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Programme 5. - Back Pain
RADIO 4
THURSDAY 25/08/05 1500-1530
PRESENTER:
BARBARA MYERS
CONTRIBUTORS:
STEPHEN LONGWORTH
PRODUCER:
ERIKA WRIGHT
NOT CHECKED AS BROADCAST
MYERS
Hello. Absolute bed rest, weeks in traction, spinal fusion - just some of the treatments for everyday back pain. Well not anymore. Now the recommendation from your doctor it's likely to be mobilisation - moving around, staying active - strengthening the core muscles and possibly manipulation - a visit to the physio. No tests, no medical interventions. It's a back pain revolution. So what happened? What do we know about back pain and its optimum management that we didn't know until relatively recently and is this really going to be the answer for everyone?
Well if you have a bad back and are wondering how to make it better call us now - 08700 100 444 is the number or you can e-mail checkup@bbc.co.uk with your questions for Dr Stephen Longworth. He's a GP from Leicester with a special interest in back pain, he sees patients both in his own surgery and at the spine clinic at Leicester General Hospital. Welcome to the programme and welcome to our first caller - Marilyn Robinson is on the line, she's calling from Southampton and has suffered for 30 years since a fall when she fractured her spine. Sorry to hear about that. But are managing to take exercise - so you're coping with your condition Marilyn?
ROBINSON
I don't have a condition anymore, I've totally coped with it. What I'm doing at the moment is Pilates, at least two or three times a week, I'm doing aerobics in the gym, I'm doing weights - I'm lifting up to 20 kilos - and I'm doing even circuits, which has allowed me to do up houses, to lead a perfectly normal life and in fact I wasn't at the time.
MYERS
Well I have to smile because Stephen sitting opposite me has put two thumbs up to your suggestion that this is the answer, this is the way forward. Is that right - is Marilyn actually demonstrating exactly what you have to do if you've got a back problem or had a back problem - you get on with it and you get very active, as Marilyn certainly is?
LONGWORTH
Hi Marilyn. Could I possibly book you to come and spend all afternoon in my spine clinic at the hospital because I'm sure it'll come much better from you than from me, these particular messages. This is precisely what I want to hear people saying today.
ROBINSON
Actually I've said - I'm supposed to be retired, I'm doing more than now than I ever did. However, that's one of the things that I'd love to do, especially with older people, because they really do not listen to their bodies and they just know in their heads that they can't do things, which is totally wrong because I was told that I was going to have a spinal fusion and I was going to have cat gut put in my spine, I've had osteopathy, I've had physio, I've had traction, acupuncture, acupressure and then so much drugs that I couldn't talk in a straight line, you know, and I just happened to go next door to my gym, having just moved house, and this lovely lady who was into this sort of thing said to me come back later in your kit and from now on you won't look back. And agreed the first couple of sessions I woke up in the night with huge headaches and things but still did it.
LONGWORTH
How long ago was this?
ROBINSON
I originally fell in the '70s and it wasn't picked up as to what it was, the fracture wasn't found until in the '80s and then I was given all these other treatments which didn't work, including the spinal fusion offer, which I declined.
LONGWORTH
And were you advised to lie down and rest?
ROBINSON
Yes and I couldn't even put my underwear on and I was absolutely terrified that my life would be at an end. I couldn't dance. I remember one year with one day - the 17th March - when I felt fine and wasn't in chronic pain.
LONGWORTH
Well Marilyn the last 25 years the medical profession's finally caught up with you, your approach 25 years ago was absolutely the right one, you did the right thing to ignore what you were told at the time. We now believe that what you're doing is exactly the right approach to deal with back pain.
MYERS
My question is it's still the same spine, nothing has changed presumably about the physiology and the anatomy of the spine, so why are we looking at the whole situation so very differently, instead of resting the back and trying to let it sort of get better, we're saying challenge it, be active - well Marilyn couldn't be more active than lifting weights for heaven's sake?
