Saturday 26 May 2018

'People with back pain are often told to do the exact opposite of what the science says' - Irish physiotherapist on back pain myths

Many back pain sufferers get harmful and useless care, but Dr Mary O'Keeffe, a low back pain researcher, asks is there a better way forward for sufferers? A new series of papers led by a team of international researchers in the scientific medical journal The Lancet establish what the best treatments are for back pain.

The Lancet Series findings are of huge importance to people suffering from low back pain in Ireland
The Lancet Series findings are of huge importance to people suffering from low back pain in Ireland

Mary O'Keeffe

World leading experts in low back pain have shown that low back pain is being mistreated on an enormous scale.

They are treating low back pain with x-rays, scans (MRI and CT), surgery, and painkillers, which are now discouraged for treating low back pain. Patients are being let down by the treatment they are offered, and the overreliance on x-rays, scans, surgery and painkillers means patients miss out on more sensible and safer approaches.

These are the findings of a new series of papers led by a team of international researchers in the scientific medical journal The Lancet. The researchers have called for a stop to outdated models of care, and the offering of useless and potentially harmful treatments for low back pain.

Evidence suggests that low back pain should be managed in primary care, with the first line of treatment being reassurance and advice to keep active and stay at work. However, in practice a high proportion of patients worldwide are treated in emergency departments, encouraged to rest and stop work, are commonly referred for scans or surgery, or prescribed pain killers including opioids, which are discouraged for treating low back pain.

“The majority of cases of low back pain respond to simple physical and psychological therapies that keep people active and enable them to stay at work,” explains Series author Professor Rachelle Buchbinder, Monash University, Australia. “Often, however, it is more aggressive treatments of dubious benefit that are promoted and reimbursed."

The Lancet Series highlighted that more care does not mean better care. More aggressive treatments for low back pain have little proven benefit and have the potential to make things significantly worse for patients. There is no evidence that routine back imaging (being sent for an x-ray or scan) improves outcomes, but patients referred for imaging are significantly more likely to receive unnecessary care and undergo surgery.

Over half the people taking opioids long-term have low back pain, notwithstanding the fact that opioids offer uncertain benefits and carry substantial risks of addiction, overdose and even death.

Rest, is one of the worst approaches, yet this advice is commonplace in many countries.

The Series authors say that health care systems should avoid harmful and useless treatments by only offering treatments in public reimbursement packages if evidence shows that they are safe, effective, and good value for money. “We have an industry that’s essentially allowed to do as it pleases in terms of marketing unproven products. People can make a fortune marketing something that’s unproven” says Professor Chris Maher, based at the University of Sydney, Australia who was involved in the Lancet report.

Imaging is required if the clinician suspects that a serious disease such as cancer, infection or a fracture is the cause of the low back pain. But the Lancet Series emphasised that in only a tiny percentage of patients is the low back pain due to a serious or dangerous underlying cause that needs specific diagnosis and treatment.

Thankfully these conditions are very rare.

The authors stated that poor general health, including factors such as obesity and low levels of physical activity, are associated with low back pain episodes.

“People who are fearful of moving their back, or those with depression or stress and who have little control over their job and life may be at higher risk of being disabled, and these types of factors might be even more important than the pain itself," explained series author Professor Rachelle Buchbinder.

The series authors advise that painkillers should be avoided where possible. But if they are required it is best to use a simpler safe option first; and no matter what medicine is chosen they should be used at the lowest possible dose for the shortest possible time.

The authors say that widespread and inaccurate beliefs about low back pain should be challenged, and focus put on reducing the impact of low back pain on people’s lives rather than seeking treatment for a ‘cure’ or an instant solution.

Back pain sufferers in Ireland should pay attention to these findings.

An Irish physiotherapist and low back pain researcher, I'm now working in Professor Chris Maher’s research team at the University of Sydney as part of her European Union Marie Skłodowska-Curie Fellowship.

I believer these findings are of huge importance to people suffering from low back pain in Ireland.

Ireland’s 2014-2015 National Health Survey found that 19% of Irish people reported suffering from low back pain over the previous year, with similar rates between men and women. This percentage means low back pain is the most commonly reported health condition by the Irish population - even ahead of high blood pressure, asthma, heart disease, depression, and diabetes. Back pain accounts for over 25pc of doctor visits in Ireland, and is our leading cause of disability. The costs are also enormous. Previous research found that disability payments for low back pain amounted to €348 million and insurance payments cost €10.5million.

The findings of the Lancet Series show that we need to totally re-think how we both view, and treat, low back pain. I feel sorry for anybody suffering from back pain as they are often told to do the exact opposite of what the science says. It must be very confusing for them!

This needs to be tackled, so more health professionals are on the same wavelength when it comes to advice and treatments given. People receive treatments that they do not need or would not have wanted if they were appropriately informed about the likely effects of the care, and the natural course of low back pain.

Less emphasis should be placed on surgery, scans, painkillers and quick “fixes” for low back pain, and more emphasis placed on reassuring people that most low back pain is not serious, and giving people the tools to help themselves and get confident again-through things like staying active/getting back to activity, going back to work, exposure to feared activities, taking steps to living a healthy lifestyle, and improving physical, emotional and general health.

Below are some tips and advice:

1. Believe you can improve as most low back pain is not serious and most episodes clear up reasonably quickly

An episode of low back pain can be very severe and frightening, and understandably make people worry they have done serious damage. While the pain can be terrible, the vast majority of low back pain should be considered a part of normal everyday life. Like the common cold, almost everybody will experience low back pain at some point, but episodes run their own course, clear up reasonably quickly, often without a need to see a health professional for treatment. It should be a relief to hear that up to 99% of back pain is not serious.

It is worth knowing that for most people, low back pain is a condition that comes and goes throughout life. This means that people should expect or not be surprised if they get recurrent episodes or bouts of pain. Again, these are rarely serious. Therefore, believing one can prevent every episode of back pain after the first episode, and find a complete permanent cure, will set people up for a lot of disappointment, and make people lose hope in better approaches. It would be similar to thinking every episode of tiredness, headache, heartbreak, heartburn or low mood (things we all experience), can be, or needs to be, prevented forever.

These things are difficult parts of life, are often recurrent, so we need to have a different understanding of the terms “recovery” and “good health”. We need to be careful not medicalize experiences of normal life and understand that good health is NOT the absence of symptoms; if it was then none of us could be considered healthy!

Approaching an episode of low back pain with a positive mind-set where people expect to improve from each episode, and get back to living as soon as possible, is a good strategy.

Pinpointing triggers (e.g. unaccustomed activity, stress) for low back pain, and finding ways to tackle these is a good thing. While tackling these is unlikely to prevent people from ever getting low back pain again, people will be better equipped to bounce back, ensuring low back pain does not disable them for a long time.

2. Avoid bed rest with low back pain as it leads to worse results

Bed rest and prolonged rest are unfortunately still commonly prescribed for low back pain. However, we now know that people with low back pain who remain active (even when in pain), do better in the long-term. The longer a person stays in bed because of low back pain, the worse their pain and ability to do their work and activities becomes.

3. Remain active and return to full activity and hobbies as soon as possible

This may sound like strange advice as one may feel movement is the last thing they want to do, when all movement might be sore during an episode of low back pain. This is understandable, but the key is finding the balance between not resting completely, and letting the low back pain settle. Having a strategy where you either cut down or alter certain painful activities (e.g. lifting) for a few days, and then gradually build up to these activities again is a good idea. However, it is important that people do NOT wait for all pain to be gone, before they start moving. So while people may need to reduce or cut down on some movements, it is best to keep up some movement (or pottering around!). No specific exercise is needed at this stage. Simply put, people should not rest completely, and should try to remain as active as they are able to manage.

When people have weathered the storm after the first few days, strong evidence shows that returning to all activities and hobbies is important. People are often anxious about returning to physical work or activities that are high impact or involve bending, twisting or lifting.

While these types of activities can often trigger an episode of low back pain, they are not bad for the lower back, and people should build up confidence to get back to them.

4. Stay at work or go back to work as quickly as possible

Sick notes and staying off work are unfortunately still commonly prescribed for low back pain. Similar to bed rest advice, it fits with the wrong belief that rest and total recovery from pain is needed before normal activities are resumed. It is generally a bad choice to take off time from work with an episode of low back pain. It will usually delay recovery.

It is also worth knowing that an improvement in pain levels is NOT associated with returning to work. In fact, work satisfaction, not pain levels, predicts being off from work due to low back pain.

So while people might feel this advice goes against the grain, people should try to stay at work-even if it means modifying or altering their usual work routine for a time. It will make a difference to recovery. One can then gradually resume full duties over a few weeks. In summary, in the same way that people should not wait for low back pain to be gone to get active, the same applies to staying at work or getting back to work.

5. Don’t rush for an X-ray, CT scan or MRI scan

Most people believe that an X-ray or scan will identify the cause of their low back pain and lead to the best treatment. These tests might be important if there is suspicion of serious disease (e.g. cancer, fracture, infection, spinal cord injury). Signs and symptoms like back pain with unexplained weight loss, general sickness, history of cancer, changes in toileting (bowel or bladder function), loss of power in legs, numbness between legs may indicate serious disease, and so a health professional may need to send for an x-ray or scan. Luckily, this accounts for only a tiny percentage of low back pain.

For everyone else X-rays and scans are not indicated. Recovery from low back pain is no different or slightly worse in those who have the scan, compared to those who don’t. As well as exposing people to unnecessary radiation, X-rays and CT scans detect stuff that are normal parts of the aging process, are common in people without low back pain, and are poorly linked with pain. MRI scans can detect even more things that are a part of normal ageing.

Common findings include disc bulges, degeneration in the discs or joints (arthritis) and disc protrusions. This means a person can get a diagnosis they did not need (e.g. disc bulge, wear and tear, degenerative spine disease, slipped disc), that won’t improve their recovery. It could also cause them harm through increasing worry about the cause of low back pain, cause people to start changing their life through resting more, not returning to work, and withdrawing from hobbies. Of huge concern, is it could increase the chances of people getting treatments that they did not need, or would not benefit from. These include strong painkillers like opioids, injections, and surgery.

Therefore, the harms of getting an X-ray or scan far outweigh the benefits for the vast majority of people with low back pain.

6. Don't call an ambulance or visit the emergency department

A severe episode of low back pain can be distressing but people should resist the temptation to call an ambulance or turn up to the emergency department. They have no better treatment options than people can get from the local GP/physio/pharmacist. People who visit an emergency department are more likely to get tests and treatments they don’t need. They might also have more chance of being admitted to hospital which means they will be resting in bed which is not advisable. And people will have to wait while they deal with the emergencies first.

7. Don’t expect medicines on their own to be the answer (and know that there is no such thing as a ‘back pain’ medicine)

Many people think strong pain needs a strong painkiller. None of the medicines we call "painkillers" actually kill the pain. At best these medicines will reduce the pain but not remove it completely; and all have the potential for side-effects, particularly medicines containing an opioid. If pain medicines are to be used, it is best to opt for a simple over thecounter option, as they often have the same effect as stronger prescription painkillers and less risk of harm. Most importantly, pain medicines shouldn't be used as standalone treatment (they should be combined with activity, etc), nor as a long-term solution. Self-medicating or using someone else’s pain medicines is unwise. It is best to speak to a pharmacist or doctor to ensure pain medicines are used effectively and safely.

Some pain medicines have been promoted as specifically targeting low back pain but that is not how pain medicines work. If people take a pain tablet the body has no way to just send the medicine to the back. As well, if one looks at the medicine packaging they will see that the back pain formulation is exactly the same as formulations for other conditions like osteoarthritis, period pain and headache. Most pain medicines used for back pain are also used for other pain complaints. There is no need have to pay more for the “back pain version”. If unsure it is best to talk to a pharmacist.

8. Surgery is rarely an option for low back pain

Surgery is of limited use for low back pain. There are some rare back conditions where there is pressure on the nerves that supply the leg which can present as leg symptoms such as pain, pins and needles or numbness. For these conditions surgery can help the leg symptoms but it is important to know that surgery is rarely needed.

Over the medium and long term, the results for back surgery are no better than non-surgical interventions such as exercise. Unfortunately, many people with low back pain get scanned too early, and then get sent for surgery (e.g. lumbar fusion).

9. The back is a very strong structure

Much of the advice and opinions about low back pain would make a person think that their back is like a house of cards or a piece of glass that could fall apart or break under little pressure. This is far from the truth. During an episode of severe low back pain, it is common for people to think that they have “put their back out”, are “locked up”, feel something has shifted out of place, or they are out of alignment. The severe protective muscular tension or spasm that can often accompany an episode of low back pain can make people feel like this.

What’s also hard for people in this situation is the fact that they cannot see their own back when they are in pain (this is very different to other parts of the body), and so they can be left feeling uncertain about what’s after happening. This uncertainty (combined with the often terrible pain) can be very distressing. However, it is important to remember that nothing is moving out of place when this happens, so rest assured that the spine isn’t falling apart.

This is particularly relevant when people hear the term “slipped disc”. It is common for people to think that some important part of their back structure has moved out, and they are now unstable. Discs, bones, joints in the back do not go 'out of place' or 'slip', ever. The discs are firmly attached between the back bones and cannot "slip" out of place. This is no way helped by some health professionals telling people they are putting their bones and discs back into place through treatments like manipulation. While the “crack” can feel nice, reduce people’s pain, any short term benefit is due to changes in the nervous system, muscle relaxation, not due to the “putting in” of discs or bones.

Lifting and bending are two activities often seen as the enemy of the lower back. It is true that lifting heavy loads in an awkward posture increases the risk of an episode of new onset low back pain. This is very different to thinking that these activities are bad for your back.

If people want to get better at lifting, it is worth building up their tolerance to lifting and getting strong for different positions, in different situations, and with different types of loads. It is worth knowing that not everybody will lift the same, as everybody has a different body type and range of movement; so what is efficient and comfortable for one person, may not be for another. Getting good at these activities requires practice and confidence in movement.

Avoiding all lifting, or lifting in a fearful manner where all the back muscles are braced to get ready for the movement, makes this task very difficult. It is worth knowing that manual handling guidelines where every worker is instructed to bend their knees, and keep their back straight, have failed to prevent or reduce low back pain in the workplace. There is no scientific evidence supporting their use. It is also common for people with low back pain to start applying these lifting principles to simple everyday activities like tying their shoes or picking something off the floor. These strategies have failed to yield any success for people with low back pain.

In summary, people should try to use their back sensibly and build up tolerance and strength for certain activities like lifting through practice with different loads, positions, and situations. The same would apply to lifting or training activities that use the shoulders, hips, knees, etc.

But people need to know the back loves movement, is designed to bend and lift, and so it should not be wrapped in cotton wool.

Sitting is another activity blamed for low back pain. While some people report sitting makes their back pain worse, there is no scientific evidence to show that sitting causes low back pain.

Slouching in particular gets a lot of attention, and many people with low back pain are told to sit up straight, and stay in rigid tense looking postures. However, despite the hype no particular sitting posture has been found to cause low back pain. Like lifting technique, different people will naturally prefer to sit in a certain way; so there isn’t a perfect posture! It is true that people can report pain if they stay in a prolonged position, but this does not mean that any of the positions are bad. The back likes to move, so break up inactivity by moving around. The good news for workers sitting eight hours a day, is that one hour of being active outside of work, can prevent any potentially bad health effects of sitting for a long time.

Schoolbags are another thing blamed for low back pain, particularly in children and teenagers. In scientific studies, where lots of children and teenagers are studied and followed up over time to see who does, and does not, develop low back pain, it is not those with heavy bags that develop low back pain. Therefore, despite all the claims, there is currently no scientific literature showing that schoolbags cause low back pain. This may be hard to understand as children can say they have back pain when wearing their schoolbag. This is very different to the schoolbag being the cause however. Giving children the opinion that taking a schoolbag is bad could have a bad influence on their levels of activity. It could also give them the opinion that their back is vulnerable to other types of load, and make them fearful. Overall activity is good and activities which involve load (running, jumping, wearing a schoolbag) will burn energy and strengthen muscles and bones. Schoolbags should not be feared!

Women, in particular, are often told that their clothes and/or footwear can be causing their low back pain. Theories of flat feet and lack of blood flow due to tight clothing are common.

Again, these are based on opinions, not facts, and have no scientific basis. People should be confident in wearing skinny jeans, large bags, heels, and other clothing and fashion items as they do NOT cause low back pain, and most definitely do not cause damage.

In summary, all of these opinions fits with the wrong belief that load is bad for the back and the back is a weak and vulnerable structure. Remember the back is a tough, strong and robust structure capable of adapting to lots of movement and load.

10. Exercise is safe, should not be avoided, and can be helpful

Exercise can be helpful for low back pain. The most important thing to remember is exercise is NOT bad for low back pain- so people should not feel they have to avoid exercise. The best exercise is the one a person can stick with over time. Exercise does not need to be gruelling and involve sweating and panting to get the health benefits. There is no special magical exercise that a person needs to do, but this message is often sold to us by the media and different health professionals. For example, walking, running, cycling, swimming, yoga and pilates all have similar effects for low back pain, and are equally safe. Walking the dog, playing with the kids more to get you moving all count towards exercise. If a person does not like one activity, they can try something else.

Unfortunately, many people are given wrong information about certain exercises. High impact exercise like running on the road or activities that involve a lot of twisting like swimming are often given a bad reputation. Again, this is based on opinion, and these activities are perfectly safe for the back. During an episode of low back pain or when getting back to exercise after an episode, it is common to feel uncomfortable doing exercise, but this is not doing damage, and people should be confident to continue the exercise.

Exercise is not a cure for low back pain. For most people it has a small effect, but this effect is the same as people would get from an expensive treatment which may have more side effects (e.g. strong painkillers, injections, surgery). So it isn’t magic, but as good as what is out there. It is also worth knowing that exercise is the only current approach that might prevent a recurrence of low back pain. On the other hand, commonly claimed prevention strategies for back pain like new desks, chairs, pillows, mattresses, insoles, which can be very expensive, do nothing for low back pain, or its prevention.

11. Don’t be a guinea pig and watch out for fake news!

It can be easy to be taken in by low back pain remedies promoted in the media. Particularly when the treatment involves little effort on the person’s behalf and when the story is accompanied by a testimonial from a patient whose life has been transformed. This can be hard to understand as when people try some of these approaches, they report feeling better. But it is worth knowing that when pain is at its worst, it will naturally get gradually better; back pain often fluctuates from week to week, or comes in cycles, and what you expect matters. If you expect something to help it is likely be helpful due to the placebo effect. The majority of so-called ‘miracle’ treatments for low back pain have never been tested by scientists. These can include stem cell injections, magnetic back supports, herbal supplements, insoles, colourful tapes, and electrical devices. Where they have been tested, the effects are very short term, not better than doing nothing, and have no long term benefit. Therefore, people should be wise with their money and not be fooled by people trying to sell a product.

12. Low back pain does not always mean there is a back problem

When people get low back pain they automatically think of their back structures, movements or activities that may have triggered the pain, and about possible damage. This is easy to understand as this is the engrained belief about the back. And in some cases, this might be true as people can break bones, fall on their back, etc.

What is really interesting is low back pain can emerge or be made worse by lots of different things, which may have nothing to do with your actual back structures. There can be emotional triggers (people thinking they will not get better, people thinking they have a bad back, fear of a certain activity, depression, stress), health-related triggers (being tired and run down), lifestyle related triggers (poor sleep, low levels of physical activity, being overweight), and social related triggers (financial problems, poor relationships or support at work or home, low job satisfaction, stressful life events like a death or illness). So low back pain is very unique to every person. All low back pain is real, no matter the trigger. This can be a sensitive topic as the mention of non-physical factors can make people feel like their pain is being dismissed or it isn’t real pain. But there are lots of different pains that can be driven by non-physical things. For example, anxiety and stress can increase risk of headache or stomach discomfort- these are all real.

So with low back pain, it is good for people to look at their own life, and see what might be contributing to the low back pain. Many of the things that people want to do to better their overall health, are also sensible ways to approach low back pain. These include getting enough sleep, getting more active, being a healthy weight, giving up smoking, spending time with loved ones, reducing or better managing work and life stress, and mastering/getting confident in tasks or activities that are important to you.

13. Five questions to ask a healthcare professional during a low back pain visit

As discussed, some tests, treatments and procedures provide little benefit for low back pain. And in some cases, they may even cause harm. These five questions have been designed by an initiative called Choosing Wisely to encourage patient-doctor conversations about unnecessary medical tests and procedures. It is worth bringing this list of questions to appointments with doctors or other healthcare professionals to make sure one ends up with the right care for their low back painremembering that the right care can sometimes be little or no treatment for the vast majority of low back pain.

  • Do I really need this test, treatment or procedure?

This is particularly relevant to imaging and medicines for low back pain. As outlined previously, imaging and medicine is unnecessary for the vast majority of low back pain.

  • What are the risks?

Will there be side effects to the test or treatment? Could that lead to more testing, additional treatments or another procedure?

As discussed above, there might be risks from getting unnecessary tests like x-rays and scans, and these are often not discussed. These tests can lead to unnecessary as well as unhelpful treatments like strong painkillers like opioids, injections and surgery.

  • Are there simpler, safer options?

Are there alternative options to treatment that could work? As discussed earlier, simple and cheap options like exercise can be just as effective as surgery for the vast majority of low back pain.

  • What happens if I don't do anything?

Ask if the condition might get worse — or better — if you don’t have the test, treatment or procedure right away. This is crucial as we know that most low back pain runs its own course with time regardless of what the person does. People can always come back for a review andreconsider these options if they don’t improve.

  • What are the costs?

Costs can be financial, emotional or a cost of time. We discussed the harms of unnecessary scanning, and the costs of medicines and surgery. It is advisable to ask about these.

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