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I get a lot of queries from readers with Chronic Back Pain who don't have access to pain clinics or pain management programmes. This may change in the future if the early promise of this new e-course lives up to expectations.The course consists of 5 online lessons, follow up e mails and homework and has shown some good early results. If you want to read a bit more about the development of the course this is a nice simple explanation from Body in Mind.
It is still is in its early days of development and they are seeking volunteers for the next round of research which starts in Sept 2014. If you want to register an interest to be a participant this link takes you to the page to sign up.
Deciding whether to have an MRI scan or an X-ray can be a difficult decision. Many of us will want to make sure that there is nothing serious the matter and doctors may feel the same. The problem with MRI scans is that they cost more to perform and may well end up highlighting normal changes. This can increase worry and may lead to unnecessary surgery..
This page talks in a bit more detail about the differences between the two types of investigation.
This website has a nice article looking to see if having an MRI scan meant better outcomes for a group of patients with back pain. Surprisingly, there was no difference.
Front page in the news this week is a story about a breakthrough treatment for back pain with antibiotics. The study looked at a subgroup of patients with back pain and gave them either antibiotics or placebo drugs. The ones taking the real tablets generally did better than the others.
This is an interesting study but I think we need to keep in mind that this treatment was tested on a specific group who had:
Not all chronic back pain sufferers meet these conditions and not all of the ones who did got better with this treatment. Nonetheless this is a new approach that I am sure will be studied in more depth and may well help a small subgroup of back pain sufferers.
These excellent articles offer a bit more reason and depth (not sensationalist newspaper headlines!).
For many people chronic back pain is soul destroying. It leeches across all aspects of life and interrupts normal work, family and social activities. One of the hardest things about it is that often the precise cause of the pain is uncertain. Chronic pain becomes a problem in its own right. This is so often the case with back pain - the term 'non-specific' is a frequently used bucket term for back pain that we can't pinpoint the cause of.
This article adds a new dimension to the 'not-knowing' part of back pain. This study looked at how pain severity was rated by people looking at photographs of someone in pain. Where there was no clear diagnosis, observers thought the person had less pain.
What does this mean? If you say to a friend 'I have a prolapsed disc' they will probably appreciate you are in pain more than if you say 'I have back pain but nobody can tell me why'. This doesn't mean I'm advocating that everyone with back pain should make up an imaginary diagnosis so as to be taken more seriously! But it does make me appreciate what an impact this lack of diagnosis can have in ways that we wouldn't have expected.
This is a nice publication from NHS Scotland that covers common questions about back pain including should you rest, should you take painkillers, is heat or ice useful? Worth a quick read.
It is increasingly accepted that unhelpful thoughts and beliefs about back pain can make it harder for you to get better. The main ones are fear avoidance beliefs ("I can't do that because it will hurt or damage my back"), and catastrophising ("I am afraid I am going to get worse and I won't be able to have a normal life"). Social support is also crucial and unfortunately being in pain and afraid of movement often causes more isolation as work and social life dwindles.
If you think this may be something that affects you take a look at this page on my site - this gives you an overview of the biopsychosocial model of pain.
Smite, D. & Ancane, G., 2012. Sense of emotional support in chronic low back pain patients. Journal of Psychosomatic Research, 72(6).
Beneciuk, J.M., Robinson, M.E. & George, S.Z., 2012. Low Back Pain Subgroups Using Fear-Avoidance Model Measures. The Clinical Journal of Pain, 28(8), pp.658–666.
Surgery for sciatica is a commonly offered as treatment for this painful condition. However, there is some doubt about whether the symptoms would have gone away by themselves with time. Some of the research shows that after a year there isn't much difference between people who had surgery and those that didn't. The main difference seems to be a shorter duration of symptoms (which means back to work sooner for some). But some people just don't get back to normal.
Going down the surgery route is a difficult decision, even though surgery these days is much safer than it used to be there is always a degree of risk. Having had several, I personally think having a general anaesthetic is not to be taken lightly under any circumstances.