LONGWORTH
The back loves to move and if it doesn't move it becomes deconditioned. If you lie down you lose 3% of your muscle mass everyday. So you become deconditioned, you become weak, you become fatigued. And lying down was a very lonely thing to do - you become depressed and distressed and we see lots of folk like this who become completely deactivated and stuck in chronic back pain. And I'd just love Marilyn to come and spend some time in my waiting room giving her talk to all my patients out there, I'm sure you'd do them far more good than I do.
MYERS
Well she's certainly put the message across to a lot of people already today. Thanks for that call Marilyn. We go to my home city now - Brighton - and Mary wants to talk to us about bed rest, which does work for you Mary you say, is that right?
MARY
Yes. Can you hear me?
MYERS
We can indeed yes.
MARY
Thank you. Yes basically I was attacked in 1992 and a disc was broken in my back. It wasn't picked up for about a year and I had to wait another six months before I had to have a microdiscectomy because I was almost unable to walk. And I've found that I quite agree with the previous lady that you do have to exercise but I think you have to temper it - it depends on every - every case is different. So I think you do have to keep moving as much as you can but if you get terrible pains - I don't like taking painkillers because on a long term basis it damages your liver - so I would rather listen to my body and just get into bed and get into a position which doesn't hurt.
MYERS
Well that's interesting - you say listen to your body, which is what Marilyn said, but she listens and goes to the gym, you listen sometimes and go to bed. Let me put that to Stephen - is there anything actually wrong with that, is Mary right to say everyone feels a bit different about this?
LONGWORTH
Well different approaches do work for different people but in general terms bed is a very dangerous place to be. If you're lying down with back pain for certainly more than a day or two there's the increased risk of deconditioning and if you lie down for weeks on end the possibility of things like pneumonia and deep vein clots, bed sores. So this is a very old fashioned approach - years ago we used to put people in traction, keep them in bed, not let them get up. But this approach has been actually shown to make people worse in the long run. So if you're going to go bed with this problem make sure it's not for more than a day or two and do try and get back active as soon as you possibly can.
MYERS
Mary, you mentioned the question of painkillers and perhaps we could just explore that. What is the role of painkillers, Mary doesn't like to take them, a lot of people don't, I mean do they have any part to play in the management of back pain?
LONGWORTH
Absolutely, if they open the window for you to allow you to get active and get moving again then painkillers are very important. They're not the be all and end all of treatments, so just simply lying there taking painkillers is not going to be a help. If painkillers allow you to start moving and get activated again, this is where they're most useful. I was interested to hear you mention about possible liver damage - was there a particular drug that you had in mind for causing ...?
MARY
Well I can't remember now, I was given Dihydrocodeine and paracetamol but I found nothing worked, nothing got to the pain, apart from soluble Dispirin, which you can buy over-the-counter.
LONGWORTH
Yes, it's an anti-inflammatory tablet and certainly if you're going to take Dispirin, which is Aspirin, long term one of the problems with that is it might irritate your tummy, so that there are better long term anti-inflammatories that you could take which would be less likely to harm the tum.
MARY
Unfortunately, I'm allergic to most anti-inflammatories, so it's the only thing that works for me. But can I just come back on the other item about bed rest? I wasn't meaning for a long time, probably about an hour or two at a time, I was only meaning very, very short term because if you do that you do jam up. So I'm agreeing with you basically, but tempering everything together.
LONGWORTH
Excellent.
MYERS
Good, we're glad that you're agreeing, that's actually helpful in that case. So yes I mean I guess pacing yourself and not rushing around like a mad thing - if you're tired for example.
LONGWORTH
Pacing is a key concept to get across to people. I mean if you, for example, are sporty and you've left off your sport for a while, then you go back and try and do it, as I did this week - going out for a run - and my legs were killing me the next day because I wasn't used to it and I did too much too soon, so that you have to build up and pace yourself to make sure that you don't actually go too far the other way and end up making the pain worse.
MYERS
Well we've got a question from Kenneth next, who joins us from South Croydon, which is about how much you can do. Interestingly enough - I hope you don't mind my saying this - but I gather you're in the older age group Kenneth and you're quite into exercise, in fact you're wondering whether there's a limit to how much you can do. Tell us a little bit about your concern.
