Lower Back Pain – The latest evidence – Part 2
Following on from my previous blog on the papers published early this year in the medical journal the Lancet, this second blog looks at some of the other important messages from this key research. If you haven’t already read these papers then here is a link to the Lancet’s website where you can find them:
One of the other and most significant messages that came out of these research papers was:
‘For nearly all people with low back pain, it is not possible to identify a specific nociceptive cause’ Hartvigsen et al (2018)
What this means is that for most people suffering with lower back pain, we don’t know the structural cause of the pain. This may sound crazy, but for the majority of people, doctors and other healthcare professionals are not able to diagnose the structural cause of their lower back pain. If you’re reading this and you have lower back pain you may have been told, that your pain is due to a structural change such as a slipped or bulging disc or it is due to degenerative changes in your spine. Although you may have been told this, these are not the cause of the pain. The reason why these aren’t the cause of the pain is because these structural changes occur naturally in everyone, even people who are pain free. Numerous MRI studies have now been conducted on thousands of people who don’t have lower back pain. What they have found is that a high percentage of these people had bulging discs, disc extrusions and osteoarthritis in their facet joints, but they were pain free and leading an active life. So if structural changes are the cause of pain, surely these people should be in pain as well?
Two examples of these studies are:
Matsumoto et al (2013) found that MRI scans showed degenerative changes [including protrusions, compressions and stenosis] in both the lumbar (lower back) and cervical spine (neck) in 78.7% of the asymptomatic volunteers. In another study, lumbar MRI of asymptomatic volunteers (age 14–82, mean age 46) showed 60% had bulges, 45% had protrusions, 31% had extrusions, 76% had annular fissures, 76% had nuclear degeneration (Kim et al., 2013). There are more studies that I have included on my website, you can follow this link to see their conclusions: http://bristolpainreliefcentre.co.uk/are-you-in-pain/useful-information/
One of the other conclusions of the Lancet papers was that we are doing far too many MRI scans of people’s lower backs and that by doing unnecessary scans it can make people’s pain worse. This is because when people find out they have a prolapsed disc or narrowing of their disc space, they naturally become more protective of their back. This can increase the protective pain response and also means people start to do less, which isn’t good. A study comparing people who had an MRI scan shortly after the onset of their back pain compared to people who didn’t have one, found the ones who did have an MRI scan had their back pain for a longer period of time (Webster et al., 2013).
There are some cases when further investigation is definitely warranted. In these cases it is to rule out serious spinal pathology including vertebral fractures, Axial spondyloarthritis, Malignancy, Infections and Cauda Equina (Hartvigsen et al., 2018). If you have one of these conditions then you will more than likely be experiencing symptoms that a physiotherapist or doctor would recognise as needing further investigation. So it’s always good to checked by your GP if you are unsure of whether you need a scan or not, but remember, if your GP thinks you don’t, it’s not just because they are trying to save money, it’s because it is unnecessary and may actually make things worse.
So what causes the majority of lower back pain?
If you read part one of this blog, I explain how it is more likely that the pain is being caused by what is happening in our lives and the emotional impact this has on us and how we respond to it. This lead to physiological responses, such as neuroplastic changes in the brain and central nervous system as well as adaptive changes in the neuro-endocrine and immune system. Although at this stage I can’t say for sure, it is more likely due to a combination of these physiological responses, triggered by life events. More research needs to be done to investigate this.
This is good news! Why? Because these changes are not permanent and by working out what triggered them in the first place, you can begin to make changes to reverse them, without the need for surgery, injections and medication.
Kim et al (2013)Prevalence of disc degeneration in asymptomatic Korean subjects. Part 1: lumbar spine. Journal of the Korean Neurosurgical Society (PMID: 23440899)
Matsumoto et al (2013)Tandem age-related lumbar and cervical intervertebral disc changes in asymptomatic subjects. European Spine Journal (PMID: 22990606), 2013, 708–13.
Webster et al (2013) Iatrogenic Consequences of Early Magnetic Resonance Imaging in Acute, Work-Related, Disabling Low Back Pain Spine (Phila Pa 1976). 2013 Oct 15; 38(22): 1939–1946
July 10, 2018
Lower back pain – The latest evidence – Part 1
Recently, there has been a lot of coverage in the mainstream media about three research articles on lower back pain, that were published in the medical journal The Lancet. These studies can be found on the Lancet’s website: https://www.thelancet.com/series/low-back-pain. In my opinion the research represents a significant shift in the way we treat lower back pain. Moving away from focusing on treating the structures in the lower back, such as joints and discs, to a more holistic approach. The main message portrayed in the press was that treatments regularly used for lower back pain, such as injections and surgery, are often ineffective and potentially harmful. Important to know for someone suffering with lower back pain, as you want to know how good a treatment option will be and whether it could cause you harm, but alongside this there was also lots of other good information about lower back pain that didn’t get picked up on. So I am going to highlight the other information that I think is relevant over a series of blogs.