So this article caught my eye, it looks to see if there are any particular things which affect how well you recover from sciatica. If we could predict who would do badly without surgery it would be much easier to decide if surgery is the right thing for them or not. The study shows that age, gender, smoking, previous history of sciatica and heaviness of work do not appear to make a difference to the outcome. It just doesn't tell us what does! So the study doesn't give us all the answers we want but it does rule out some of the things we might have thought played a part in how well you do.
Of particular interest to me, is that lots of the sciatica studies didn't look at thoughts and beliefs - the psychosocial factors - this may be a big missing link. Psychosocial factors are well documented as having an effect on how well you do when you have simple back pain - maybe its similar with sciatica.Ashworth, J., Konstantinou, K. & Dunn, K., 2011. Prognostic factors in non-surgically treated sciatica: a systematic review. BMC musculoskeletal disorders, 12(1), p.208.
A lot of people describe their back pain as 'sciatica', which is an irritation of a nerve root as it leaves the spine. This irritation can cause pain, changes in sensation (tingling and numbness) and also a feeling of weakness. Actually very few people have true sciatica - only about 5% of all back pain sufferers. This page on the site talks a bit more about the symptoms of sciatica.
This is one of the most concise and clear explanations I have seen on what happens in chronic pain. He uses the example of a young woman with a sprained wrist to illustrate the misery of this condition. But chronic pain can affect anyone - and it is a really big problem with back pain too. If you have chronic pain then you may have noticed that sometimes just a light touch on your back feels really sore. This video will help you understand why.
Having said that posture has a smaller role to play than a lot of people give it credit for, it is still worth moving your body and avoiding prolonged periods of time in the same position.
I have found a few little programme's to remind you to move if you sit at a desk all day:
Focus Booster - this neat free programme lets you set a length of work time - it lets you divide your day into chunks. You can set it for 25 mins for example and then have it schedule a five minute break. In the break, get up , move about, do a few stretches. Very nice and simple, I use this one myself.
The other one I have tried out is a programme called The Movement that not only reminds you to move but it includes some set stretches and exercises to do in the break. It costs $19.99 per user. I tried the trial and I liked it.
Paul Ingraham - Does Posture Matter
I trained as a physio in the early 90's and it was accepted wisdom that if you had a patient with back pain then you needed to assess their posture. If this was found to be 'poor' it was expected that a big effort would be made by both you and the patient to try and improve it. This effort involved education about 'correct' posture, some stretches or strengthening work to help maintain the new 'proper' posture, and finally lots of reminders and will power.
Over the years I began to doubt the wisdom of this as I could see that so many different people had so many different postural habits - it didn't make sense that it could always be the cause of the pain.
I did see some positive results though, sometimes when ergonomic changes were made to office set-ups or when someone used a lumbar roll to change lower back posture in sitting. So even now I continue to assess posture and make practical suggestions if something obvious is amiss.
I have just found this really interesting article which looks at the science behind the 'poor posture' theory and I am interested to see that my hunch was correct. This is a very informative article by Paul Ingraham from saveyourself.ca with a good treatment ideas section at the end.
if you have been diagnosed as having 'postural' back pain I would urge you to read it.
This is a short, informational video which nicely illustrates the way a nerve impulse is generated and how it passes along the nerve to the brain. I was a bit worried that the video would focus entirely on the mechanics of this and would overlook the importance of the brain in modulating this experience. So I was pleased to see, right at the end, that this is covered in the video.
So, if you want a really nice snapshot of the physical processes that occur in the nervous system this is a great introduction that does not overlook the importance of your thoughts and feelings.
This is a fascinating short video looking at some of the facts and figures behind the placebo effect. I think many back pain 'cures' and miracle treatments are drawing on this amazing phenomena. This may also help explain why some people swear that a particular treatment works for them, even when the scientific evidence from research trials is far less certain.
I get knee pain quite badly and I take ibuprofen which helps me a great deal. Many of you with back pain will get some relief from taking over the counter drugs like ibuprofen and aspirin. This video is a brilliant few minutes which explains very clearly how these painkillers work.
I was really pleased to see at the end that they talk about how the experience of pain is controlled by your brain (pain is an output of the brain) and by the sensitivity of your central nervous system. As a result sometimes drugs alone are not the answer and other treatments need to be added to the mix. My previous blog post shows an example of how changing the way you think about your back pain can help.
