Beating Back Pain

A massive 80 per cent of us will suffer from disabling low back pain (LBP), or lumbago, at some point in our lives. Although most of us will make a quick recovery, for some the pain will become a chronic problem, interfering with work, sleep and daily routines. In fact, in the UK, back pain is the second most common cause of long-term sickness, following stress.

Most of the time, it’s not possible to identify a specific cause of the pain, and the treatment usually involves course after course of painkilling drugs, which can end up doing more harm than good. Opioid analgesics such as oxycodone and coedine, for example, can lead to a laundry list of nasty side-effects, including nausea, dizziness, constipation, addiction, depression, anxiety, hypogonadism (resulting in reduced testosterone levels, diminished libido and erectile dysfunction) and even death.

On top of all that, they don’t actually work very well: more than half of all ‘regular’ prescription opioid users still have back pain, according to the published reports. Paradoxically, the drugs may actually increase sensitivity to pain (a condition called ‘hyperalgesia’) by interfering with the brain, spinal cord and peripheral nerves (Pain Physician, 2008; 11 [2 Suppl]: S105-20; Pain, 2005; 119: 95-103; J Am Board Fam Med, 2009; 22: 62-8).

But drugs aren’t the only solution for LBP. Consider the following list of tried-and-tested natural treatments before popping that painkiller.

Treating low back pain

Exercise
Many back-pain sufferers may be tempted to avoid exercise and take it easy, but the evidence shows that staying active could be the best medicine. One review of several studies concluded that exercise can reduce pain and improve physical function in chronic or recurrent LBP (Joint Bone Spine, 2008; 75: 533-9).
The most effective strategy appears to be an individually designed exercise programme that includes stretching and strengthening, and is partly supervised-for example, home-based exercises with regular follow-ups by a therapist (Ann Intern Med, 2005; 142: 776-85).
Group exercise can also help, especially if you join a class that focuses on the mind as well as the body.

The following have had good evidence of success:

Yoga
A two-year study showed that an Iyengar yoga class twice a week can improve functional disability, pain intensity and depression in adults with chronic LBP. The class also led to a drop in the use of pain medication among the participants (Spine [Phila Pa 1976], 2009; 34: 2066-76).

Pilates Method
Increasingly used to treat chronic LBP, this form of exercise can be effective for reducing pain and improving general physical function (J Bodyw Mov Ther, 2008; 12: 364-70).

Qigong
The main posture used in this form of exercise is similar to the posture recommended by healthcare professionals dealing with back pain (Wien Med Wochenschr, 2004; 154: 564-7). In a study of chronic pain patients using medication, those participating in weekly half-hour qigong sessions had better pain relief than those in the control group (Am J Chin Med, 2010; 38: 695-703).

Acupuncture
In a review of 15 controlled studies by Milton Keynes Hospital in the UK, this traditional Chinese medicine technique was superior to the usual care for treating chronic LBP, so justifying its recent recognition as a therapeutic option for LBP by the National Institute for Health and Clinical Excellence (NICE) (Ann R Coll Surg Engl, 2010; 92: 595-8).

Massage
A review of all of the relevant studies in the medical literature suggested that therapeutic massage is useful against chronic LBP, especially when combined with exercise and self-care education. In one trial, the benefits of massage were still evident one year after the therapy had ended (Spine [Phila Pa 1976], 2009; 34: 1669-84).

Alexander Technique
This discipline, which emphasizes self-perception of body movement, was more effective than conventional care or massage for chronic or recurrent back pain. What’s more, just six lessons followed by prescribed exercises were nearly as effective as 24 lessons of Alexander Technique on its own (Br J Sports Med, 2008; 42: 965-8).

Spinal manipulation
Performed by chiropractors as well as osteopaths and physical therapists, spinal manipulation was recently pitted against back school (consisting of group exercise and education) and individual physiotherapy (including exercise, passive mobilization and soft-tissue therapy) for the treatment of chronic LBP.
The results showed that spinal manipulation provided better short- and long-term functional improvements, and more pain relief, than either back school or individual physiotherapy (Clin Rehabil, 2010; 24: 26-36).

Biofeedback
This mind-body technique proved more effective than either behavioural therapy or conservative medical treatment for sufferers of chronic back pain. The researchers also reported that biofeedback was the only method to significantly reduce pain over the two-year follow-up (J Consult Clin Psychol, 1993; 61: 653-8).

Supplements
In addition to a balanced diet, try the following:

Vitamin D could be the key to curing LBP if you’re deficient (see box, page 26). In 360 patients with chronic LBP, vitamin D eased symptoms in virtually all those with the lowest levels of vitamin D (Spine [Phila Pa 1976], 2003; 28: 177-9).

Although sunshine is our best source of this vitamin, most of us don’t get enough that way. Pain expert Stewart Leavitt recommends (with the supervision of a qualified practi-tioner) taking 2000 IU/day of vitamin D3 (cholecalciferol) along with a daily multivitamin including calcium and 400-800 IU of vitamin D. But be patient, as it can take up to nine months to get the maximum effects of this regimen.

