Ordinary pain

    21 February 2015

    Treatment for lower back pain is undergoing a sea change. Why? Well, mainly because it has to: according to a report released earlier this year, lower back pain is the biggest cause of disability, globally — and because of an ageing population the burden on healthcare is due to get a lot worse.

    Given the number of nerves that run alongside the spine’s 24 vertebrae, protected and supported by muscles and ligaments, it’s no wonder that one in three people every year are affected by lower back pain. The back is the superhighway of the body, and about 2.5 million of us are parked on the hard shoulder — that’s how many have serious enough back pain to visit their GP each year.

    The good news is that only a small minority will need surgery — around 5 per cent, according to Mr Nick Birch, orthopaedic surgeon and medical director of the Spinal Rehabilitation Unit at the Chris Moody Sports Injury and Rehabilitation Centre. The bad news? There is no miracle cure for chronic back pain — and it affects so many of the working population.

    Doctors will first discount any serious causes for back pain, asking about ‘red flag’ symptoms: a pain in the back plus a fever can equal an infection, although as Dr Dawn Richards of VitalityHealth says, ‘It’s unusual.’ She adds, ‘A fracture of the spine or collapsed vertebrae can happen without any trauma if there is an underlying cause such as osteoporosis or cancer.’


    Numbness in the genital area, loss of power in bladder muscles and bowel disturbance may point towards cauda equina syndrome, when the nerves at the bottom of the spine are compressed. This needs urgent medical attention to prevent permanent damage to the nerves. If a spinal disc prolapses, it can lead to pinched/compressed nerves, and in the case of the sciatic nerve pain, tingling and numbness may go down the leg to the foot. This can be treated with muscle relaxants such as diazepam to stop the spasming or locking of the muscles, and epidural injections of cortisone and local anaesthetic are often very good at relieving severe leg pain. There are also inflammatory conditions such as ankylosing spondylitis, causing pain and stiffness of the back.

    If your pain is not linked to one of the above diagnoses, it may be termed ‘non-specific low-back pain’. Diagnostic imaging such as X-rays or MRI scans are not always required in these cases and are only recommended by Nice when serious pathology is suspected. ‘Diagnostic tests often do not help clinicians come to a conclusion as to what is causing the patient’s symptoms. There are many normal changes to the spine that have little to do with why the patient has pain. The findings are often not helpful in deciding the best course of treatment to help reduce symptoms,’ says John Doyle, chartered physiotherapist at Nuffield Health ( ‘Patients will generally benefit from a simple exercise programme as well as reducing the time they spend sitting.’


    When it comes to pain, ‘The back is very stupid, for want of a better word,’ says Mr Birch. Most lower back pain is non-specific because ‘there’s a very small area in the brain that processes the information from your back.’ Just look at the sensory homunculus to see why. This figure that plots sensation to scale has huge eyes, ears, tongue, hands and (ahem) genitals; but a tiny body. ‘The brain knows that the back is either “fine”, or “it hurts” — a little or a lot.’

    ‘Our understanding of pain hasn’t moved on in 25 years,’ agrees Mr James Scott, orthopaedic surgeon and editor emeritus of The Bone and Joint Journal.

    Low-back pain sufferers can get into a vicious cycle of avoiding movement and slowing recovery. The effect on mood, too, can put a negative spin on everything. ‘Pain is not always a sign of damage,’ says Doyle. ‘Patients often worry that if they have pain and they move, they will cause more damage, but this is not usually the case.’ He recommends that ‘patients should stay active as this will keep the joints mobile and the muscles strong leading to quicker recovery’. There are many therapies that may help, particularly in the short term, and most episodes of back pain will settle down with no treatment at all. However those with ongoing back pain may benefit from ‘an exercise programme that gradually increases strength, mobility and fitness levels while addressing any of the worries or concerns about pain that the patient may have’. This combined physical and psychological approach was recommended by Nice in their 2009 low-back pain guidelines.


    ‘Patients often report that their pain reduces, or that it has less impact on their lives as a consequence of regaining normal movement, improving strength, fitness and function, and having a better understanding of pain from the cognitive behavioural approach,’ says Mr Birch. The ‘low-intensity’ group therapy module of three-hour sessions once a week for five weeks is proving to be the more budget-friendly, costing £750 per person, as opposed to the high-intensity inpatient model based on two- or three-week residential stays in specialist units at a costly £6,000 pp.

    Ultimately, the days of resting a bad back are gone, and getting back to normal activities is what is encouraged. The research clearly shows that low-back pain places significant burden on the economy. The costs of treating back pain and the financial impact linked to sick days and long term disability continue to grow. in these straitened economic circumstances, the state — both in terms of healthcare and sign-off-work-with-a-bad-back culture — can no longer support.

    Maybe this is a good thing. Historically the medical industry has presented itself as the answer to everyone’s bodily suffering. But to give patients the tools to deal proactively with their conditions gives sufferers back responsibility for their own health — and that should be embraced.