For some of you it certainly won't be but for others it will. I have seen people dramatically turn their lives around, simply by understanding that pain does not always mean harm and by gaining confidence in normal movement.
This is a really inspiring video of someone who was in quite a bit of trouble and became much better.
Non-specific or simple back pain is the most common type of back pain - in fact it accounts for 90% of the back pain problems we all have. Sometimes movement can help ease the discomfort of this problem. I have compiled a few ideas on this page for some easy stretches which some of my patients have found helpful. Some even have videos too!
As usual discuss with your doctor before starting an exercise programme.
This is an radio recording and is nice and short at 10 mins. This is an interview with Lorimer Mosely, author of Painful Yarns (Amazon Link), where he explains what pain is and how we have got a bit mixed up in our understanding.
If this is the first time you have heard anything about our newer understanding of pain and how we experience it be prepared to be a bit challenged!
I have always felt that fitness is a really important part of managing lower back pain - one of the first things I do with my patients is sit down and look at ways they can increase their activity levels. A recent study has reinforced how important that is - but it has an extra twist to the tale.
The study looked at almost 2000 police employees and asked them how active they were. It also measured their fitness in the lab (muscular endurance and lung fitness). The results showed that the fitter employeees had less low back pain. The really interesting thing is that there was no relationship between how active they said they were and their back pain.
What does this mean to you...
Even if you consider yourself an active person it may not be enough. Make sure you have good cardiovascular fitness and endurance to improve your chances of overcoming back pain.
Heneweer, H. et al., 2012. Physical fitness, rather than self-reported physical activities, is more strongly associated with low back pain: evidence from a working population. European spine journa 21(7), pp.1265–1272.
The answer is yes and no. In my own practice I have seen many people get completely better within a few weeks while others are plagued with the problem ever after. A recent study has shed some light on this and supports my experience.
This study found a rapid recovery for most people from 0-6 weeks after an initial back pain, in fact most people get much better quite quickly. The outcome for those that had pain for more than 12 weeks was not so good - lots of them going on to have persistant pain a year later.
What does this mean for you? If your back pain is 'acute' or less than 12 weeks old you should try not to worry, if you manage it by keeping active and taking appropriate pain relief there is a really good chance it will go away. If you have had it more than 12 weeks it might be worth trying some more specific treatments to help improve your symptoms. Go and see your doctor to get advice tailored to you.
You can read more about first aid for back pain on this page from my site.
If you want to look at the paper more closely you can find it here:Menezes Costa, L. da C. et al., 2012. The prognosis of acute and persistent low-back pain: a meta-analysis. CMAJ : Canadian Medical Association Journal, 184(11), pp.E613–E624.
(This research is a 'meta-analyis' which means it combines the results of many different trials to reach a conclusion - this is a good method as it increases the likelihood of the findings being correct)
This is the last video in the nice series of Shirley Sahrmann stability exercises that I will share from You Tube. There are a couple more on the Fitday channel if you follow the link but I wouldn't choose them for someone with back pain. As ever, discuss with your physio before trying this.
For years I have planned to one day write an e-book about pain relief. I want to list all the hundreds of treatments, techniques, advice and suggestions that are available and go through them one by one - looking at the evidence for and against. Time always gets the better of me though and the book remains in draft form.
In the meantime I have found this fabulous article by Paul Ingraham that does a great job. He has taken a look at some treatment ideas and has recommended some useful things to try - based on either positive evidence, or some promising treatments that are unlikely to harm. It's a very inspiring article for me and extremely useful list of things for you to try if you have pain.
You can take a look at it here :Pain & Injury Survival Tips
I'm often asked about the effectiveness of various 'over the counter' supplements for back pain. One of the ones I am asked most often about is fish oil especially Cod Liver Oil. I am interested in its effects and I haven't seen anything yet that suggests taking it is harmful but I remain a bit unconvinced.
So I was delighted to find this web site called Examine.com which takes a science based view and looks at all the research on a variety of supplements including Fish Oil.
And the findings? Mixed. 9 studies showed no change in inflammation, 7 studies showed an improvement. No studies showed any harm. So, it might be worth a try I think.
