PhysioMonkey

So what can be done for back pain?

People seem to think the answer is "Not a lot".  This is WRONG.

There are a number of areas to cover:

• What other people can do.
• What nature will do.
• What you can do.

I'll deal with these in order.

What other people can do.

These can get split even more into

1. General (family) doctors - most people's first choice.
2. Specialist doctors - orthopaedics, rheumatology and pain.
3. Physios - me and my ilk.
4. People who live with you.
5. Colleagues and bosses.

1 - General Doctors

I'll repeat this again: "A general doctor will not know huge amounts about musculo-skeletal problems".  Everyone should remember this.  You need to either get to a specialist doctor OR get yourself referred to a physio. 

What can a general doctor do?  General advice that would be useful in part for most cases of back pain.  They can also prescribe drugs for pain relief or for reducing inflammation or relaxing muscle spasm.

If you're in the UK they can also refer onwards to physio or orthopaedics or rheumatology.  I assume that's similar in other countries.

A general doctor SHOULD be able to make sure that you have nothing nasty happening.  Look at the "What is" back post to see what the worrying signs are.  If you have some of these make sure you tell the doc, don't wait to be asked.

2 - Specialist doctors

Specialist doctors, by definition, know plenty more about their area than generalists.  Having said that my experience is that specialists have egos the size of Belgium and they have their own preferred ways of doing stuff.  This means that one doc may want to operate whilst another may want to inject, a third may refer you on to a physio.  You may have noticed by now that there is rarely much agreement about specific treatments for back pain.

Some docs will suggest injections - these are not well proven to my knowledge.  Some people have good responses but that's not the norm.

Surgery - Really please avoid this if at all possible.  There is a general lay-person view that surgery will heal all their ills.  It really won't in most cases.  Back surgery should be avoided like little else.  "But there's new surgical techniques!"  That's true but the problem with new techniques is that the long-term success is very poor.  They have developed replacement discs but these invariably go wrong after a short while causing far more problems than there were before the op.

Think about what structures are in the area.  If the surgeon slightly nicks your central nervous system (CNS) then you'll be buggered (excuse the term but I don't think I'm being over dramatic).  If you wish to know how well the CNS repairs itself then take a look at Christopher Reeve.  CNS does NOT repair itself. 

I can't state this more urgently: Do NOT let a surgeon anywhere near your back until you have discussed everything about what might happen.  Ask about short-term prospects, long term prospects, chances of screw up etc...  And don't even think about surgery until you've exhausted as many other options as you can first.

Scans are another thing that people think are necessary.  They're really not that useful in 90% of cases.  They're a waste of your money or time.  In the UK whilst you're waiting for an NHS one you could be having some useful intervention.  If you pay for treatment directly you'd be better off spending less on physio treatment.

X-rays are generally even more useless than scans and not ony are they (usually) useless they increase your chances of getting cancer.  Do you still want a back x-ray?

3 - Physios

Now we're into my happy zone. 

"There is plenty a decent physio should be able to tell you about how to deal with your problem. "

Now have a look at that sentence again.  The first important word is "decent"; sadly there are poor physios just as there are bad doctors or even bad jugglers (like me).  If your physio treats you like my brother's did him then tell him to stuff his payment.  (My bro was told: "You've got a bad back mate, live with it".  Not bad from a person who supposedly spends his working life dealing with back pain.)

The next important words are "your problem".  Much as you want someone to do this for you it doesn't work like that.  This IS your problem, you are going to have to deal with it.  The physio should be able to tell you how YOU are going to get you better and then help YOU try to do it.  There is no magic trick that will suddenly take your pain away and keep it away.

First some myths:

I see people who have been to a local private physio.  He uses ultrasound, interferential therapy (electricity basically) and heat.  The heat MIGHT be vaguely useful but people are paying this guy through the nose to have their time wasted with useless treatment; they all say that they had no benefit.  Ultrasound has NEVER been shown to be particularly useful generally but it really has NEVER been used as a treatment for backs.  If you have had lots of sessions that you've paid for then go back and demand that your physio gives you your money back. 

In short - ultrasound or electrotherapy is no use for you.

Truth?  You need to work the right muscles and move and hold yourself correctly.  That's basically it but I'm sure you can appreciate there's quite some variation that needs to be addressed.  The physio should look at how far you can move into every different direction, how good the quality of that movement is, how poorly controlled the back is, the nerve supply to the legs and more.  In addition they should check for all the worrying signs as noted in the "What is" article.

You will most likely get quite a lot of explanation of what's happening and some exercises.  That's all I'll say for now.  Much of what you'll get will be an explanation of what's in the final section of this post only tailored precisely for your presentation.

4 - Those who live with you or friends that you see regularly

The first and most useful thing they can do for you is not to mollycoddle you (I like that word).  If you stop doing stuff or you're always asking for help then your back will be getting less fit and more likely to end up causing you chronic problems.  But people are generally nice and will want to help.  If you're the patient try and do as much as possible.  If you're the other person then make him/her get up off his backside occasionally to do some activity.  Just because their back hurts doesn't mean they can't do stuff. 

