Back Pain (pt 2): What to do when you can't do anything

In my article last month I cited the generally accepted view that 90% of bad backs get better within 6 weeks.  Low and behold, the week that that Newsletter came out, an  Australian study reported that this widely held belief may be quite wrong.  The  researchers followed 1000 patients with back pain for a year, and found that after two months only 50% had fully recovered.   At the twelve month mark, only 72% had completely recovered.  The factors which were associated with a longer recovery time  were: older age, compensation cases, higher pain intensity, longer duration of back pain before consultation, feelings of depression and a perceived risk of persistence (BMJ, 2008;337;171).

Anecdotally, none of this is particularly surprising.  If you have a job, you tend to get back to work within two weeks ( 50% in the study did) for an number of reasons, economic included.  The condition colloquially referred to as “Mediterranean back”  during the 70s and 80s associated back pain with malingering in the public consciousness, and  anyone who has had chronic back pain knows that people tire of asking about it very quickly.  In my experience, once a person can stand up straight again and is not visibly in pain, they tend to just 'get on with it'.  Research has shown that early movement is the key to earlier recovery, but getting back to a sedentary desk job does not usually comprise movement, of therapeutic or any other kind.  And if no specific follow up is done, then this becomes a recurrent problem.

Self management is the key to minimizing, or hopefully eliminating, back pain.  We would all love to be 'fixed' by a therapist with a tweak here an another tweak there, but if the patient is not recruited in the management of their own back condition, it will recur; it is just a matter of time.  The reason you have back pain in the first place is usually  because one (or more) of your spinal segments is not playing its part, usually in the lumbar (lower) region.  If you think of the spine as a stack of thick coins  joined together with scallops, the coins are the bony bits (the vertebrae) and the scallops( full of porridge like goo), are the discs.  The discs are shock absorbers, and should be like plump cushions.  When one becomes compressed and hard, it causes a 'stiff link' in the spine.  Eventually this shows up on an Xray as 'joint space narrowing', or degenerative change'.  As the front of the disc  thins, it drops in height, and may  cause an over-riding of the facet joints at the back of your spine.  These are the beautiful joints that normally allow your spinal segments to 'glide' when you move.  The facet joints then 'rust', as the local tissue becomes inflamed, and eventually become arthritic, hence  the term 'facet joint arthritis'.

As the disc becomes thinner and flatter, and the defect is further exacerbated by  weakness of the local deep supporting muscles, your back is poised for an 'acute episode'.  Some movement, however slight, finally breaks that last frayed section of the worn out rope, that I described last month.  The back then locks itself  as a nauseating pain envelops you.  The  long muscles either side of the spine, called the  'erector spinae', become as rigid as metal cables, making movement of any sort painful;.  Your back is 'in spasm'.  You feel as if you may never stand up properly again.  You may have to crawl about on all fours, or limp painfully.  Getting on and off the toilet is difficult.  Getting up from lying is agony and tortuously slow.  Your back has gone into 'lock-down' to protect itself, and you are terrified and in pain....

If the disc further degenerates over time, the fluid in the middle of the 'scallop' dries out and the middle part hollows, so that the physical load is transferred to the edges of that disc.  Sometimes the wall of the disc perishes like a  gasket at the points of greatest strain, usually one of the back corners.  With excessive twisting and lifting what fluid is left can extrude through the fissures in the disc wall.  This is the so-called prolapsed, or 'slipped disc'.  The pressure of the prolapsed nucleus material  irritates the surrounding structures, and causes acute pain. If it presses on one of the big nerves that leave the spinal cord at the lumbar level, the irritation can case sciatica, or leg and/or buttock pain. Only about 10% of back pain is actually caused by a slipped disc, and in those cases, care must be taken to avoid missing a 'red flag symptom' which suggest that there is impingement of the spinal cord (urinary incontinence/retention, leg muscle weakness, etc.  These cases usually require a laminectomy, or 'surgical decompression' of the disc)

If this degeneration further continues, the damaged disc can no longer 'shock absorb', so that with every bend of the spine, it wears away, putting more strain on the surrounding spine ligaments and facet joints, so eventually this segment of the spine becomes 'unstable'. The person becomes vulnerable to recurrent episodes of back pain : “My back has gone out again”; “I've slipped another disc”, etc. Usually it is the same spinal segment, the same disc, just further degeneration, and if that person has not been co-responsible for their recovery or taken the time to understand what is happening, they feel helpless and frightened.

