“Back pain” is not a diagnosis, it is a label or a description of symptoms that come from one or more of the structures in the back: including vertebrae (the bones of the back), discs – cartilage-like things between the vertebrae (think Dippy ), muscles, ligaments, nerves, tendons, blood vessels. These structures might be damaged for one or more reasons: injury, a prolapsed disc, damaged nerves, chronic misuse – (sitting badly), weak muscles, torn muscles, tendons or ligaments or any combination of the above. Prolapsed discs need rest to encourage healing whereas torn muscles need gradual exercises to get them working as soon as possible.
Studies of back pain rarely separate symptoms from causes, and thus it is that despite decades of “modern health care” and scans, there is still no cure for back pain. Rest is generally bad but in some cases essential, taking painkillers, in small amounts may be helpful but, in that pain is there partly to stop further injury, might prolong the problem long term, because they bypass the need to correct the problem.
Most people with severe back pain have one or more MRI Scans, which give an impression of the structure and general condition of the back. They lack the clarity (or radiation) of a CT Scan and rarely diagnose the cause of the back pain or the function of the back. Everyone over the age of 30 has degenerative changes, but not everyone with degenerative changes or even prolapsed discs has pain. Equally people with pristine scans can be crippled by severe pain
The evidence suggests that steroid injections can help with a prolapsed disc but otherwise do not help. This is not surprising. A piece of prolapsed discs causes local pain and inflammation, reduced by steroid injections. However back pain caused by general wear and tear doesn’t have a lot of inflammation. For example, it may be caused by over-stretched ligaments, due to poor posture and sitting too much – (which is why improving muscle tone- “exercises” help). Repeatedly injecting steroids and local anaesthetic into poor quality muscles is building trouble for the future
Overall, the medical evidence suggests that most doctors treating most patients with low back pain by prescribing painkillers, especially opioids such as tramadol, codeine and oxycontin, spinal injections and “rest” are not improving the situation (1).
Referring someone with back pain to a “Pain Clinic” may be the least helpful of all. It is easy to do, in a busy GP surgery where no one is thinking long term. Someone has been complaining of pain for months, simple painkillers are not helping – send them to a “Pain” specialist. But that as already mentioned, pain is not a condition, it is a symptom of an underlying problem. Pain clinics came into being because patients with terminal cancer were in severe pain and significant distress and were helped by specialist input at that stage. Their disease is incurable and their symptoms distressing. Then patients who had chronic pain but not cancer were referred because pain is bad and now anyone gets referred and prescribed potent addictive drugs. The CDC reported 67,300 Americans died from drug-involved overdose in 2018 (2).
TREATING BACK PAIN
As sports doctors and therapists well know, musculo-skeletal problems are almost all bio-mechanical in origin and have bio-mechanical solutions. As far as back pain is concerned, although painkillers may help short term, only ongoing exercise programmes such as yoga and McKenzie exercises show ongoing benefit. These are generally intensive individual programmes with motivated patients and therapists. Very little else helps. Even though most people are not cut out to be county level athletes, most people’s bodies could serve them better than they do.
PREVENTING BACK PAIN = POSTURE, POSTURE & POSTURE
Muscles protect joints and ligaments keep the joints in place. What is a good posture? Upright!! with good muscle tone, a balanced spine, sitting, when required, on the “sitting bones” or Ischial tuberosities, and instead of sitting prefer walking and standing as much as possible.
Most people don’t have back pain most of the time. On its own, a lot of effort is needed to keep back pain at bay, however as part of a “health package” of all round exercise, healthy diet, sleep, rest and relaxation the return on time invested looks better.
There is no escape from an unhealthy body, and playing victim to illness is no better than playing victim in any other area of life. Yes there are real illnesses to which we have no answer but equally, the vast majority of illnesses are the consequences of stress and lifestyle
DIAGNOSING BACK PAIN
At the moment, there is no technology that diagnoses back pain. Scans show structure but that is not the same as function. A view of the structure, combined with a good history can give an idea of what has gone wrong. However understanding the back’s function is where the rubber hits the road. The body is enormously forgiving, it heals whenever it can. Persistent pain is a warning, often of ongoing damage, not an indication for or deficiency of painkillers or injections.
Technology has gone a long way to making our lives easier and safer than has ever been possible. Imaging has stormed ahead, not only does it provide incredible insights, it is scaleable worldwide and very few cities do not have an MRI Scanner. However have doctors been hypnotised by the images from their scanners that show the structure but not the function of the back? and has that been one of the pathways to epidemic of global illhealth.