If you let someone sit in their own juices and complain there will be a few effects. 

• Firstly you'll get hacked off with doing everything for them quite quickly.  They are probably already grumpy because of the pain they have - you getting annoyed with them will not help.
• Second: they'll get less fit thus worsening their problem NOT easing it.  So by leaving them you're making their problem both worse and longer lasting.
• Third: their reduction in fitness will lead to increased weight which in turn leads to more back pain and less use of the right muscles.  Again this leads to increased chronicity.

Don't let someone with your basic back pain waste their time with inactivity but allow that they may not be able to help with heavy tasks.  Normal activity should not cause more injury although it may cause pain.

"Pain" is not the same as "harm".

5 - Boss and Colleagues

We spend a third of our lives working (unless you're very lucky) so work is probably the single most likely place you'll have problems.  We know that the longer you are off work the less likely you are to ever get back to work.  This should be prompting you to think about working as soon as you can.

The points for bosses are the same as for those who live with you.  Don't mollycoddle but don't expect full fitness at first.  Bosses also have legal responsibilities for the safety of all staff and if they don't think you can safely do your job they're not going to be happy about taking you back until you're better.  This leaves us in a Catch-22 situation.  You need to return to work to get active and fit but you can't until you're active and fit.  You need a good Occupational Health team or a pushy doctor.

Try and go back part-time at first.  Or go onto light duties.  Then build up to full-time and normal duties.  The process will probably cause you some pain.  Sorry that's how it goes.  If you're not doing anything stupid you're not doing damage.

Colleagues can help by not griping too much that they're doing all the heavy work.

Bosses (in the UK at least) have a responsibility to make sure all the physical tasks you do are safe.  If there is a code of practice, use it!  If there isn't, ask why not. 

Health and Safety law also requires that every worker has their own responsibility to themselves and to their colleagues.  So if you see someone trying to lift a large photocopier then it's worth suggesting they don't.  If they injure themselves and you saw it was likely and let them carry on then you are as culpable as they are.  If you specifically ordered them to do it then expect a legal action coming your way.

What Nature can do

This is easy to split into 2 parts.

1. What nature does that is helpful.
2. What is unhelpful.

1 - Helpful

Your body repairs itself - that's it really.  If you have damaged a structure then the body will heal it as well as it can.  This is why most back pain episodes last less than 6 weeks.

2 - Unhelpful

It'll make you want to do less - not good (see above).

The muscles that you need will stop working when you get pain.  This is normal for any area of the body.  If you bang your elbow your biceps won't pull as hard until the pain's gone.   But the back works slightly differently in that the muscles you need will NOT return to use when the pain goes.  You will need to specifically train them yourself.

Right this is loads longer than expected so I'm going to split the topic into 2 posts.  The next post is what you can do for yourself.

Related Posts

Back Pain - Myths and Truths

What is - Back Pain

Back Pain - Treatment 2 - What you can do

So another huge topic to be done succinctly.

Firstly the vast majority of back pain is not worrying medically.  Of course it may concern you but it doesn't mean there is a horrible problem underlying it.  For clarity we're talking about lower back pain here.

Let's talk about the common things that people have heard about:

1 - Lumbago

Definition: Lumbago: painful condition of the lower back.  In other words "back pain".

This is NOT a diagnosis.  It is a way of telling you that you have back pain.  You would probably already know that though.

2 - Sciatica

Definition:Sciatica: Pain along the sciatic nerve usually caused by a herniated disk of the lumbar region of the spine and radiating to the buttocks and to the back of the thigh. [from dictionary.com, def 1]

Firstly this definition is WRONG [Edit: actually there is some debate about this.  Technically you could argue that you need true nerve iritation to be "proper" sciatica which would mean that the above definition is correct.  However the term is generally used to mean "pain down the back of leg" by pretty much everyone except pedants].  Pain down the leg may be down to a disc problem but rarely is.  More commonly it's down to a problem with joints in the spine or possibly a muscular issue in the buttock.

3 -  Slipped Disc

Definition: Slipped disc: a painful rupture of the fibrocartilage of the disc between spinal vertebrae; occurs most often in the lumbar region [from dictionary.com]

So some anatomy.  If you want more there are loads of anatomy sites out there on t'interweb.

There are 24 seperate bones in the spine, the top 7 make up your neck, the next 12 have ribs coming off them, this is the "thoracic spine" and the last 5 bones are called the lumbar spine.  At the top is your skull, at the bottom is a bone called the sacrum which is like 5 of the spine bones all fused together, under the sacrum is the coccyx or tail bone, this is tiny but can cause real pain (if you've ever fallen and landed hard on it you'll know about it).

Inbetween the bones are what are known as the discs.  Think of them as a jam donut.  The outside is fibrous and strong and the inside is gooey.  They act as shock absorbers for the spine.