KENNETH
I would say listening to the first caller it seems to be the sky's the limit.
LONGWORTH
Correct.
KENNETH
Well I found that the only relief I got was by doing sit ups to improve my stomach muscles - I'm not overweight, I'm not paunchy or anything like that, so I'm pretty slim. But by doing that I avoided these sharp stabbing pains that I used to get. And I went through the usual procedure of going into hospital to try and find out what was causing the back pain and actually it went down to one of my legs, so I've got a wasting of one of the leg muscles and the only way I could get any rest was actually sitting - couldn't lie down, so I could sit up with my back against the wall, sort of business, at right angles. As soon as I sort of slide down then the pain started, like cramp, you know, it was shocking. And I think they gave me Ibrufen or something, but anyway ...
LONGWORTH
What exercise did you find the most useful?
KENNETH
Pardon?
LONGWORTH
What exercise did you find to be the most useful?
KENNETH
Sit ups. Tucking my feet under an immovable object and sitting up. So I gradually increased the strength of my muscles.
LONGWORTH
Yes you're strengthening what's your core muscles, these are the muscles in the back and also the muscles that are actually in your tummy.
KENNETH
Tummy muscles yeah.
LONGWORTH
Have you got a six pack Ken?
KENNETH
Almost yes, even at my age, it's amazing, yes.
MYERS
Which is what - you're being coy - hold old are you?
KENNETH
I shall be 80 at the end of the year.
MYERS
Right well that's pretty good going, I have to say, isn't it.
LONGWORTH
Can you come and do a double act with Marilyn in my waiting room please?
KENNETH
I think I'd better have a word with your first caller and she give me a workout programme.
LONGWORTH
Excellent.
MYERS
Well can we use this opportunity just to explore a bit more some of the most appropriate exercises because we've talked about the importance of getting moving, generally mobilising yourself, but then that next stage of actually taking on an exercise routine - and it suits Kenneth to do this - sit ups - I'm not sure I could quite cope with sit ups and I haven't got a bad back, so what would be a reasonable exercise routine and how might you find out more, so that you can follow something sensibly?
LONGWORTH
Well the good news is it's really quite simple and it's all about being aerobically fit. Any kind of aerobic exercise is good for your back. And by aerobic exercise what I mean is the kind of exercise that gets you a bit hot, a bit sweaty, bit out of breath and makes your pulse rate increase. So this might be cycling, jogging, swimming, brisk walking, dance, brisk bout of gardening, for example. And you don't necessarily have to get out the Jane Fonda tape and jump up and down in your lounge. As long as by the time you've done, say, 20-30 minutes every other day or most days a week of something that gets you hot sweaty out of breath and makes your pulse rate increase you're doing aerobic exercise. The best scientific studies show that compared to doing standard physiotherapy sessions or compared to doing special exercises on special machines to strengthen your back up, doing general aerobic exercise is just as successful at helping with back pain. So you don't have to invest in any flashy machines, you don't have to do flashy courses, you just have to get fit.
MYERS
And Marilyn mentioned Pilates, which I think is becoming increasingly popular.
LONGWORTH
I'm a big fan of Pilates, I think it encourages people to improve their spinal stability by teaching them about their body and teaching them about their - how their back functions. Yes if it helps, go for it, by all means.
MYERS
Is it a little bit like doing sit ups and those stronger abdominal exercises but in a more controlled way, would that be the essence of Pilates?
LONGWORTH
Yes, yes I think you've hit the nail on the head there absolutely.
MYERS
And what about this question, from Margaret, who's asking should people with back pain play golf?
LONGWORTH
Absolutely, why not, it's a good aerobic workout. As long as you don't get on the golf cart to go between the holes, that's the only thing.
MYERS
Oh so it's the walking ...
LONGWORTH
It's the walking that will do you the good. I mean swinging the golf club itself is a certain amount of aerobic exercise, it's the walk between the holes that will do the most good.
MYERS
You see common sense says that you might strain yourself doing that and you did mention gardening, and I know there are a lot of people who come in having done a session of digging, they're actually doubled up, I mean they can't straighten up.