B-complex vitamins may also help. A combination of vitamins B1, B6 and B12, taken twice a day at 50 mg, 50 mg and 1 mg, respectively, together with the popular non-steroidal anti-inflammatory drug (NSAID) diclofenac (50 mg twice daily) was better at relieving back pain than the NSAID alone (Curr Med Res Opin, 2009; 25: 2589-99).

Proteolytic enzymes, such as trypsin and serrapeptase, may help as they are known to have anti-inflammatory properties (Indian J Pharm Sci, 2008; 70: 114-7).

Herbs
Capsaicin, found in all hot peppers, can ease many types
of chronic pain when applied regularly to the skin. Indeed, a capsaicin plaster was significantly better than a placebo in patients with chronic back pain (Arzneimittelforschung, 2001; 51: 896-903).
Devil’s claw (Harpagophytum procumbens) works when the daily dose provides at least 50 mg of the active ingredient harpagoside, and was just as effective as the NSAID painkiller rofecoxib (Spine [Phila Pa 1976], 2007; 32: 82-92).

White willow bark (Salix alba) is chemically related to aspirin and appears to provide short-term relief of LBP at daily doses standardized to 120 mg or 240 mg of salicin, which acts like an anti-inflammatory (Spine [Phila Pa 1976], 2007; 32: 82-92).

Joanna Evans

Factfile: Preventing back pain

• Stay active. Lower levels of physical activity are linked to LBP (Aust J Physiother, 2009; 55: 53-8), while regular exercise appears to prevent the condition (Joint Bone Spine, 2008; 75: 533-9). This makes sense as having strong, flexible muscles are essential for a healthy back. However, overly strenuous or excessive exercise can be bad for the back (Pain, 2009; 143: 21-5). According to Wisconsin-based spine expert Dr Peter Ullrich, an ideal back workout includes a combination of stretching, strengthening and low-impact aerobic conditioning.

• Watch your weight. Being overweight places an additional burden on the spine and strain on the back muscles. In one study of more than 60,000 men and women, a high body mass index (BMI) was significantly associated with an increased incid
  ence of LBP, particularly in women (Spine [Phila Pa 1976], 2010; 35: 764-8).

• Stop smoking. Cigarette-smoking appears to be linked to LBP. In a recent meta-analysis that pooled the results of 40 separate studies, current smokers were 80-per-cent more likely to suffer from chronic LBP and also had more than twice the risk of disabling LBP (Am J Med, 2010; 123: 87.e7-35). More worrying, exposure to secondhand smoke during childhood can increase the risk of developing back problems later in life. Researchers think this might be because tobacco smoke has detrimental effects on the developing spine (Eur J Public Health, 2004; 14: 296-300).

• Get enough sunshine. Mounting research suggests that a lack of vitamin D, produced naturally by the body in response to sunlight, could be contributing to chronic musculoskeletal pain, including LBP (BMJ, 2005; 331: 109). In one study of patients with chronic, non-specific (no obvious cause) LBP, more than 80 per cent of them were found to have abnormally low levels of vitamin D. After supplementing with vitamin D, improvements were seen in all those who had low levels to start with (Spine [Phila Pa 1976], 2003; 28: 177-9).

According to Dr Stewart Leavitt, a member of the American Academy of Pain Management and editor-in-chief of the online journal Pain Treatment Topics, vitamin D deficiency can lead to musculoskeletal pain by causing hypocalcaemia-abnormally low levels of circulating calcium-which “sets in motion a cascade of biochemical reactions negatively affecting bone metabolism and health”.

• Manage stress. Psychological factors such as stress and depression are also thought to play a role in LBP. In one UK study that followed 4500 adults for 12 months, the likelihood of having a new episode of LBP was greater among those who scored in the upper-third of a questionnaire for psychological distress (Spine [Phila Pa 1976], 1995; 20: 2731-7).

• Avoid poor posture. In particular, sitting in a chair for long periods of time creates imbalances in the musculoskeletal system that can increase the risk of pain and injury. According to one study, workers who sit for more than half a day in awkward postures are significantly more likely to suffer from LBP (Eur Spine J, 2007; 16: 283-98). (See WDDTY vol 20 no 3 for tips on keeping a healthy back while sitting.)

Poor lifting technique can also be the cause of back pain. You should always push, rather than pull, when you need to move heavy objects and, if you have to lift, let your legs do the work by holding the load close to your body while keeping your back straight and bending only at the knees. Above all, avoid lifting and twisting simultaneously.

• Don’t ignore childhood back pain. Contrary to popular belief, non-specific LBP is a serious problem among children and teenagers. Indeed, a review of all the relevant published studies suggests that rates are almost as high as in adults (Ugeskr Laeger, 2002; 164: 755-8). There are also clear links between experiencing LBP as a child/adolescent and suffering from LBP-especially chronic LBP-as an adult (Arch Pediatr Adolesc Med, 2009; 163: 65-71). It is vital, therefore, that the condition be dealt with earlier rather than later.

The possible causes of childhood LBP include intensive sports activities and carrying a too-heavy backpack, as well as all the factors mentioned in this box (Rev Chir Orthop Reparatrice Appar Mot, 2004; 90: 207-14). For backpack safety tips, see http://orthoinfo.aaos.org/topic.cfm?topic=a00043.

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