The name "slipped disc" is rather a misnomer giving the impression of the whole disc shifting somehow.  The definition above is correct for a change, the "jam" pushes backwards (in most cases).  In minor cases the back of the "donut" bulges backwards and pushes on nerves.  In extreme cases the disc ruptures causing massive pressure and chemical irritation of the nerves. This is a slipped disc.  The other notable thing about slipped discs is that they tend to come on in an instant (but not always).  Often this is during a normal activity that may even be much less strenuous than you'd expect problem movements to be.  Eg you work as a builder and lift heavy weights all day, one evening you bend down to pick up a pen and your back "goes"; that's the classic slipped disc pattern.

One of the benefits of getting old is that the "jam" dries up so leaving you less likely to have a slipped disc.  Most slipped discs happen in people aged 30-50.

4 - Mechanical back pain

The most common form of back pain by far.  The non-specific title tells you a lot about the mechanisms here.

Quote: "In the majority of cases, it is impossible to identify the exact cause of backache" [netdoctor.co.uk]

I'd agree with this.  People then assume that nothing can be done with it.  This is rubbish, almost all physical back pain can be treated.  It's a combination of muscular problems, joint problems, postural deficit and sometimes hormonal changes and anxiety/stress.

5 - Chronic back pain

Definition: chronic: Of long duration. Used of a disease of slow progress and long continuance. [dictionary.com]

This is distinct from recent onset back pain (aka acute back pain).  Chronic pain is a whole different area of medicine.  It involves physiological changes in the brain, perhaps some emotional difficulties either directly because of or not helping the pain, changes to the perception of self and your pain and numerous other things.  This is much harder to deal with if there is no specific pathology (as with most back pain).  Imagine being told that there's actually nothing much wrong physically if you've crippling pain.  The only demonstrable help there has been for this problem is a combined approach involving physio, doctors, psychologists and other medical profs eg occupational therapy.  You'll be damned lucky to find a service that'll help you out with this.

Please note that simply having back pain for a long while means that the pain is chronic (in time terms) but doesn't necessarily mean you go through all the physiological changes that result in nasty "chronic pain" meaning what's in the paragraph above.

Things you need to know.

Normal episodes of back pain.

• The vast majority of back pain is not medically concerning.
• Most episodes will last less than 6 weeks.
• Most back pain is called "simple, mechanical back pain".
• Treat it yourself (check the "treatment" posts).
• You need to get the muscles working.
• The worst thing to do is "nothing".
• You're not likely to injure your back further with normal unloaded activity.

Concerning things

• Nasty, unrelenting, unchanging pain.
• Sudden, significant and unplanned weight loss.
• Pain doesn't change at all (most will vary depending on position, posture or activity).
• Real difficulty sleeping because of the pain.
• Numbness around the inner thighs and groin.
• Inability to control bladder or bowel normally.
• Recent onset major muscle weakness in the legs.
• Pain started after major trauma.

These are what we call "Red Flags" they can indicate some pretty nasty things that need urgent checking.  If you have more than 1 of these then get yourself checked quick.

We also have "Yellow Flags" these are described as "factors increasing the risk of developing long term problems or disability".  These are:

• Belief that back pain is harmful or severely disabling.
• A legal or compensation claim in progress.
• Fear of movement or activity.
• Anxiety/depression.
• Expectation that someone will heal them rather than to play an active role in their own health.

So if you see these in someone without any serious pathology then give them a kick up the backside from me.

Related Posts

Back Pain - Myths and Truths

Back Pain - Treatment 1 - What others can do for you

Back Pain - Treatment 2 - What you can do

I'm thinking of setting up a workshop / lecture for circussy types and parkour-ers at maybe the University in Leicester.  The plan would be for a day session of lectures on injury, warm-ups and prevention of problems.  To sweeten the pill I'd lay on a massage workshop too. 

In addition I'd try and get a parkour expert in as well as trainers to do some actual physical training.  But assume this bit won't happen at first.

Does this sound doable?

How much could I charge for a day chock full of professional teaching/workshops?  I had a look at the Circus Space website and they charge £95 per person (!) for a circus taster day.  I was thinking something more like £10-15 (as an initial offer) with handouts extra.  I think a max of 12 people would be about right too.

Would anybody want to come?

Suggested plan for the day (Jugglers only):

10.00 - 10.30 Intro and questions answered.

10.30 - 11.00 Sudden injury (lecture) - What to do and how to avoid.

11.00 - 12.00 Repetitive injury (lecture) - What to do and how to avoid.

12.00 - 12.30 Warm-ups (Myths and falsehoods) (Lecture)

12.30 - 1.00 Break

1.00 - 2.00 Neck and back control (Workshop)

2.00 - 2.30 Practice and questions answered

2.30 - 3.30 Shoulder control (Workshop)

3.30 - 4.00 Practice and questions answered.

4.00 - finish Break then massage (Workshop).

I thought I'd put the sit down stuff at the start when people are alert and then the workshops at the end to get people moving and working rather than sitting listening again.