As a physio who works in a busy clinic and treats lots of different people, one of the phenomena that I’ve observed over the years is how many patients, who present with back or neck pain, and also mention they have lots of gut / reproductive problems. These gut problems are generally mild symptoms like feeling bloated and constipated. Even when mild, these symptoms can be accompanied by pain [5]. When asked if they’ve seen a doctor, patients often report that they’ve had a battery of tests and nothing has been found. This leads to confusion for the patient.
This observation of a link between front and back pain complaints raised several questions for me. How many patients who have low back pain also have pain in the front of the bodies? Are patients who have pain in the front of their body different from patients who just have pain in the low back and do they recover more or less quickly? As part of my PhD studies we investigated these very questions. We were lucky enough to collaborate with a large Danish Spinal Hospital which provides care for a large number of patients with chronic low back pain. We investigated 2974 patients, who presented to this secondary care spine centre for low back pain. On the patient’s first visit, they were asked to identify every area on their body where they felt pain and draw these on a body chart. In our study, if patients identified pain on the front of their body in the abdomen, chest or groin, they were classified as having “anterior trunk pain.”
We found that close to 20% of chronic low back patients also had anterior trunk pain. That’s a pretty large number if you think about how many people in our community complain on ongoing low back pain. At baseline, we found that the people with anterior trunk pain had greater low back pain intensity and more disability compared to their counterparts, who only had low back pain. When we followed our study subjects for 12 months, we found that the patients with anterior trunk pain described more intense pain and disability over the entire 12 month period. Yet, when we analysed whether the presence of anterior trunk pain altered the course of their low back pain over one year (i.e. how much they changed over time), we found that it did not. In other words, whether participants had anterior trunk pain or not, did not seem to influence how much their pain and disability outcomes changed over the year [4].
Because we know that anxiety [1], depression [1] and widespread pain [6] can alter how people perceive their pain, we included these as covariates in our analysis, and we found the between groups difference typically remained. In other words, whether patients had anxiety, depression or widespread pain didn’t alter our results.
So what does this all mean? This study demonstrates that there appears to be an association between pain in the anterior trunk and in the low back. It seems that if you have anterior trunk pain, your low back pain might be more intense than otherwise.
If you look at anatomy textbooks, it’s interesting to see that there are lots of connective tissue (fascia) and nerve connections between the gut, the skeleton and the nervous system. We know that internal organ disease can lead to referred pain in to the musculo-skeletal structures around them [2] but we also know that the spinal pain can be associated with pain referred to the anterior muscles of the trunk [3].
At this stage, it’s too early to tell which tissue, if any, is driving the direction of pain referral but it’s intriguing to think that some people’s low back pain might not just be coming from their back. Our study opens up new questions like: Why do we find more pain and disability in these anterior trunk pain patients? Are they a different subgroup to “standard” low back pain patients without anterior trunk pain? Should we manage them differently? But that’s research for another day…….
About John Panagopoulos
John is a PhD student and clinical physiotherapist working in private practice. John completed his undergraduate training in 1998 following a degree in Medical Science. After many years of working with clients varying from elite athletes to sedentary office workers, John returned to embark on further studies investigating low back pain. He is particularly interested in visceral causes of pain and has recently presented the results of an RCT investigating the use of visceral mobilisation techniques on low back pain at the Interdisciplinary World Congress on Low Back and Pelvic Pain.
References
[1] Andersson, G. (1999). Epidemiological features of chronic low-back pain Lancet, 354 (9178), 581-585 DOI: 10.1016/S0140-6736(99)01312-4
[2] Foreman RD. Mechanisms of visceral pain: from nociception to targets. Drug Discovery Today: Disease Mechanisms 2004
[3] Mollica Q, Ardito S, & Russo TC (1986). Pseudovisceral pain due to posterior joint pathology in the dorsolumbar spine. Ital J Orthop Traumatol, 12 (4), 467-71 PMID: 2956217
[4] Panagopoulos J, Hancock MJ, Kongsted A, Hush J, & Kent P (2014). Does anterior trunk pain predict a different course of recovery in chronic low back pain? Pain, 155 (5), 977-82 PMID: 24502844
[5] Sperber AD, & Drossman DA (2010). Functional abdominal pain syndrome: constant or frequently recurring abdominal pain. Am J Gastroenterol, 105 (4), 770-4 PMID: 20372129
[6] Wolfe F, Clauw DJ, Fitzcharles MA, Goldenberg DL, Katz RS, Mease P, Russell AS, Russell IJ, Winfield JB, & Yunus MB (2010). The American College of Rheumatology preliminary diagnostic criteria for fibromyalgia and measurement of symptom severity. Arthritis Care Res, 62 (5), 600-10 PMID: 20461783