So what should you do when that searing back pain and spasm hits?

There are many schools of thought, but this is what I have distilled over the years, and is a bit of a 'belt AND braces approach', but when you can't stand up, I don't believe in sparing the horses.

1. Rest on a firm surface for the first 24-36 hours.  I suggest lying on the floor with a pillow under your chest, or on your back with your knees bent at right angles and your lower legs resting on a chair.  Evidence shows that there is nothing to be gained by resting for more than 48 hours, and in fact this may delay recovery by exacerbating 'disuse' syndrome and thus atrophy of the muscles that support the spine.
2. Heat and /or cold   Received wisdom suggests that  cold should be applied in the  first instance (such as a bag of frozen peas in a towel), but most people find heat (such as a wheat pack), more soothing.
3. Every two hours, do some gentle spine stretches, and if possible,  small rotations.  A New Zealand physiotherapist called Robin McKenzie came up with a particular method of managing back pain in the '60s, which was considered quite revolutionary at the time.  He is somewhat out of fashion now, but his principles for the management of acute back pain are very useful.  He prescribes a series of three exercises that should be done every few hours when you are in the initial phase of back spasm.  They are based on breathing, muscle relaxation and a type of modified 'cobra' pose, for those of you familiar with yoga.  They are available in detail on the web (just Google 'McKenzie method/exercises'), and  are too detailed to be reproduced here.  Though they sound simple, correct positioning is paramount.
4. Drugs   Non-steroidal anti -inflammatory drugs (NSAIDS)  have been shown to be better than placebo in acute back pain, though there is no evidence to distinguish between NSAID types.  I favour Naprosyn, 1000mg once daily, but I have no evidence to support this preference, but once daily dosing is handy and easy to keep track of.  NSAIDS theoretically short- circuit the inflammation which may be at the root of the pain, as well as having some analgesic effect themselves.
5. Analgesia  The NH&MRC recommendation is that you start with simple paracetamol, and work up from there.  Two paracetamol (2x500 G) four hourly is the therapeutic dose, and there is little point taking any less.  If this doesn't give sufficient relief to enable you to move without yelping, try Panadeine or Panadeine Forte (remember, they are constipating).  As I mentioned in the last article, it is better to treat pain adequately in its acute stages, as the long term outcome is better - so don't be a martyr! Night times can be very difficult, as every time you roll over in your sleep, you wake up with the pain, so you may need a stronger analgesic then.
6. Muscle relaxants  Diazepam, a long acting muscle relaxant, used to be used a lot for back spasm, in the mistaken belief that it would 'relax' the back muscle spasm.  If only!  The only benefit to its use in the short term is the blotting out of the pain, misery and the slow movement of time; in the longer term, its use is very addictive, so use your wisdom.
7. Muscle support  When you are changing position, tense your deep tummy muscles and your pelvic floor to support your back. There's no better time to start familiarizing yourself with your pelvic girdle (“core muscles”), if you have not  so far been introduced, as these are the muscles you are going to have to work on to help to prevent relapses.  The deep abdominal muscles are the ones that you tense when you laugh (remember that?).  If you are a man, your pelvic floor muscles are the ones that you tense if you are trying to drag your scrotum towards your perineum; if you are a woman, you will already be familiar with them. (An aside: research has shown that men ought to be regularly doing pelvic floor exercises, as it helps to maintain urinary continence and erectile function later in life)
8. Make an appointment with a physiotherapist, osteopath, chiropractor or another health practitioner of your choice.  Personal recommendation works best, I think. None of the above will want to see you while you are 'acute', if they do, be suspicious.  You will need to wait a number of days before anything useful can be done
9. Phone a friend and read a back book: You need to keep your pain in perspective, so talk to a sympathetic friend, preferably one who has had back pain.  You need to be reminded that you will get better, and that 'tincture of time' is required.  Get someone to buy or borrow you a copy of a good back pain book, as this is the ideal time to read it from cover to cover.  I recommend anything by Sarah Key, especially 'the Back Sufferer' Bible' (Allen & Unwin) or 'Treat your Own Back', by Robin McKenzie. Then phone another friend; avoiding despair is most important!