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BRITISH BROADCASTING CORPORATION
RADIO SCIENCE UNIT
CHECK UP Programme No. 6 - Back Pain
RADIO 4
THURSDAY 17TH JULY 2008 1500-1530
PRESENTER: BARBARA MYERS
CONTRIBUTORS: STEPHEN LONGWORTH
PRODUCER: PAULA MCGRATH
NOT CHECKED AS BROADCAST
MYERS
Hello. Well in this final edition of Check Up we're inviting your questions on bad backs. Now there's been a revolution in the treatment of back pain - it's out with bed rest, routine x-rays and surgery on the spine, it's in with simple painkillers, advice to keep moving and reassurance that in 9 cases out of 10 the back will sort itself out within a matter of weeks. Sounds simple - but what if that doesn't help you? Four million people visit the doctor every year with backache, so the problem hasn't gone away.
If you are in pain and wondering what's gone wrong or what you're doing wrong then you've come to the right place to put your questions to my expert in the studio today who is Dr Stephen Longworth, he's a GP with a special interest in the prevention and management of back pain.
And Phil Attwood from Romford is on the line to us now. Phil, I gather you've hurt your back very recently, what's happened?
ATTWOOD
Barbara, I'm a working paramedic and obviously back pain is part of the job and while long boarding a patient, a very innocuous move - stepping down from a room into a patio with a patient on the long board, me holding it - felt a twinge in my back and by the end of the shift I could hardly stand up straight. Normally a couple of days rest is sufficient but I went to work two days later and unfortunately for me the very first job was a full cardiac arrest with a very heavy patient to move, quite a frantic situation, as you can imagine, and now I'm in severe pain and my back feels like it's in a girdle.
MYERS
Well I'm very sorry to hear that Phil, in trying to help other people you've caused yourself some grief. Let's see what Stephen has to recommend, what sort of treatment perhaps would help Phil in this situation.
LONGWORTH
Phil, presumably there are two concerns here. One is what you might do to yourself by being at work and the other one is what effect this might have on your ability to do the job - I mean you don't want to go dropping any of these people that you're carrying about presumably.
ATTWOOD
Exactly and I'm 57 years old too, so I'm looking long term to a healthy back future as well.
LONGWORTH
Are you taking some medication currently for this?
ATTWOOD
Well I took some ibuprofen and had some rubbed into my back by my wife but, as I say, unfortunately instead of being sensible and perhaps taking a few days off I went back to work and unfortunately the next job was, as I say, a very heavy duty job which hasn't obviously helped the situation.
MYERS
Should Phil be off work at this point, would you say Stephen?
LONGWORTH
Phil, is there any opportunity to modify what you're doing at work, I mean can you speak to your boss about doing something that perhaps doesn't put you quite on the frontline, so that you can stay at work and stay in the right sort of environment, which is all very positive, but not necessarily be thinking to yourself oh dear I'm in a situation here where I'm going to put myself or a patient at risk?
ATTWOOD
It would be lovely to do that, unfortunately when you're in the frontline paramedic you are essentially available for any job that comes up and you should in theory be as fit as any person on the staff to do it.
LONGWORTH
This is one of the situations that we see very often, that folk think that they have to be either 100% or off work and what I find is that employers are often very accommodating and one would hope that the NHS, which is presumably who you work for, would be the most accommodating employer of all in this situation and perhaps the most understanding. So my usual recommendation is to say to folk look go and talk to your boss, see if they can find somewhere to keep you there but take you off the frontline, if you're doing something a bit different - maybe you could be doing some paperwork, some office work, but you're there, you're at work and it's positive. Also think about maxing up your pain relief, so if you're just taking ibuprofen what about adding in some regular paracetamol or co-codamol to that? If that's not helping perhaps see your GP about a stronger anti-inflammatory and maybe even a muscle relaxant for a short period. And stay positive, keep moving, go out and do some exercise while you're not at work - do some swimming or some cycling on a road bike or an exercise bike if you can - keep the back moving. And if you stay positive, give yourself lots of positive thoughts like okay it's hurting, it's not harming, the pain doesn't mean there's serious damage going on - I'm going to use it or lose it - your outlook is - your outlook in the long run is good with this.
MYERS
Sounds like good advice. I'm going to move on but hopefully you'll take that advice and perhaps even quote it to your boss if that's what's required. But generally I mean this is so different isn't it, Stephen, from what might have been said really not very long ago, which is bed rest, off work, give it time to heal - we're simply not going there anymore are we?
LONGWORTH
Twenty five to thirty years ago, I mean when I was at medical school and a junior doctor that was the management - you put people to bed for two weeks. And it seemed commonsense that that would make you better.
MYERS
But what's wrong with it?
LONGWORTH
What's wrong is it actually makes you worse. I mean once the idea was put to the test in scientific studies it was shown not only was it not helpful it actually tended to slow recovery, it's kind of counterintuitive that staying active and keeping moving something that's hurting will actually get you better faster. But the joints in the body are made to move, they don't like to rest, they stiffen up, the muscles round them get weak, you get de-conditioned, it has negative psychological effects. Being out of the work environment is very bad for most people and I think a lot of folk don't appreciate how therapeutic work can be.
MYERS
Distraction therapy is always a good one.
LONGWORTH
Absolutely.
MYERS
Let's go to another caller. Chipping Sodbury now and Margaret is waiting to speak to us about a compression fracture, I think you've got, so what sort of pain or discomfit does that mean for you Margaret?
MARGARET
Well a great deal actually. It means that I can't lean, bend, walk very far or sit comfortably, so I quite often throw myself on my comfortable bed just to ease the pain.
MYERS
How did you get this compression fracture?
MARGARET
Well it arose the morning after we went to a club and danced a lot to Status Quo and I woke up in the morning screaming and that was five weeks ago. And I've had an x-ray and that showed the compression fracture.
MYERS
Oh well I'm sorry to hear that your evening out, which sounded fun, was rather ruined by the result. But let's see what Stephen has to suggest in that case.
LONGWORTH
Margaret, can I ask how old you are?
MARGARET
I'm 54 today actually.
LONGWORTH
Have you got any things in your medical history which might make you more prone to osteoporosis that you can think of?
MARGARET
Well none in my family but I have taken carbamazephine for 11 years for manic depression.
LONGWORTH
Right this is a tablet for epilepsy?
MARGARET
No manic depression.
LONGWORTH
Oh for manic depression okay. Well these tablets can have an effect on the bone density, so have you had that looked into?
MARGARET
Well only very recently, my daughter looked on the internet and saw it, then I went to the GP and he said yes and so I insisted on having some calcium tablets as well as the codidramol painkillers I'm on. I just wonder how much longer this is going to go on for because my husband is having to do all the pink jobs - all the shopping, washing, cooking, cleaning, everything.
MYERS
The pink jobs - does he do that while listening to Status Quo, I have to ask?
MARGARET
Yes I think so.
MYERS
Okay so he'd be quite keen for you to be up and active again and you'd be pleased to be out of pain and then there is the business of the sort of what might be behind this with the - perhaps this osteoporosis or the weakening of the bones anyway let's get an update on this from Stephen.
LONGWORTH
Well having a compression fracture at your age is a little bit unusual, it usually would happen in perhaps older ladies.
MARGARET
Yes I thought it would be another 20 years yet.
LONGWORTH
So the question is - presumably you've talked to your own doctor about this, are they happy that they've been on this medication is the explanation for it, certainly - not speaking about you particularly but ...
MARGARET
Well they're sort of skating round that a bit, you know, nobody likes to hold their hands up and say oops yes, you should have been on calcium pills for 10 years.
LONGWORTH
As a general principle someone at a younger age coming to see me with a compression fracture there are some investigations that I would do just to rule out some other conditions which might occasionally cause it. And then having satisfied myself that there was no other underlying reason for this than that it was due to medication calcium and vitamin D tablets probably sounds like a good idea, there are other medications that you can take on a once a week basis - drugs called bisphosphonates - which can help to strengthen the bones up in the long run and help to make sure that they're nice and strong. Often one would arrange a thing called a DEXA scan which is...
MARGARET
Yes I had one of those in 2006 because I'd broken first one foot, then the other.
LONGWORTH
Did that involve your spine that scan?
MARGARET
Yes it was a whole body scan and it came up okay but that was a couple of years ago, I don't know can you crumble in two years?
LONGWORTH
Oh I don't like the word crumble, that sounds way too negative.
MARGARET
Well it feels like it.
LONGWORTH
Let's try and be more positive about this, for someone in your situation, assuming we've ruled out other underlying conditions that might be related to one of the bones going a bit squashed under its own weight, I don't like the word crumbling, then there's lots of things that we can be positive about. Certainly for most people who have a compression fracture in their spine in the fullness of time the pain settles, right, so you're not going to be left like this forever, that's the first thing to say. And there's lots of things that you can do in terms of maximising your pain relief so you can get going. And then in terms of activities - were you doing that dance to the Status Quo where you bend forward and swing from side to side with the thumbs in the front of your jeans?
MARGARET
Yes how did you guess?
LONGWORTH
Yeah I thought you might have been doing that.
MYERS
We're all of the same generation I think that's why.
LONGWORTH
Yeah I've done that one many times myself.
MARGARET
Swinging your hips round and your arms round.
LONGWORTH
Well if we just stay with Status Quo for a minute the advice would be not to lie down down deeper and down, okay, get going, get moving, do some more dancing but maybe something that doesn't involve all that bending and rocking from side to side. But aerobic activity of a non impact type, so cycling, swimming, walking on a treadmill - these are the sorts of things that would be very good to get your fitness back.
MYERS
Margaret, thank you for that. I didn't think it would be long before we had a question about slipped discs and we've got Shirley on the line now from Portsmouth with two of them. What's happened and where are you up to with your slipped discs Shirley?
SHIRLEY
Well the slipped discs seemed to have improved, that was a couple of years ago, and I've now got a problem with the lower back where one of the discs seemed to have degenerated quite a lot. I've just been for a discagram and I'm going back to the specialist for the results of that. But he said he's under the impression that probably there's a good chance I'm going to need an operation on my spine. And it's just really that before I go back and see him I'd like to try and find out as much as I can to ask the right questions because I don't particularly want an operation.
MYERS
Alright, well let's see whether you need an operation. If you were seeing Shirley what would you be saying to her?
LONGWORTH
Shirley, is this purely back pain or do you have sciatica, do you have pain going down one or either leg as well?
SHIRLEY
I had sciatica when I had a slipped disc but this time it's just purely back pain.
LONGWORTH
Okay, so are we talking about a spinal fusion operation here?
SHIRLEY
Yeah basically.
LONGWORTH
Okay. This is obviously an interesting discussion when you get a group of spine surgeons together about what their feelings are about this and some are perhaps a bit more gung ho than others in terms of recommending this kind of surgery and some are more conservative. In the clinic where I work in a hospital where we do this kind of operation on people we like to make sure that they've actually gone through every other possible option before looking at surgery, including a full rehabilitation programme to try and strengthen the back up, particularly as there is some evidence that if you fully rehabilitate you can get results that are virtually or even as good as having a spine fusion operation. And it's a quality of life decision. So I would say to any patient of mine if you've tried absolutely everything else and I tell you what my figures are for doing the operation and what my colleagues figures are for doing the operation in terms of success and these are the odds, at least we can tell you this is your chance of being better, this is the chance of having complications or side effects, this is the chance you'd be no better and so on, what do you think about those odds compared to putting up with this in the long term and getting on with it. So that's the discussion to have with your surgeon, I'm sure you've probably already had it.
SHIRLEY
Well it's basically when I go back he's going to take me through the options, it was just being as prepared as possible because it's slightly concerning to say the least.
LONGWORTH
Well there is a booklet that you can read all about this, it's available from the Stationery Office and we'll put this on the website so you can look at it.
MYERS
Indeed and we'll give you the reference for that later. But again what's interesting I think to hear is that this is something that, if you like, is negotiable now between the patient and the doctor, it's not a matter of going to a spine expert and being told yes spinal surgery is going to be the answer, it's really something you have to share and make decisions between yourselves, is that how you handle it when a patient sees you?
LONGWORTH
That's absolutely critical. If you've got acute appendicitis and you're going to have peritonitis and maybe die, there's no argument about whether you need an operation but we're talking about quality of life issues here and for many people - you'll have two patients with precisely the same problem in their back or precisely the same sciatica problem, precisely the same appearances on a scan and one's saying to you I just can't cope, I'm screaming with pain, it's completely interfering with my life please let's have an operation and somebody who appears to be identical say you know this is a nuisance but I can get on with it and I'll wait for things to settle down and they get on with it.
MYERS
And they do settle down?
LONGWORTH
In the fullness of time most people eventually get better and there's only a very small minority that are left with this serious or residual pain that we'd be talking about spinal surgery in this manner.
MYERS
Hope that's been helpful Shirley, two slipped discs down. We've got another slipped disc coming along, more recently I think in this case, we'll go to Celia Holden, who's in Hemel Hempstead, had a slipped disc six weeks ago and again I think wondering what your options are, is that right, are you in pain at the moment by the way?
HOLDEN
Yes I am.
MYERS
I'm sorry to hear that. It's pretty all pervasive, isn't it, when you are in pain with back pain?
HOLDEN
Yes I think everybody seems to have the same thing - codidramol and diclofenac ...
MYERS
So you're taking quite strong painkillers.
HOLDEN
And also one that was a muscle relaxant to start with but with a process of elimination I thought I'd done it gardening and eventually realised that I'd done it in February originally climbing out of the sea on to a yacht, which I'd never done the thing before so I really did a good job on it. But my question really is that I've been given the chance to have this injection apparently that you can have by a neurosurgeon or - and my question really is - is to whether I should have some sort of osteo - what do they call it? - physio type of thing ...
LONGWORTH
Manipulative treatment.
HOLDEN
Yeah that type of manipulative, which I have had before in the past, which has helped, what would you advise?
LONGWORTH
Are we talking about an injection for pain in the back or for pain going down your leg?
HOLDEN
Yes the injection would be pain in the back with - cortisone I believe.
LONGWORTH
Yes.
HOLDEN
And then I thought well I used to go to the osteopath and that helped, would you recommend one more than the other one?
LONGWORTH
In the clinic where I work the experience that we have is that spinal injections are good for leg symptoms, so if you're talking about somebody who's got sciatica or nerve root pain going down the leg ...
HOLDEN
Yes which I have.
LONGWORTH
... then an injection around the nerve root, usually done with an x-ray machine so you get the needle in exactly the right place, to put some local anaesthetics, and some people just use local anaesthetic, some put local anaesthetic and a steroid around there.
MYERS
And is that to relieve the pain that's caused by the slipped discs which is pressing on the nerve and causing that sciatica or pain down the leg?
LONGWORTH
Yes it's essentially the irritation of the disc on the nerve, is what's giving the pain down the leg, so putting something in there to relieve the pain in that locality seems to help for about 60% of people seem to have a good result where it settles the pain down. And certainly for many people if they're contemplating surgery we can keep them away from surgery by doing that operation for the symptoms down the leg. The experience in the clinic where I work is that for symptoms in the back, for back pain, the injections are perhaps not such a good option, still lots of people getting injections in and around the back, perhaps they're doing something different to what we used to do in the past. But where I work at the moment we've stopped doing them because we don't think the results are as longstanding, so we prefer this other option around getting people fit and getting them moving again.
MYERS
And so where does manipulation, physical therapy, osteopathy on this case, come into the picture, is it helpful for slipped disc causing sciatica, is it helpful for back pain?
LONGWORTH
If you're seeing somebody who knows what they're doing, and I presume you are, then it's a treatment that's very, very unlikely to harm you and there is certainly for back pain, for people who have back pain more than 12 weeks, reasonably good evidence that manipulation is a helpful treatment and also for people with shorter back pain as well. I manipulate people in my surgery all the time that come along and you get the pop or the click from the back, they get up off the couch say thank you very much, I'm not quite sure what I've done but they seem to get better. So for folk in a situation like yourself there's no reason why you can't combine these treatment - go and see your osteopath or chiropractor and think about having the injection as well. And if that prevents you from having to have an operation that's fantastic.
MYERS
Thank you very much for that advice, thanks for the call Celia. We'll go to Liz, Liz Williams, has degenerative disc and wondering about what sport you can do. So are you in a lot of pain or are you ready to get moving again Liz?
WILLIAMS
I haven't stopped - I've never stopped moving, I've always played netball and I've been running and doing weight training. And I went to see the consultant yesterday who said stop these things and then said I could do pilates or yoga. But I'm not actually quite sure of the range of things I can do because although I don't want to stop netball I realise it's an impact sport.
MYERS
And is this based on the fact that he has diagnosed a degenerative disc?
WILLIAMS
Yes, I'm due to go back and have an MRI scan at some point so we can get some more information but in the meantime I want to know what I can do to keep active because I feel if I stop then I'll just stop.
MYERS
Well you're speaking to Stephen who's very keen on everybody keeping active at all costs, would that apply to Liz with this particular diagnosis?
LONGWORTH
Yes, do you find that playing the netball hurts in the back?
WILLIAMS
No, while I'm playing netball it's fine and it doesn't seem to go any better or worse when I've played. He just told me to stop, the consultant told me to stop because it was an impact sport and the same with running.
LONGWORTH
Well I'm sure your consultant has some particular reasons why he's told you these things. In general terms I would advise folk to be as active as possible. If activities aggravate the pain, particularly impact activities, then I would recommend cycling, swimming, walking on a treadmill, brisk walking, line dancing - anything that gets you a bit hot, sweaty, out of breath, makes your pulse rate increase - that's aerobic activity and it's good for you, it's good for your general heart and lung fitness and good for your bones and joints as well.
WILLIAMS
And that's what I want to keep doing because I've always been fit so I want to carry on doing that but when he told me to stop certain things I wasn't sure what I could do, so would you recommend that I can play netball?
LONGWORTH
Well I wouldn't want to contradict the advice that's been given to you by somebody who's obviously had an opportunity to speak to you and examine you but in general terms if you want to replace that activity then I would say get on your bike, quite literally and get down the pool and then perhaps have another discussion when you go back and see your consultant if the netball's not actually hurting when you do it is it absolutely essential that you leave it out. But perhaps once he's seen the scan he might change his mind about it.
MYERS
Liz, I hope that's been helpful. