A large percentage of patients being treated by general practitioners and being referred to various specialists suffer from back pain. Such patients constitute one-third of the total attendance in the orthopaedic out-patient departments, excluding accident cases. X-rays, electrocardiograms and other investigations are carried out and these patients are then informed that they do not have any serious problem. They are only able to give a vague description of their pain. Unable to find any abnormality in these conditions, the physician treats the problem as a psychological one and often refers them to a psychiatrist.

The pain is mostly in the upper back between the two shoulder blades. It is a postural problem: a wrong way of sitting, standing, or doing home or office work. A majority of sufferers are typists, secretaries and housewives, more commonly females than males. According to our own findings too, such problems occur almost four times more in females than in males. The pain is usually only on one side of the spine. In a few cases it may radiate to the lateral border of the shoulder blade or upwards to the neck. The patient may feel a deep-seated chest pain. Sometimes the pain is excruciating as if somebody is piercing a nail in the back or an abscess is present in the back. At other times it is diffused and a certain heaviness is felt in the back. A few patients describe their pain as a burning sensation or painful tension. Sometimes they point to a specific point on their backs which hurts them the most.

The pain is common in people who use their hands at the level of the chest without providing any support to the elbows. A farm girl doing strenous work in the field may not get any pain, but when she starts knitting, she may develop a severe pain in the upper back. Among those who have to do work with a stooping posture or where the posture is not correct, the pain may start – as in the case of a typist sitting and stooping for hours over her typewriter. Housewives who either have a low kitchen platform and have to stoop and work, or sit on the ground stooping and working for hours to cook food, complain that when they roll chapatis, they experience pain in the upper back. The pain may be absent while they are engaged in other activities. This pain is common among ladies who use a hand-operated sewing machine or those who iron clothes. Carrying a heavy shopping bag may increase pain. Sometimes the pain occur at night when the head is in an odd position or when using too high a pillow.

Even wearing a heavy overcoat for a long time may bring about pain. The pain is sometimes so severe that the patient cannot carry on with his work. Pain may also be felt after a sudden twist or turn. It can be severe and excruciating; a deep breath may hurt but coughing may not be painful. This is just the opposite of lumbago (lower back pain) where coughing hurts but deep breathing does not have any effect. A few days of rest may relieve it. While bending the trunk forward, it may recur due to compression on the intervertebral joints. The pain may be felt on one side of the upper back on one occasion, and on the other side on another occasion.

A clicking sound may be felt during manipulation and following this, the pain may change its side. This is a clear indication that thoracic pain is caused by a disc lesion. The pain often radiates to the front at the level of the lower ribs. Sometimes the whole chest may be involved and the pain may travel down to the upper part of the abdomen.

This when confusion starts. Since the pain starts suddenly, for example, while lying down, the symptom may suggest a heart problem like coronary thrombosis or even a myocardial infraction. In the case of a real heart attack occurring at middle age, the patient may have a similar history.

Differentiation between these two chest pains, namely, a prolapse of the intervertebral disc of the dorsal spine or a real heart attack may be made by asking the patient to take a deep breath. If there is pain during deep breathing, it is most likely that the heart is not involved and the cause of pain is the dorsal spine. An electrocardiogram should also be taken to exclude cardiac involvement. The slipped disc of the dorsal spine is self-curing It is common among patients like typists, who have to sit for long hours every day. The patient feels comfortable when he wakes up from sleep and for a few hours thereafter; then after sitting for some hours, the pain starts playing up. It goes on increasing as the day wears on. Standing or lying removes the pain in a few minutes. The cause of the pain is the posterior bulging of the disc, which recedes as soon as the forward stoop is no longer there.

When the nerve roots are compressed, the pain may be felt in the lower part of the abdomen or may radiate to the testicles. Sometimes symptoms may appear as in cases of gastritis or cholecystitis, depending on the dorsal involvement. In such cases we should examine the chest and abdomen very thoroughly and any pathological disturbances involving the chest or abdominal organs must be excluded first.

Generally the chest and abdominal symptoms which arise due to pressure on the dorsal nerve root are forgotten while diagnosing different diseases of the chest and abdomen. Most chest or Abdominal pains are due to disease of the local organs, but when the pain is in front of the trunk, and gets aggravated by exertion and bad posture, then you may conclude that it is due to pressure on the dorsal nerve root.

Treatment: Postural Correction

If a straight posture is maintained while working in the office or at home, the pain may not occur. For example, a clerk may raise the height of his table so that he may sit more erect than usual. This can even be done by cutting the legs of the chair to lower its height. A typist may put his or her papers just above the typewriter on an inclined board, or keep them vertically tagged on the wall on a drawing board. Housewives may raise the kitchen platform if it is too low. They may use a chapati maker which involves pushing down rather than rolling.