LONGWORTH
Well it's all about doing bending and lifting in an appropriate manner. And can I just take this opportunity to plug the back book?
MYERS
Yes, please do.
LONGWORTH
Which is from the Stationery Office, which is a tiny little booklet, costs £1.25, written by the country's, in fact the world's, leading experts on back pain, which is full of advice like this about how to lift and bend and how to get fit and active again. And so long as you don't do anything stupid in terms of bending and lifting you're not going to damage your back. The back loves to move, it's made to move and if you don't move it, it stiffens up, it gets weak and it gets more painful.
MYERS
And that wasn't necessarily a plug for a book that you've written in fact, because you haven't written this book.
LONGWORTH
No, no, no it's not by me.
MYERS
Plenty of other professors have - a professor of general practice, of orthopaedics, of physiotherapy, of osteopathy and psychology - have combined their information into a very slim but very readable and very important booklet that you'd like to mention.
LONGWORTH
I give this book out to everyone that comes to see me with back pain, I've a stack of these on my shelf and they all go out with one.
MYERS
Okay, available from the Stationery Office.
Okay, thanks for all that, we'll move to another caller, if we may now, in London, Carol McCann, who's asking about a slipped disc. Question Carol?
MCCANN
Yes good morning, no afternoon. Six weeks ago I slipped my disc and woke up in the middle of the night in excruciating pain and got to the local hospital at Lewisham and they said it was definitely a slipped disc. Subsequently when I eventually was able to
get to the doctor, about two weeks later, they'd sort of gone through things that I could do and said that I really need to consider lots of physiotherapy but also later down the line, if it continues, then I should possibly consider having an operation, which of course concerned me a little bit. So six weeks later I was doing very well and I did exactly what the physio had said and also the orthopaedic consultant - I went along to the gym and did some moving about in a warm Jacuzzi - nothing more than that. The next day the whole thing had reversed itself completely and I'd actually relapsed. So went back again to the orthopaedic consultant and he said it could just be that I'm one of those people who the disc has gone out so far that it's just going to constantly go and come back and that I should possibly at some point consider having the operation because there's no [indistinct word] how long it could take for it to get better.
MYERS
Okay, I mean that's a very interesting question, can we slightly backtrack if we may, Stephen, just to explain a little about slipped discs because you used to - in fact I think you still do hear people talking about their slipped disc, often as not they have got a sore back, but it's not necessarily a slipped disc, I mean clearly in Carol's case it is. So what is a slipped disc and what is the remedy?
LONGWORTH
Well your discs are the shock absorbers that sit between the bony blocks of your spine and the way I like to think about a disc is it's a bit like a Jaffa Cake - it's got a spongy outside and a jelly inside. And what happens the disc doesn't really slip, some of the jelly leaks out from the spongy bit and rubs against the nerve. And this is what generates pain that you feel often in the buttock, thigh, leg, down to the foot and ankle, sometimes with unpleasant sensory symptoms. Is that the sort of symptoms that you've had Carol?
MCCANN
Absolutely, in fact from the knee down, across my ankle, big toe, you can't even touch it.
LONGWORTH
Yes, it's a most unpleasant thing to have.
MCCANN
Unbelievably unpleasant, I've never experienced anything like it before.
LONGWORTH
And what treatment have you had so far besides the physiotherapy?
MCCANN
Just physiotherapy and obviously my physiotherapist has been giving me acupuncture.
LONGWORTH
Okay, is that helping?
MCCANN
It has been helping. Initially I wasn't sure but at the last couple of sessions has actually helped me with my sleeping.
LONGWORTH
Oh that's good.
MCCANN
And that has made a difference because it's the pain management I find the most difficult thing.
LONGWORTH
And are you taking some painkillers for this?
MCCANN
I've started to come off them because I was taking them just every time they wore out - every four hours because it was so painful. So I've come off them to avoid my tummy being so upset.
LONGWORTH
Right.
MCCANN
And I was on this Codrygenal [phon.] for a while and the doctor said I think he'd given me about 100 or 200 altogether, so he said that was enough, try and just deal with the pain. And they said there's nothing more to do but deal with it. I'm just a little bit shocked that I reversed it so much.
