2.5 Sort out your back

If you get a sudden bout of back pain then you should know that in almost everyone it will calm down and improve with time.

We also know that back pain frequently comes back again.

Many people get stuck in this cycle where back pain is never far away but the slight improvements stop them from taking action. There are many treatments for back pain but there is a lot you can do when you are not in pain to reduce the risk of problems. Building a strong and resilient back is a great investment in your future quality of life.

Treatments for back pain

It is estimated that there are over 200 treatment options available to treat low back pain and there is no single one which is clearly better than another. That emphasizes nicely the scale of the challenge in finding an effective treatment if you're suffering from back pain. On the plus side, it does give you plenty of options to try.

It is worth pointing out that despite a ton of research, much of the medical literature is characterized by a lack of evidence. Sometimes there are studies, but they show little effect and sometimes areas we would like to look into have been little researched.

The other difficulty about low back pain is that it is a condition that needs types of treatments that go beyond pills, and those are difficult to research.

Unquestionably, when I see somebody who is in sudden and severe pain, then pain relief medication can help reduce muscle spasm and give relief. However, the evidence for any medication in back pain has weakened in recent years. When it comes to longer-term pain, then the best treatments certainly include the physical therapies. Education about back care has been shown in many studies to be an important element of any long-term strategy toward a healthy back.

"Therapeutic massage helped me more than physical therapy. Going to the gym, yoga and trigger point release. Trying to avoid the chiropractor because adjustments sometimes make the problem chronic (e.g. over-stretching ligaments)."

Gabrielle Garbin, The Healthy Writer survey

Medications in low back pain

My general advice is to go for the simplest medication, with the fewest side effects, that gives you some relief.

That might seem obvious, a principle to which all prescribing should be held, but it is surprising how this basic idea around medication is often ignored. The bottom line is that few medications make a lot of difference to long-term back pain. There is some evidence that non-steroidal anti-inflammatory (NSAID) drugs can be helpful but it is surprisingly weak. NSAIDs also have a long list of side effects, some of them serious, and if you use them on anything other than an occasional basis, it’s worth chatting to a healthcare professional.

There has been recent evidence that the use of paracetamol (acetaminophen in the USA), which has the advantage of having very minimal side effects, may not be that helpful.

It is probably worth a tilt, but make sure you take a proper dose. Don’t just pop one every day or two and curse it for not working. Take it regularly for a few days and if you don't feel it is making a difference, sack it off. A great deal of care should be taken with opioid medications for any long-term back pain, and the increasing use of opioids in North America has been called an epidemic. There is more in Chapter 1.5 on chronic pain.

Yoga and back pain

There has been a flurry of reviews around the benefits of yoga in the last few years. A systematic review in 2017 found the evidence points toward benefits at three months, six months and one year. The overall clinical effects were modest but were there. It is certainly worth a look and Joanna’s experience of yoga, documented in the next chapter, has been nothing short of transformative.

"I have found Pilates to be excellent for my core strength, and it's suitable for people who have existing injuries/weaknesses."

Sandy Vaile, The Healthy Writer survey

Walking and back pain

One activity that most people can do is walking. A systematic review of walking published in the journal Clinical Rehabilitation found that walking was as effective as other non-drug methods of managing low back pain. It was noted that one study found ‘normal’ walking to be superior to treadmill walking.

One nifty study in the European Spine Journal found that increasing your walking steps reduced neck pain in people who didn’t start with problems. Those that increased their daily walking steps by 1000 had a 14% reduced risk of neck pain. It didn’t seem to have any direct impact on low back pain, though.

Alexander technique

The Alexander technique is often described as a method to help people go about their daily lives with less muscular tension. You need to learn the Alexander technique from a qualified practitioner and it tends to be a one-on-one learning process.

A systematic review in 2012 suggested there was some evidence for the effectiveness of the Alexander technique for long-term back pain. The other effects on things like respiratory function and posture were not terribly conclusive.

Interestingly, the Alexander technique has been investigated in musicians and it has been suggested that it could improve performance anxiety. If you suffer from quite a bit of chronic back pain and you are doing a fair bit of public speaking, neither of which would be unusual in a writer, the Alexander technique may be a particularly useful option to consider.

Pilates and getting active can help back pain

Pilates was developed in the early twentieth century by Joseph Pilates from Monchengladbach in Germany. He called his system contrology and he would be astonished at how far his program of exercises has spread. There are now millions of practitioners worldwide.

Pilates is a general physical and mental conditioning program and there is a strong emphasis on core stability and flexibility that can reduce pain and improve functioning if you are having chronic low back pain.

The research backs it up as well. Studies show that Pilates can give significant improvements in pain and functional ability in the shorter term compared to usual care and physical activity.

Does it have to be Pilates, or can participation in any sport or other leisure physical activity reduce the risk of back pain? A systematic review found that leisure time physical activity may reduce the risk of chronic back pain by 11 to 16%. That’s not a huge amount, but highlights the importance of doing something active.

Exercise is good for your back.

It can take many forms, such as walking, yoga, Pilates, or any sport. Being active will also help you manage your weight, which is a known factor that makes back pain more likely. There is no single method that is clearly better than another, and being active doing something is almost certainly more important than what you do.

"Healing came from a chiropractor visit and advice in readjusting my laptop and chair."

Traveller, The Healthy Writer survey

Chiropractors and back-crackers: the art of manipulation.

One treatment that is often considered for back pain is some manipulation on your spine.

Doubtless you will have been told tales of colleagues or friends who have visited some practitioner, been pulled in one direction or another, possibly involving a dramatic crack, and walked out cured. This kind of treatment usually comes under the category of manipulative therapy, and it does have a little bit of a controversial past in that it is often administered by chiropractors and osteopaths.

Both of these groups have had some challenges in being accepted in the mainstream, not least because some, though not all, practitioners have rejected the main theories of medical practice and science, and have made dramatic claims for the ability of spinal manipulation to cure all manner of diseases.

In terms of back pain, a recent review of this treatment suggested that the overall size of the benefit from spinal manipulations seems at best small.

Of course, when you look at studies, there may be some patients who get a dramatic improvement, but these are mixed with those who get only a very minor benefit or none at all. If you are one of those who have had your back cracked and then walked out like a new person, then you may well be evangelical about the treatment. The use of chiropractors is very common in the USA but relatively rare in other parts of the world. There has been some concern about the safety of manipulative therapy. There are certainly rare case reports of serious complications where the spinal cord has been damaged.

However, none of the large studies that have been reviewed have identified any serious complications. Contrast that with the well-known and serious kidney and gut side effects of medications like the non-steroidal anti-inflammatory drugs and, in reality, the risks of something like manipulative therapy pale into comparison.

It is important to highlight that while manipulative therapy from practitioners such as chiropractors does not appear to be any worse than the other treatments for back pain, there is no reasonable evidence to support its use as a treatment for diseases such as diabetes, heart failure, or thyroid disease. Issues of physical manipulation aside, one of the things a chiropractor can do is educate you around back care and good habits.

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