Using a hard bed with no pillow or a very low pillow while sleeping is helpful. Sitting in an ordinary office chair instead of a low sofa is better. One must keep reminding oneself to sit straight as the habit of sitting in a wrong way may be difficult to change. Three exercises are of advantage:

Dand. This is a well-known Indian exercise. The patient rests on his arms and legs. The body is drawn backwards initially, till his hips reach the highest point. This is the starting position. Then the head travels slowly down in the direction of the arms, and after the nose has reached the floor level, the chin and the chest are gradually brought to the same level. Now the upward journey of the head and trunk starts in an arch till the final position of the exercise is reached where the spine is in full extension. This exercise is somewhat difficult. To make it easy, hands should be placed on a higher level than the feet – perhaps on the side of a table or bed. Six repetitions done morning and evening will be very useful.

Shoulder Raise. The patient stands erect with his hands on the side. Both shoulders are raised up and without bringing them down, taken behind as far as possible and then dropped down. This exercise can be done twelve times in the morning and evening. This also helps to alleviate upper back pain.

Swimming. Swimming helps patients with a postural backache problem. Keeping the head out of water keeps the body in a posture of extension. When the body floats, all the compression strain on the body ceases.

Manipulation

Manipulation is attempted in all cases unless contraindicated. In quite a few cases, a tender point can be located 2 cm from the middle of the spine at the level of the fifth or sixth dorsal spine. Pressure over this reproduces the exact pain which the patient is complaining of. Some years ago Kellagren injected 1 ml of hypertonic saline solution at the above-mentioned tender point. For a few minutes this injection produced the habitual dorsal pain which the patient had been complaining. Of. He proved that there was an involvement of the dorsal spine in such pain and, therefore, manipulative manoeuvres were justified for its treatment.

The lower cervical spine involvement as a causative factor for upper back pain has already been discussed in earlier chapters. Manipulation of the lower cervical and dorsal spine should be done in these cases. Manipulation can be done without general anaesthesia. It should be repeated once a week till final recovery takes place.

Case Histories

• A 41-year-old woman with a two-year-old child had occasional pain in the upper back and both shoulders for a year. Then for three months it became continuous and severe. She would get severe back pain after ironing clothes or rolling chapatis. Along with pain in the upper back, she felt heaviness in the chest. After resting for 1-2 hours, she felt somewhat better. She underwent treatment from her doctors for a few months but this provided no relief. She then came to me and after a clinical examination and investigations, manipulative treatment was started. Her pain subsided gradually and she was able to do all her household work without any discomfort. She was asked to do the upper back and shoulder-raise exercises.
  
  
  
• A shop-keeper aged thirty-six, had pain in the chest now and then and a persisting heaviness in the same region. After a year, neck pain also started. Though he had suffered no injury, the pain increased and became persistent. He would also get occasional stiffness in the neck and pain in the arms while lifting heavy objects. However at nights he slept well. Treatment by general physicians and medical consultants did not help him. He consulted an orthopaedic surgeon but to no avail. His chest X-rays and electrocardiogram were normal. The X-rays of the cervical spine and dorsal spine were normal. Laboratory tests were also normal. The manipulative treatment of the dorsal and cervical spine was started. He felt better after the first manipulative manoeuvre. His chest pain became less frequent and much less intense, and the pain in the neck did not occur after the second treatment. The chest pain and heaviness completely subsided after eight weeks. He was told to sleep on a hard bed and without a pillow. He was also told to do exercises.
  
  
  
• An engineer, aged thirty-three, employed with a large company, used to get pain in the lower ribs and chest off and on. This became more prominent when he had to do any job bending for a long time. This pain persisted for two to three days. When he lay flat in bed, the pain subsided slowly. The pain was incapacitating and allowed him no exertion. He would also get pain in the upper back and lower back occasionally. The chest pain followed the low back pain and with this pain he became bed-ridden for fifteen days. X-rays of the chest and electrocardiograms were taken on several occasions but they were all normal. Laboratory tests too did not reveal any significant abnormality.
  
  
  
• Manipulation was done on his dorsal spine. The pain subsided in six weeks’ time. He could bend and work for hours without any pain at all. He was also told to do exercises for his back for five minutes every day, and use a hard bed and a low pillow.
  
  
  
• An engineer, aged twenty-nine, met with a car accident while in the US. He started getting pain in the upper back following this accident. The X-ray showed that he had a compression fracture of the fifth dorsal vertebra. He was hospitalised for eight days and later flown to India for treatment. Though he became better and improved, a mild pain continued for about a year. His hectic lifestyle also aggravated the pain.
  
  
  
• He came to me with the above complaint. His X-ray showed an old fracture of the dorsal spine. Manipulative treatment was given to him for the cervical and dorsal spine. He improved and there was no pain at all within six weeks. He improved and there was no pain at all within six weeks. He was taught exercises and advised to be careful about his posture as he was in the habit of sitting and walking with a forward stoop.