in use include:

• TENS (Transcutaneous Electrical Nerve Stimulation) – which delivers an electric current in milliamps with a low frequency of 2-150Hz, stimulating the larger nerve fibers that produce a shut-down of the flow of pain signals. (Gate Control Theory of Pain).

• Electronic Muscle Stimulator (EMS) – the low voltage electrical currents, are adjusted to produce stimulation and contraction of a muscle, and increasing the local blood supply. It helps relax muscle spasm, producing pain relief and helps muscle tissue avoid disuse atrophy.

• Interferential Stimulator (IF) – produces a field of interference between two electrical currents of medium frequencies (one current at 4000Hz and another at varying frequencies reaching 400Hz). It tends to penetrate deeper into treated body tissue than TENS does.

• High Voltage Pulsed Galvanic Stimulator (HVPGS) – Constant direct current (DC) applied with positive electrode pad acting as an ice pack (tending to reduce swelling, edema and pain), and negative electrode pad acting as hot pack (promoting increased circulation to speed up local healing)

• Microcurrent – a physical therapy modality providing electric current in millionths of an ampere, producing bio-stimulation.

Since Microcurrent Therapy utilizes a small current – approximately 100 times lower than that used in TENS, there is rarely any patient discomfort. In fact, the currents are often barely noticeable by the patient when being applied for treatment. It is comparable with the low bio-electric currents produced in a human body during the cell’s healing process. In contrast to other electrotherapy modalities, Microcurrent utilizes bio-stimulation (neutralizing the oscillating potential of injured cells, increasing local synthesis of protein and ATP, enhancing the cellular permeability for the repair of injured cells) to produce pain relief.

Some of the possible applications of Microcurrent Therapy include –

• Wound healing
• Pain relief in chronic pain conditions
• Fibromyalgia and myofascial pains
• Traumatic sports injuries
• Enhancing fracture union

If you are suffering from any of the above medical conditions, or other difficult aches and pains, it would be a probably be good idea to discuss Microcurrent Therapy with your doctor, and find out whether it would be a suitable treatment option.

Some of the characteristics which make the Bioptron useful for medical applications include:
1. Polarization – Bioptron light moves (or oscillates) in parallel planes.
2. Polychromy – Inclusion of light waves within the visible and infra-red spectrum     (wavelength 480 nm – 3400 nm), without the harmful UV radiation.
3. Incoherency – Light waves in the Bioptron is not synchronized with each other.
4. Low energy – Bioptron has a low energy density, producing less heat at the site of application.

The Bioptron has been found to modulate inflammatory processes, thereby decreasing the chemicals that produce a pain sensation. It has also been thought to accelerate the production of endogenous opioids (chemicals that help result in pain relief).

The Bioptron can be used for pain relief in various situations:

1. Rheumatology (including degenerative joint diseases and rheumatoid arthritis)

A systematic search of clinical evidence from 1998 to 2005 reveals that the level of pain in Rheumatoid arthritis decreases by 1.1 point on a Visual Analog Scale, along with a decrease in the period of morning stiffness of the hands by approximately half an hour.

A review of Osteoarthritis knee patients, in 11 RCTs (Randomized Controlled Trials), showed a reduction in pain.

2. Sports medicine and soft tissue injuries (tendonitis, muscle tears, epicondylitis)

Evaluation of 50 patients revealed the super-additive effect of Bioptron with exercise, to relieve pain and improve the functional disabilities caused by Lateral Epicondylitis (Elbow pain caused at the outer aspect)

3. Physiotherapy adjunct (for chronic non-specific back and neck pain, musculoskeletal injuries)

A clinical trial on 75 patients suffering from chronic low backache (divided into 3 groups – “exercise alone”, “phototherapy alone”, and “exercise + phototherapy”), showed that the pain level decreased more in patients treated with “phototherapy + exercise” or “phototherapy alone”, as compared to the “exercise alone” group.

If you are suffering from any of the above medical conditions, or other difficult aches and pains, it would be a probably be good idea to discuss with your doctor the Bioptron, and find out whether it would be a suitable treatment option.

1. Muscle and ligament stress
The most common type of neck pain is non-specific pain, also referred to as ‘simple’ or ‘mechanical’ neck pain. The precise causes of this are unknown, but often attributed to muscle stress triggered by excessive pressure exerted on the neck. Over time, the muscles and ligaments in the neck become tired, which leads to neck pain.

2. Poor posture
Aside from muscle stress, neck pain is also widely attributed to bad posture. Spending long hours bent over a keyboard or sitting or sleeping without proper neck support can build up stress in, and weaken the neck muscles, causing pain in the neck.

3. Degenerative conditions

• Chronic degeneration

The degeneration of the cervical (neck) bones can cause persistent pain in the neck; this is a common occurrence in older people. Everyone experiences degeneration to a certain degree, most without significant pain. Unfortunately some people do encounter pain caused by this. When degeneration affects the cervical spine, it is termed cervical spondylosis.

• Cervical radiculopathy

This arises when a nerve is damaged in the cervical areas surrounding the spinal cord in the neck, and may cause numbness, prickling sensations as well as pain or weakness in the affected arm. This is usually the result of a ruptured spinal disc.

4. Traumatic experiences
Being involved in a car accident can result in whiplash injuries – this type of injury occurs when the sheer force of impact jerks the head forward and then backward, causing undue and sudden stress on the neck muscles. Even when treated with dedicated physiotherapy sessions, whiplash injuries usually take months to heal.

In addition to all the above, there are many other conditions that, though rare, can cause neck pain. Some of these include bone disorders, infections, cancers, serious injuries to the spine, and rheumatoid arthritis.
Patients experiencing neck pain for any significant amount of time should always consult a medical doctor to diagnose the cause, rule out any dangerous and urgent conditions, and to be treated effectively.