Expertise does not easily scale. Sports and musculoskeletal therapists have an individual understanding of the body shaped by their experiences and the patients they see. The science behind their treatments is hard to establish because there is no common ground of objective measurement, either with respect of diagnosis or treatment.
Science depends on being able to make consistent measurements, pain is subjective, function is subjective – depending on the person’s circumstances, priorities and requirements. Self employed, high level athletes and those with interesting jobs have high levels of motivation. Those without such advantages are more likely to be ill for longer. The same treatments work well for one group but not another. The best judgement is the best guess by experts, of whom we are rightly suspicious.
Biomechanics underpins musculoskeletal function. Poor quality, unbalanced muscle activity strains joints, leading to long term problems, such as arthritis and chronic pain. It is now technically possible to measure and quantify gait, with respect of bone lengths, mechanical forces and muscle activity. At present there is little will to do such investigations outside of the elite sports arena, nor funding for such long term projects. Nonetheless until muscle function is taken seriously and objectively assessed, along with pain and quality it is difficult to imagine any great step forward in the management of musculoskeletal conditions. Expertise has to be scaleable and this means finding out what the people with the best results know that the rest of us don’t and modelling it. Experts however can be tricky, they may not know why they do what they do or they may not always want to share it, although the trend is far more towards sharing expertise and perhaps less about studying it. However expert opinion must be studied to find out what experts think, why and then scrutinising their reasoning.
The technology exists to record investigate the biomechanics of back pain comparing muscle patterns, of people with and without back pain and compare them with people who do have back pain. Would this tell us anything we do not already know? that strong muscles are important, that being overweight puts a damaging strain on the back, that a poor diet worsens health. It might tell us in a way that encouraged more people to take action, but there still has to be a shift in attitude. Instead of scaring people to death with talk of pandemic viruses, a better quality government would encourage people to become healthier and not close gyms and swimming pools at the first sign of a sniffle.
There is plenty of money around for investment, but it goes to the wrong people that is people who are expert at writing grant applications rather than the more deserving poor. There is no money in a healthy population, who look take responsibility for their health and consequently require little healthcare. The lifetime value of such “patients” is little above zero. In order to capitalise on expertise, that expertise has to become scaleable. Unfortunately scaling expertise scaleable does not make for lucrative patents or innovative technology. For the most part it is about using existing technology to benefit more people. Chest X-rays enabled a scaleable chest examination, replaced chest physicians with respect of screening for TB and as a consequence transformed the management of TB. The equivalent investigation would be to perform MRI scans of the nation’s backs, and selecting those whose spines were degenerating prematurely, treat them as a high risk population and give them intensive exercise programmes, with the intention of preventing incapacitating back pain further down the line.
EARLY DETECTION OF THOSE AT RISK
Despite the above, it may be that early degenerative changes in the back may indicate those more at risk of developing incapacitating back pain later in life. And it may be possible to motivate those people to be more careful about the weight and general fitness. However we do not know even whether it is true that people with early degenerative changes in their back, as shown on MRI are at greater risk of later back pain, it just seems likely. An MRI of the back costs approximately £200 – and if the above is true then spending £200 at the age of 30 is a good investment, providing that people take note of the findings and make appropriate changes. This compared to the cost of a corrective programme later in life. However, as with all screening programmes, if someone is shown to have a good back, will they rest on their laurels and not work as hard to keep themselves healthy as they might have done otherwise? Certainly this was true in my experience of Health Screening – getting a “good” health screen did nothing to deter smokers and drinkers.
The cost of people incapacitated by degenerative conditions is wasted lives, which comes with social, economic and health costs. A society plagued by illness is not healthy, already the UK is the most sickest and most obese country in Europe. Yet the NHS has the structure, if not the will nor means to change that. Improving Healthcare is not about putting more money into a failing system, but about specific policies to tackle specific problems for which there are answers. There are no magic wands, only intelligent hard work that brings concrete results.
1 Review Lancet : 2018 Jun 9;391(10137):2368-2383. doi: 10.1016/S0140-6736(18)30489-6. Epub 2018 Mar 21.
2 National Institute on Drug Abuse
3 Mechanical Low Back Pain Will, J S, Bury D, Miller J A Am Fam Physician. 2018 Oct 1;98(7):421-428.