This is a brilliant global research project which has looked at the leading causes of disability and death across the world compared to 1990. If you are someone who likes to look at these trends this interactive chart lets you look at these causes by geographic area, gender and age etc. If data is not your thing then just skip this!
So what has this got to do with back pain?
Back pain is right up at the top for western Europe and USA - disability and distress from this condition grows and grows. It affects all ages and genders yet we still have no cure for this extraordinarily common problem.
Looking at this data made me feel two things. Firstly, dismay and sadness that so many people are living lives that are blighted by chronic musculoskeletal pain. Secondly, gratitude that I live in a wealthy society that has virtually eradicated many of the dreadful ailments that poorer countries have to deal with such as diarrhoeal diseases.
In the west we have a long way to go to try and turn the tide on this musculoskeletal burden dominating our health.
Piriformis syndrome is a sort of 'mock sciatica' and is often misdiagnosed because of this. The most common cause of true sciatica is an irritation of the sciatic nerve as it leaves the spine. This is usually caused by a closing down of the space because of a disc problem.
Piriformis syndrome is something completely different. The piriformis muscle sits deep in the buttock, attached at one end to the tailbone (sacrum) and the other at the hip. In about 30% of us the sciatic nerve runs through the piriformis muscle. if the muscle becomes short and tight it can cause an irritation of this nerve and cause leg pain and sometimes numbness which mimics sciatica.
This page I have recently updated looks at the pirifomis muscle, explains the causes of this problem and offers some tips for managing it - including a video of my favorite stretch.
You can see more written about this study in the LA Times
And you can read the full document here if you are inclined:
Another stabilising exercise from Fitday on You Tube - a physio shows you how to strengthen your core using your legs to increase the difficulty. Check with your physio before attempting this, if you don't have enough control to start with you will need to do some easier exercises first.
Is it more important what you do with your body or how well you look after yourself? Or is it all just down to your genetics and family history? In fact it is a combination of all three - which is what makes simple back pain so tricky to treat. This page looks at these different reasons .
I really believe that if you know what might be making your back pain worse you are in a much better position to know what to do about it. Hopefully this page will give you some ideas.
For a long while we have known that the chemicals in cigarettes have a bad effect on your circulation and that if you smoke you are more likely to get lower back pain.This new study is really interesting. It shows that if you give up smoking you improve your chances of reducing your back pain and of avoiding surgery. And if you don't give up? Those that didn't give up didn't improve.
I'm not a nag, and I do understand that it's difficult to stop if you smoke but if you are a smoker with back pain and you are thinking of giving up - read this - it may give you a little push in the right direction.
This is an excellent animated video explaining up to date thinking about pain. It talks you through all the different things that affect your pain. It also covers the difference between acute and chronic pain and introduces the biopsychosocial model of pain. It's a really helpful video - highly recommended.
Diagnosis of non-specific back pain is done in stages. Your doctor will ask questions and take a history and then will examine you. To start with they will be making sure they are ruling out serious or worrying problems.
This is a process of elimination and when all these other causes are thrown out you are left with simple back pain.
Once you have the diagnosis finding the exact tissue that is the source of your pain is much harder. X-rays and MRI scans only tell half the story and you may find that a very precise diagnosis is not possible. Find out more about how you diagnose simple back pain here.
Non-specific low back pain accounts for 95% of all back problems. Most people with this type of back ache complain of three main symptoms:
This page gives you a look at the three symptoms and explains a bit more about what they mean.It will also help you find out how this problem starts and how long it is likely to last.
Most back pain is labeled as 'non-specific'. This type of back pain is incredibly common - over 95% of back ache is diagnosed as being this one. Whilst it is not serious or life threatening it can be very disabling and difficult to manage. It is also very confusing to understand because the diagnosis is more of a label or 'bucket' term rather than a specific finding.
I have written a new hub page - what causes lower back pain - where I take a look at this type of back pain, explore what is in the bucket, what causes it, how you can recognise it and what your doctor will do to diagnose it.
A recent study looked at Spanish schoolchildren and came to the conclusion that if they carried a backpack that was greater than 10% of their body weight they were more likely to get back pain. It seems that girls were more at risk then boys.
