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Chronic back pain

MagazineDecember 2010 (Vol. 21 Issue 9)Chronic back pain

There is now a multitude of effective drug-free alternative treatments for this common, often disabling, condition

There is now a multitude of effective drug-free alternative treatments for this common, often disabling, condition.

More than 80 per cent of us will suffer from disabling low back pain (LBP) at some point in our lives. Although most of us will recover within a few months, some will go on to develop chronic LBP-pain that persists for three months or longer. In most cases, it's not possible to identify a specific cause of the pain, and the treatment usually involves course after course of dangerous drugs (BMC Musculoskelet Disord, 2010; 11: 163).

Happily, there's a vast array of complementary and alternative therapies now available for chronic LBP, many of which are supported by good evidence of success (see box, page 26). But perhaps the best way to tackle LBP is to prevent it from becoming a problem in the first place.

Preventing back pain

According to the latest evidence, there are a number of ways you can reduce your risk of LBP.

o 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), so be sure to choose the right form of activity for you. According to Wisconsin-based spine expert Dr Peter Ullrich, an ideal back workout includes a combination of stretching, streng-thening and low-impact aerobic conditioning.

o Watch your weight. Being over-weight 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 prevalence of LBP, particularly in women (Spine [Phila Pa 1976], 2010; 35: 764-8).

o Stop smoking. Cigarette-smoking appears to be linked to LBP, according to several studies. 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 have postulated that this might be because tobacco smoke has detrimental effects on the developing spine (Eur J Public Health, 2004; 14: 296-300).

o 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 attending spinal and internal medicine clinics in Saudi Arabia for six years, 83 per cent were found to have abnormally low levels of vitamin D. After supple-menting with the vitamin, however, symptomatic clinical improvement was seen in all those who had low initial concentrations of the vitamin (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 cause musculoskele-tal pain by causing hypocalcae-mia-abnormally low levels of circulating calcium-which "sets in motion a cascade of biochemical reactions negatively affecting bone metabolism and health". One of these reactions is increased para-thyroid hormone (PTH), causing a spongy bone matrix to form. This leads to fluid absorption, resulting in an expansive pressure that trig-gers the abundant pain fibres in the tissues overlying the bones. This suggests that anyone who has non-specific LBP should be tested for vitamin D deficiency.

o 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 (aged 18 to 75 years) 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). In another study, psychological dis-tress was a better predictor of back pain than the standard diagnostic techniques (Spine [Phila Pa 1976], 2004; 29: 1112-7). Psychological factors are also implicated in the transition from acute to chronic LBP (Spine [Phila Pa 1976], 2002; 27: E109-20).

o 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, keeping your back straight and bending only at the knees. Avoid lifting and twisting simultaneously.

o Treat childhood back pain. Contrary to popular belief, non-specific LBP is a serious problem among children and teenagers. Indeed, a review of the relevant studies suggests that rates are almost as high as in adults (Ugeskr Laeger, 2002; 164: 755-8). There are also clear correlations 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, when it arises, be dealt with promptly.

The possible causes of childhood LBP include intensive sports activities and carrying a too-heavy backpack, as well as the factors mentioned above (Rev Chir Orthop Reparatrice Appar Mot, 2004; 90: 207-14). For backpack safety tips, see http://orthoinfo.aaos.org/topic.cfm?topic= A00043.

Joanna Evans

Drug-free treatment for back pain

o Exercise. Not just good for preventing back pain, exercise can treat it, too. One review 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 carried out under limited supervision-for example, home-based exercises with regular follow-ups by a therapist (Ann Intern Med, 2005; 142: 776-85). However, group exercise can also help, especially if you join a class that focuses on the mind as well as the body.

o 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, and also allowed the use of less pain medication (Spine [Phila Pa 1976], 2009; 34: 2066-76).

o 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).

o 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). Also, when used as an adjunct to drug treatment, this meditative form of movement and breathing techniques can successfully relieve chronic pain (Am J Chin Med, 2010; 38: 695-703).

o Acupuncture. In one major review, acupuncture was found to be superior to the usual care for treating chronic LBP, thereby justifying the recent recognition of this traditional Chinese medicine technique as a therapeutic option for LBP by the UK's National Institute for Health and Clinical Excellence (NICE) (Ann R Coll Surg Engl, 2010 Jun 7; Epub ahead of print).

o Massage. Several studies suggest that therapeutic massage is useful against chronic LBP, especially when combined with exercise and patients' self-care education (Spine [Phila Pa 1976], 2009; 34: 1669-84). In one trial, the benefits of massage were still evident 9-10 months after the therapy had ended (Trials, 2009; 10: 96).

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

o Spinal manipulation. Performed by chiropractors as well as some osteopaths and physical therapists, spinal manipulation was recently pitted against back school (consisting of group exercise and education) and individual physiotherapy (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).

o Biofeedback. This mind-body technique was found to be more effective than 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).

o Hypnotherapy. Numerous studies show that hypnosis is an effective treatment for a range of chronic pain conditions. In a small preliminary study to assess its success in chronic LBP, a brief, four-session standardized self-hypnosis protocol, combined with psychoeducation, dramatically reduced pain intensity and pain interference (Int J Clin Exp Hypn, 2010; 58: 53-68).

Supplements. In addition to a balanced diet, a number of supplements may be useful for beating back pain:

o Vitamin D could be the key to curing LBP if you are deficient in this nutrient (see main story). In a study
of 360 patients with chronic LBP, vitamin D eased symptoms in virtually all those with the most severe D deficiency (Spine [Phila Pa 1976], 2003; 28: 177-9). Although sunshine is our best source of this vitamin, most of us don't get enough of it that way. Pain expert Stewart Leavitt recommends (with the supervision of a qualified practitioner) a daily supplement of 2000 IU of vitamin D3 (cholecalciferol), along with a daily multivitamin that includes calcium and 400-800 IU of vitamin D. Be patient, as it may take up to nine months to experience the maximum effects of this regimen.

o 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).

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

Herbs. The following may help to relieve back pain:

o Capsaicin, found in all hot peppers, can ease many types of chronic pain when applied regularly to the skin. In one study, a capsaicin plaster was significantly better than a placebo in patients with chronic back pain (Arzneimittelforschung, 2001; 51: 896-903).

o Devil's claw (Harpagophytum procumbens) is effective for LBP when the daily dose provides at least 50 mg of the active ingredient harpagoside. One trial found it to be just as effective as the NSAID rofecoxib (Spine [Phila Pa 1976], 2007; 32: 82-92).

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

WDDTY VOL. 21 ISSUE 6


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