Back pain: the universal curse

This seems to be the season for bad backs.  I've had six patients with lumbar back pain in the last three weeks, all men, all over 40 and all not amused.

All of them were doing something 'simple' or 'silly', when their backs “went out”, leaving them unable to straighten up.  One  had sneezed, another had picked up the cat, another was getting the washing out of a front loader washing machine - at least that's what he told me.

One had felt a twinge after picking up his toddler and throwing her above his head: this is a very common way for men in their 30s and 40s to present,  and causes a swift change in persona from that of youthful vitality to that of an old man.  This chap had hurried off to his usual masseuse to get the spasm 'sorted out' (it had worked in the past!), but after 40 minutes on the table, he literally couldn't get up.  The masseuse wanted to call an ambulance, but  Derrick, my patient, has a morbid fear of hospitals and needles and the thought of this  made his spasm worse.  We got some strong pain killers to him, got him home and he was off work for a week.  During that time, he saw a very good physio who told him some home truths, ie, that he is unfit, overweight and can't expect too much of his spine, which like all human spines, is only designed to last for 40 years. My patient was  a bit put out, but pain is a strong motivator.  He had some treatments, he did some exercises. As soon as he felt almost better he was back at work, and cancelled his next physio appointment and the subsequent Pilates sessions.

One of life's great truisms is that humans forget the misery of pain.  If they didn't, no woman would ever re-visit childbirth voluntarily.  When a person has a severe episode of back pain, it is all- absorbing.  They think they will never forget how miserable  (and scared)  they feel. They resolve to do anything to  prevent it EVER happening again. Once it is better,  they think it is unlikely to happen again, especially men, who tend to suffer from delusions of invincibility. But when it is bad, they want it fixed NOW!

 I had a call from a patient the other day, who, when I asked him how he was, replied “Angry!”.  I thought I'd done something to offend him, but he was 'angry' that his back was sore and had been so for two days. (Sub-text: 'how dare my body disappoint and inconvenience me like this.  I am important. I need someone to fix it now, so I can be back at work tomorrow, and I don't have time for more than one session with a physio, chiropractor, exercise specialist, doctor, etc).

It so happens that I am very good with backs, as I had several years of severe back pain myself.   Unlike most doctors, I don't think of clients with back pain as “heart-sink patients”. It took two operations to fix my back, and I keep it 'fixed' with regular exercise and Pilates, and I freely admit that those  were the most miserable years of my life.  But my case was extreme.  Fortunately, 95% of bad backs get better within one month, and this seems to be independent of what treatment, if any, is employed.  Physiotherapy, chiropractic, osteopathy, acupuncture, medications alone or in combination, appear to have the same or similar efficacy.  Even just getting advice from a GP (who is often the least useful font of advice), allows backs to heal. This is reassuring, but not terribly comforting for someone in the throes of an acute episode of back pain.  One month is an awfully long time to feel as if you have instantly aged 50 years, and to be dependent on help to put  on your  trousers or do up your shoes, let alone empty the dishwasher.  And cars!  Getting in and out of cars is one of the most challenging things.  I have often thought that every single person should have one day of severe back pain, just so they know what it is like.  Going by the above hypotheses above though, they would most likely forget.

At least 80% of people will have  back pain at some stage in their lives, so it's good for the health budget that the vast majority  do get better on their own.  Doing fancy Xrays or MRIs on backs rarely changes the medical management, and costs the tax payer a lot of money. They must be done if there are so called 'alarm symptoms', which suggest that the spinal cord itself is impinged (incontinence, for instance, or leg numbness). These days, though, people want to feel that something concrete is being done, or that they are at least being taken seriously, so a lot of strictly unnecessary imaging is done.  But getting a CT scan can be therapeutic, in my experience, as I often find middle  aged men (in particular) are reluctant to accept that their spines have underlying  structural pathology, which has probably been there since they played schoolboy rugby, and is not going to get better  without their help. When the framework beneath looks like a WW1 battlefield , it is never going to be pristine again, though strengthening the surrounding musculature will help.

Radiologist love using the words 'degenerative' and 'prolapse' in their reports, and I find these  frequently have a sobering effect.   I like to explain the acute episode of pain as being like the last strand of a thick rope unravelling.  It has been fraying for years, off and on, and is hanging together by a thread, when one final insult, such as bending, twisting and lifting, or even just sneezing, is all it takes.  It has not occurred out of the blue, but on a background of slow degeneration and muscle disuse.  Very fit and active people do get back pain, too, but most people who get back pain are sedentary and under-exercised, and this describes, let's face it, most  of us. 

The best advice for an acute episode of back pain is rest and analgesia for the first 24 hours, then mobilisation.  I advice people to dose themselves up on enough painkillers to allow them to walk about a bit and to do some gentle rotational spine movements.  Massage can help in th early stages, but the danger is it can stir the evolving spasm up, and trigger it,  as in the case of Derrick. There is also evidence now that it is far better to take adequate analgesia to allow early mobilisation, and to take enough in the fist 24 hours to manage the pain, as you are much less likely to go on to develop chronic pain if you have quelched the pain in its acute phase.  This has been worked out at the microscopic level of the pain receptor, and is truly exciting stuff, as it applies to all or most  injury related pain.  Persuading people to actually swallow the pills though is often an Herculean task.  “Oh no, I don't like to take pills”, or “I'd rather not give in to pain”  are common refrains.  No one will admire you for being a martyr to pain and if subduing it allows you to get active sooner and therefore get better quicker and decrease the possibility of a negative outcome, why not?

Twenty years ago, the advice was to rest for a month, and not infrequently people were put to bed in hospital for 2-4 weeks, or, in the 1970s, had a plaster 'body jacket' applied for 6 weeks, from armpits to groin, to immobilize the area.  These  treatments caused the muscles supporting the injured structures to atrophy, which in turn made the person more likely to have further episodes.  It's only in the last decade that the multifidus, a group of deep stabiliser muscles, have been identified, and that these muscles, together with transversus abdominus, need to be activated  in order to protect and heal the spine. This is what is involved in turning on 'the core' that so much is heard about these days. Most Pilates exercises are based on this.  Generally these muscles  have become inactive in  sedentary people and in people with back pain, and one must re-learn how to activate them.  With practice, they activate automatically   Exercising the core musculature of the back is more than just trunk straightening, but involves the motor re-learning of inhibited muscles.  A substantial part of this ground breaking research has been done in Australia and New Zealand, especially at the University of Queensland.

So why do we get back pain?

Since we starting walking on two legs about two million years ago, we have been able to move faster and use our arms for many useful things, but this has come with a price.  Walking on two legs means a lot more weight  must be carried by the spine, hips, knees and ankles. Hardly surprising then, that these joints give humans a lot of trouble, and especially the lower spine.  It bears the greatest stress and is most prone to injury.  Added to that, we are heavier from our high fat, high calorie diets, less fit, and we tend to lift heavy objects,  bend, twist and sit in awkward positions for extended periods of time. So, back pain is an inevitability for most people at some stage in their lives.  The key is to knowing how best to manage it when it happens to you, and to learn how to prevent it from recurring. I will address this next month.