Unfortunately, when you look more closely at the results, it is not so clear cut - girls were more likely to experience back pain than boys - even when there were no differences in backpack weight by gender. So I can't 100% trust the conclusion that its all down to back pack weight...
This makes me think that we just should use common sense. If your child is lugging about a heavy bag all day and if it makes them alter their posture for long periods then that may lead to pain...so try and keep the weight down a bit perhaps?
This is a link to the full research paper if you want to read it.
Shirley Sahrmann is someone whose work I respect a lot. She has done a lot of research and written a great book on stability and the spine (recommended for Physios but a bit complex unless you are really interested in the science).
These are a couple of Sahrmann exercises, they are shown performed by a physio (who is mainly aiming them at new mum's) but they are relevant to anyone who has back pain and has been told by their doctor or physio to start a core stability programme. If you have ever done Pilates you will see there are some similarities.
One of the most commonly prescribed group of drugs for managing back and joint pain are called Non-Steroidal Anti-Inflammatory Drugs (NSAIDS for short). These include familiar names like Ibuprofen and Diclofenac. The problem with these drugs is tat although they are often great at pain relief they do have side effects. One of the most serious side effects is bleeding of the stomach and intestine. This bleeding can be fatal - estimates suggest that between 12-16,000 Americans die every year as a result of this. I was startled by that number. I take them myself for joint pain and so I was really interested to read that using a gel may offer similar benefits with perhaps less of a risk of side effects.
This is a nice summary of the evidence if you want to read more.
Derry, S., Moore, R.A. & Rabbie, R., 2012. Topical NSAIDs for chronic musculoskeletal pain in adults. In The Cochrane Collaboration & S. Derry, eds. Cochrane Database of Systematic Reviews. http://summaries.cochrane.org/CD007400/topical-non-steroidal-anti-inflammatory-drugs-for-chronic-musculoskeletal-pain-in-adults [Accessed November 5, 2012].
Massey, T. et al., 2010. Topical NSAIDs for acute pain in adults. In The Cochrane Collaboration & M. Moore, eds. Cochrane Database of Systematic Review.ttp://summaries.cochrane.org/CD007402/topical-non-steroidal-anti-inflammatory-drugs-nsaids-for-acute-pain-in-adults [Accessed November 5, 2012].
Sitting down for long periods is never a good thing - and if you are unlucky enough to get back pain when sitting and you have an office job your life is going to be difficult. This workstation treadmill may be a novel solution.
Can you imagine spending the day walking while working? It would keep you fitter, keep you moving and stop you staying in the same position for too long.
I would love one of these but my study is far too small! If you work in an office that has space and you have some influence over office furniture purchases take a look at this treadmill desk review from Mashable.
This is a great video which gives some insight into what it is like living with chronic pain and how you have to pace your activities.
The young woman who wrote this has a disease called lupus but the problems she describes are similar for anyone with chronic pain - including chronic back pain. It's a bit loud for me (maybe its my age...!) but you can watch it with the sound down if its too much for you as there is no voice over.
I think it is an excellent way of describing the choices you have to make when you have a chronic pain condition. One of the main problems she describes so well is activity cycling - this is where you overdo it and then suffer - she describes this really well at about 3 mins 51 when she talks about borrowing 'spoons'.
You can find out more about pacing on this page on my website.
Hot packs are an easy and really popular way to manage back pain. 462 people say they use it on patientslikeme.com and most of them are using it for pain.
Reasons to try it.
You can read more information on this page on heat therapy.
Are they worth it? The jury has been out for a good while on whether stability exercises are helpful for lower back pain. There is conflicting research - some studies show it works, others that it makes no difference. Despite this uncertainty core stability is often pushed as a 'cure all' for back pain.
Personally, I think core stability exercises are good for some of you with back pain. This research study found core stability exercises helped reduce disability in some patients with back pain. The difference wasn't huge when compared to exercise or manipulation - but it was a positive difference none the less.
Another interesting finding is the worse the stability was at the beginning the greater the benefit was after treatment. This gives us a clue that if you have very poor core stability it is worth trying to improve it.
I consider poor core stability to be one of the 6 feeder 'pools' that contribute to back pain - want to find out more? Take a look at my e-book the Back Pain Action Guide.Ferreira, P.H. et al., 2010. Changes in recruitment of transversus abdominis correlate with disability in people with chronic low back pain. British Journal of Sports Medicine, 44(16), pp.1166–1172.