MYERS
Done it again.
LONGWORTH
Yes, the sort of natural history or the sort of the general pathway of sciatica can be a bit up and down, just as it can be with back pain. But the good news is that for the majority of people who have sciatica and it's often the people who have the worst episodes that actually do the best, it's the little bulgy discs that seem to cause the more long term pain. If you have a real rip roaring episode of sciatica those are the ones that actually very often the bit of the jelly material comes out, loses contact with the disc, loses its blood supply, shrivels up and you get better completely. So don't despair. I would follow the active management plan of the back book for back pain, stay as active as you possibly can be, don't be fearful that you're going to set it off or make it worse by being active. Find an exercise like cycling or swimming that you're comfortable with and do that on a regular basis. Regular physical exercise actually releases natural chemicals, called endorphins, which act as natural painkillers and so you can get a buzz or some pain relief just by doing exercise. Take a regular umbrella of pain relief, like some regular paracetamol, two of them four times a day. If you've taken anti-inflammatory on a regular basis and it's upset your tummy talk to your doctor about some tummy protecting tablets that should stop that from happening. There are also other tablets - an anti-depressant called amitriptolene in low dose is sometimes very helpful for the unpleasant sensory symptoms in the leg and it often helps you sleep a bit better, we use it a lot in the clinic where I work.
MYERS
And it doesn't suggest that you're having depression.
LONGWORTH
We don't think you're depressed if we put you on this medication, it's actually used to block pain and relax muscles and it also helps you improve your sleep pattern. And keeping people ticking over, allowing them to keep active and giving them pain relief while nature in most people puts this right is all we need to do. A very small percentage of people do go on to have surgery and if you're in that category don't be frightened of that because I've certainly seen people who wake up the next day completely pain free after surgery and do very well indeed after it.
MYERS
And so is the recommendation, and if it is would you accept the recommendation, that you should continue to do all this and wait and see how you get on before you have surgery - is that what you're saying Stephen and is it acceptable?
LONGWORTH
Well if you look at people who have an operation for sciatica, for this disc problem, early on compared to people who wait, and certainly in the States for example you'll get your operation a lot quicker than you will in the UK, we're much more conservative about dealing with this problem in the UK than in the States, so certainly if you have the operation early your pain gets better quicker but at a year down the line there's actually not much difference between people who've had surgery and people who've used these other methods and just waited, most people get better anyway.
MYERS
Carol, does that help?
MCCANN
Yes it does actually because I'm in between decisions, in fact D Day is today.
LONGWORTH
Oh dear.
MCCANN
I have to call them.
LONGWORTH
Well clearly this will be an issue for you to discuss with your consultant, those specific details, and presumably you've had a scan have you of your back?
MCCANN
I can't lie down properly on my back long enough for the scan.
LONGWORTH
Oh that's a nuisance for you.
MCCANN
It is a bit of a nuisance. Although he's 99% sure it's definitely a prolapsed disc I think he said.
LONGWORTH
A prolapsed disc - that - there's lots of different names for this condition - slipped disc, prolapsed disc - think of the Jaffa Cake.
MYERS
Well thank you very much for the call, I hope we've been helpful, you're sounding relatively cheerful under the circumstances, which is good news and hopefully what you've raised will help other people in this situation. Could I also raise a point, it comes from Margaret, and it's by way of an e-mail and it refers back to taking pain relief. She's saying that she takes two paracetamol everyday for her back and she's recommending it, she feels good and she says it keeps her going. But again questions - people don't like to take any kind of medication indefinitely, so she's saying does continual use of paracetamol do any harm?
LONGWORTH
There's no good scientific evidence that taking regular paracetamol long term is harmful. The maximum dose would be two of them four times a day - two 500 strength tablets four times a day. And I say to my patients take two breakfast, lunch, evening meal, bedtime by the clock, so you've laid down a regular umbrella of pain relief that allows you to get going, don't wait for the pain to become severe and then take something, take - do a pre-emptive strike, get some medication inside you, get active.