The first paper published in the Lancet is titled: What is low back pain and why we need to pay attention (Hartvigson et al., 2018), and one of the key messages I took from this paper was:
‘Lower back pain is a symptom and not a disease’
The article explains that in the majority of people there is no nociceptive cause for lower back pain, this means there is often no known structural cause for their back pain (I will go into this in more detail in my next blog). If in most people there is no known structural cause of their pain and lower back pain is a symptom, what is it a symptom of? In the article it reports that the cause of lower back pain is related to a combination of psychological, social and biophysical factors, but what does all that mean?
In my experience after treating thousands of people with acute lower back pain, the onset of pain is a symptom of what is going on in someone’s life, rather than they have damaged their back. It is related to the circumstances they find themselves in and the emotional impact this is having on them. It is very rare that people with lower back pain have done something physical, to have damaged their back. Our lower backs are very robust and it takes a lot to damage them. Instead what I have noticed, is that there has often been a change in circumstances prior to the onset of pain. This change in circumstances usually has an emotional impact, it may also have a physical impact and it takes them out of their usual routine. By doing this it means that they lose their coping strategies and it means that the situation becomes stressful. I’ll use an example of a typical (but made up) presentation of a patient with lower back pain to explain this:
‘A 55 year old gentleman comes to see me with lower back pain, which started a week earlier. There was no physical reason for this pain, he hadn’t lifted anything heavy or over worked himself at the gym, it had just come on one morning. The pain is very intense and limiting his movement, but there is nothing concerning and he is generally healthy. After questioning him further it turns out that he has a quarterly target to meet at work and he is behind, meaning he is working longer hours than usual. He also has a sick mother who lives in a different city, two hours away, who he visits most weekends. He has a wife and two children, who he is not seeing as much and is finding it difficult to take his children to their various clubs. He usually attends the gym twice a week, but hasn’t been able to find the time.’
The circumstances this man finds himself in are having a large emotional strain on him. He is under more pressure at work than usual and working longer hours. His mother being sick is also having an emotional impact on him and he is having to drive to see her at weekends, sitting in Friday traffic. He has his normal duties to attend to, but is finding it difficult and he is not getting as much downtime as usual. He misses seeing his wife and children as much and may feel guilty that he isn’t helping out as much as he normally would do. He is also sitting for longer periods, which is not good for our metabolism and general health. The combination of these events is having a psychological and physiological impact on him, which means he is under a lot more stress than usual. At some point something needs to change and if it doesn’t people often experience pain. It’s your body’s way of telling you to slow down, or get some help. There are physiological responses that lead to this, which I will also explain in a later blog.
For most people an acute episode of lower back pain will usually settle within a month or so. Usually because the pain has the desired effect and it makes someone change what they are doing, or get some sort of support. Sometimes it can develop into chronic (long-term) lower back pain. In my experience this is because we haven’t acknowledged what else is going on in someone’s life when the pain began, we have focused on the structure of someone’s back, even when the research shows that most of the time there is no known structural cause for lower back pain. Maybe, by being more aware of the psychosocial factors in someone’s pain, we can be more affective at preventing lower back pain and stopping long term problems?
If you are suffering with lower back pain or know someone suffering with lower back pain, my advice would be, rather than look for a physical reason for the pain, think about what is going on in your life at present or in the recent past, or if you have chronic pain think back to when the pain started. Has there, or was there a change in your circumstances that lead to there being more stress then usual? What was the emotional impact of this? Has it taken you out of your usual routine? By acknowledging this and then giving yourself more time out, it may help to reduce the pain and allow you to get back to normal more quickly.
May 4, 2018
Can thinking affect your running?
A while ago a gentleman came to see me suffering from recurring shin pain whilst running. This had been going on for about a year and is a common complaint with runners, often attributed to poor biomechanics and from increasing your running distance too quickly. The pain had been ongoing for three months and he had completely stopped running in the past two weeks, but he hadn’t increased his running hurriedly and when I examined him he didn’t have any pain over his shins or the muscles surrounding them, which made me question whether biomechanics and overload were the cause.
So, digging deeper, I asked if there was any significant stress at the time the pain began, knowing that this can produce over-activity in the nervous system and lead to pain. He said that yes, he had been particularly busy with work and also had some family issues to deal with. When the pain began, he attributed it to a biomechanical overload of the shins and in his subsequent runs he consciously focused on this area to assess whether the problem would reoccur. I asked him what he had been thinking about during his runs and he said he was analysing whether he could feel pain in the shins or not.
He calculated that the pain had begun about eighteen minutes into his last run. When it got close to that time into his next run he began to focus even more closely on his shins and, sure enough, at that point, whilst feeling anxious of the potential pain, it reappeared. By consciously focusing on the shins, the nervous system became more protective of this area and, as a result, the pain increased as part of a protective mechanism.
This is a particularly common occurrence amongst runners. There are few distractions when engaged in a solo activity and the mind can easily focus on parts of the body where there may have been a past injury or where you perceive there to be one now. As a result, the nervous system becomes activated and focused on this area of the body. This leads to over-activity of the receptors in that area with a subsequent increase in localised muscle activity. Not only could this lead to pain, but is also likely to make you a less efficient runner!
Next time you’re out running and happen to experience pain, be aware of what you were thinking about. Were you running stressed? Were you thinking about problems at work or difficulties at home? If so, it may have been this that caused the pain. Were you focusing on that calf that felt a little tight in your last run? Or were you thinking about that patella tendon or ITB that was sore a few years ago? If so, you may be causing over-activity in the nervous system and potentially causing the pain by over analysing your body.
Energy follows thought
So what can you do to help prevent this? Well, mindfulness meditation is a great way of reducing stress by focusing the mind on your breathing and not on the things that could be causing you stress. It helps to induce relaxed breathing, improving circulation and relaxation in the nervous system and muscles. You can do this before or during your run.
Visualisation is also an effective technique. If you are imagining that your muscles are tight or that your ITB or patella is rubbing, then this could lead to over-activity. Imagine the muscle feeling energised and relaxed, bathed in a warm healthy blood flow and it will more than likely respond by relaxing and not tightening up.
Or tell yourself that you are going for a run just to enjoy it, for the love of it, not worrying about your time or doing well, just enjoying what you love. Focus on your surroundings rather than your body.
February 21, 2018
Have you ever had that overwhelming feeling and you just don’t know why you feel that way? It may be that you feel really anxious or depressed, or you feel run down and not yourself. I’ve had this feeling before and it can feel very daunting, particularly when you can’t work out what it is that’s making you feel that way. It could be down to any number of things going on in your life, but you just can’t put your finger on what it is. On some occasions, you may think you know what the trigger is, but can’t work out why it is making you feel like that. It feels like your brain is fogged up and it can seriously stress you out!
It may be the situation that you are in is stopping you from working things out. It may be that you are too busy to find time to figure things out, or it may be that you are ruminating on one thing, which is stopping you from having enough headspace.
At times like this, it may be that you need to change what you are doing to allow you to gain perspective. So what could you do to help give you time to think? Can you take some time off work? This may worry you because you lose a day at work, but in the long term you will probably feel better for it. If work is feeling particularly stressful, it can be good to give yourself a break and get yourself away from the usual routine.
More simply, take time out of your day to go for a walk and get yourself out of the office, or get out for a long walk in nature at the weekend; this can help to clear your head. The outlook can look much better from the top of a hill, walking along the coast or taking a walk in the woods. If it’s possible take a holiday, the amount of people who get better from a painful condition after a holiday is remarkable.
Talking to friends or family can also help give you a better perspective on things, often they know you better than you know yourself. If you feel like you can’t do this then maybe seeking professional help might help to make things clearer. If you don’t feel like talking to someone then try writing down your worries or problems, once they are on paper they may not feel so big.
However bad you feel, if you keep doing the same thing over and over it won’t help. Try to break away from your normal routine or try to get help from someone you trust, it can make all the difference to helping you feel less stressed.
November 10, 2016
The joy and pain of watching Leicester City!
I’m a Leicester City fan and for those of you that follow football, you will know that they are having an incredible season and are currently top of the premier league! Before the season they were relegation favourites and in my wildest dreams I couldn’t have predicted this happening. So it is all very exciting!
This weekend I watched them play against Watford and they won 1-0. It was a great result and it meant they went five points clear at the top of the league. Although it was a great result, until the final whistle was blown I couldn’t relax, I was a bundle of nerves, jumping out my seat and biting my lip. At times I felt like I was physically shaking. Even after the match had finished it took me a while to calm down. I text some of my friends and joked that I wasn’t sure I could watch for the rest of the season as I might have a heart attack!
The next day I read a report on the BBC website explaining how positive events create stress and place strain on the heart that can cause a condition called ‘acute stress cardiomyopathy’. A bit depressing really! It explained how exciting and happy life events, such as getting married, someone having a baby…or your favourite team being top of the league, although positive, create stress and put extra pressure on your heart. In summary positive life events can be as stressful as negative ones can. You can read the article here: BBC article
Luckily I already knew this so didn’t feel too down. It is something that I’m often explaining to people, but find they have difficulty accepting. When I am working with people in pain I try to help them understand the link between their stress and pain. If I explain that the promotion at work or finding out your wife is pregnant is a cause of stress, people often question it by saying ‘But it was a really positive time for me?’ and they’re right, it is a positive time, but it can also increase stress levels. It creates extra physiological load, increases heart rate, blood pressure and may not allow you to sleep properly. If this carries on the unconscious part of your brain may activate a protective mechanism to try and make you slow down. Pain is often that mechanism, as it makes you stop, slow down or makes you rest.
This all may seem very depressing, but it’s not if you can recognise it. If you recognise it you can do things to balance and counteract the level of stress. You can make sure you do things that help you to relax, like exercise, walks in the countryside, meditation, offloading by talking to friends or writing things down.
So, even though I know it’s stressful, am I going to stop watching Leicester City this season? No chance! This is the most exciting season I’ve seen as a Leicester City fan! Even if you don’t follow them you have to be impressed by what they’ve done. I’ll just make sure that the level of stress it creates between now and the end of the season is counterbalanced with time spent switching off!
Come on the foxes!!!