In the spirit of exploring the science of pain this is a nice, humorous video of Lorimer Mosley at TEDx looking at how our brain changes our perception of pain. The video is about 14 mins long but I would urge you to stay with it to the end as it goes through some mind blowing pain experiments.
To overcome fear and feel more confident with your back pain it's really helpful to have a basic understanding of what pain is - and what is isn't. I have written about some of the things I think are most important for you to know about in this pain section on my website.
I have also just found this great article called 'Seven Things You should know about Pain Science' which helps by explaining the science in a nice straightforward way.
Spinal manipulation is a technique commonly used for lower back pain relief. It is a sudden, quick movement, usually out of the control of the person receiving it. Often, a back manipulation is accompanied by a ‘crack’ or ‘popping’ noise. This is called cavitation and is caused by the release of a vacuum from within the joint. This technique is commonly performed by chiropractors, osteopaths and physiotherapists.
Two research papers have had a look at the most recent evidence for and against this type of treatment to see if it is shown to be helpful when compared to other treatments. The results are a bit surprising as they found very little difference between manipulation and other active treatments such as exercise. The references for these studies are below but if you are interested in a nice plain English explanation this is a useful Pain web site.
Rubinstein, S.M. et al., 2012. Spinal manipulative therapy for acute low-back pain. Cochrane Database of Systematic Reviews.
Rubinstein, S.M. et al., 2011. Spinal manipulative therapy for chronic low-back pain. Cochrane Database of Systematic Reviews
The Canadian Institute for the Relief of Pain and Disability are taking registration for some interesting chronic Pain webinars in a series entitled 'Chronic Pain, Improving Life While Living It'.The subjects include opioids and pain and also how to talk to your health care provider about your problem.
There are some older pre recorded presentations on this page too that look really intersting as well.
It is normal to read that acute pain is less than 6 weeks old and chronic pain older than 6 weeks old. This is a bit of an oversimplification as the main differences between them are more to do with how the pain is being processed by the brain. I have read an annoying amount of poor information about this on the internet - it makes it very confusing. I have made a short video that hopefully helps explain and simplify it a little.
Apologies for the video sound track - I'm talking a bit quietly so you will have to turn your speakers up a bit until I get time to re-do it with my new mocrophone!
Spinal stenosis is caused by a squeezing or squashing of the spinal cord. This is normally caused by age changes to the discs, joints and ligaments in the spine but can sometimes be caused by a slip of one vertebrae on another.
In this updated section I will show you the causes, symptoms and diagnosis of this common problem
This is a lecture type video produced by the American Chronic Pain Society. It is part of a series of lectures for war veterans with chronic pain. The videos are quite long but you can download a transcript if you prefer and the information is really helpful.
Serious complications from back pain are rare but there is one particular problem which is serious and needs urgent medical care. This problem is caused by a compression of the lower end of the spinal cord and is called cauda equina syndrome. Untreated, this can lead to permanent loss of bladder and bowel control, leg weakness and even paralysis.
Find out what the causes, symptoms and treatment options are for cauda equina syndrome.
If you want to read some case stories, or get some support if you have had this problem, this support group is an excellent resource and includes case studies of people who have had this problem.
Revised and updated page on the most common symptoms of a pinched nerve or sciatica
Acupuncture has been around for centuries and many people find it really helpful to manage their pain. The debate about whether it helps back pain has been raging for years and has picked up a bit more steam this month with the publication of an interesting research paper.
This study combined the results of lots of different trials and came to the conclusion that there was an improvement in pain with acupuncture. The other finding was that improvement was greater with real acupuncture rather than 'sham' or pretend acupuncture. The story was picked up by the media which headlined it as proof that acupuncture definitely works.
Things of course are rarely that simple. Close analysis of the study shows that while there were statistically significant differences between real and 'sham' or pretend acupuncture, the amount of difference was really quite small and may not make a noticeable difference to pain.
Vickers, A.J., 2012. Acupuncture for Chronic Pain- Individual Patient Data Meta-analysis. Archives of Internal Medicine, p.1.