MYERS
We've got a call now from Frank who's more I think in favour of what you might call traditional or herbal remedies. What is it that you're asking about Frank?
FRANK
Well no actually it's the other way round. My back pain comes and goes, it's quite alright at the moment but whenever I mention it a dear friend of mine, he really drives me crazy telling me to take cider vinegar and honey for back pain and I really don't believe this. Has that treatment been investigated, studied?
LONGWORTH
I'm not aware of anybody looking at that specific remedy in any kind of scientific way. I mean people tell me all the time that they do things and take things which they find useful and if someone has confidence in a particular remedy and they find it helps them to get going, so long as it actually helps them to get going and get active I'm quite relaxed about people doing things like this, I don't think you could - well I suppose you might get drunk if you drank too much cider but ...
MYERS
Or maybe that's what works.
LONGWORTH
Yes, maybe it's that that works, come to think of it yes.
MYERS
It touches on another - thanks very much for that, so if it helps it helps, is all you can say I think Frank. But another e-mail here says: Do freezing sprays help? I think the question is really whether they mask the pain and therefore cause you to do more harm than good if you use something to take away the pain.
LONGWORTH
This is an issue that people raise with me very frequently and it's a complete misconception, people think that if they don't feel the pain there's some ongoing damage and they're going to make it worse by using it. Nothing could be further from the truth. The main messages to bear in mind are okay it's hurting but it's not harming - the pain doesn't mean there's serious damage going on. You've got to use it or lose it. So anything that actually helps you to get going and get active - if a freezing spray takes the pain away such that you can then activate that's fantastic, it's the activity which will ultimately get you better again.
MYERS
Okay, we'll move to another call now, we've got Judith who's waiting to talk to us, she's in St. Helen's in Lancashire. Judith has chronic fatigue syndrome, needs a lot of rest, which may cause problems for your back Judith, is that the concern?
JUDITH
Hello.
LONGWORTH
Hi, hello Judith.
JUDITH
Yes it does. I think I've got like secondary problems really from lack of activity and I'm conscious of it really. And I can't do too much in case I do overdo it and that sets up pain and yet I'm all the time thinking - what can I do to kind of protect my back and keep as much strength as possible really - it's a bit of a cleft stick somehow you know.
MYERS
You're right Judith and it must apply to a lot of people perhaps who've got other conditions that mean they can't be as active as they'd like to be and are they putting their back under a lot of stress or if their back is painful can they do anything really to relieve it.
LONGWORTH
People often spiral down into a very deconditioned state when they're not using their muscles and have you been on a chronic pain management programme or had advice from physiotherapists, occupational therapists, psychologists about dealing with this?
JUDITH
Apparently I'm too bad to go on - there's a graded exercise programme and I'm not really good enough for that, if you know what I mean, I'm too bad for that, I couldn't cope with it.
LONGWORTH
That surprises me because I would have thought a graded exercise programme was aimed at exactly the sort of problem that you have.
JUDITH
Well apparently - there must be different levels I guess. But I am waiting to go to some sort of group sessions about pacing myself.
LONGWORTH
Well that's the key word - pacing, absolutely.
JUDITH
Yes I mean I picked up on that - you mentioned it before didn't you. But then there's use it and lose it - oh you know.
LONGWORTH
Yes well I don't want to frighten you too much, I think you're wasting away there doing nothing. But the key issue here is that you're - one of the things that inhibits people from getting better is fear - fear of the consequences of moving and fear of the pain. And if you have lots of reassurance and people who can help you to pace and get your fitness back you will ultimately do well.
MYERS
Good message and that's our final message on the subject today, because we're out of time. Thank you very much indeed for that call. Thanks to all our callers and thanks particularly to Dr Stephen Longworth for his expertise. You can listen to the whole programme again, if you missed any you can go to our website or you can get more information from a real person if you call our free and confidential helpline, that's on 0800 044 044. And join me again for Check Up next Thursday at 3.00, if you will, we'll be taking your questions on another revolution in medicine, this time it's the cholesterol lowering drugs statins, they've been shown to significantly reduce heart attacks and strokes. So is there any reason we shouldn't be taking them? See you then.
ENDS
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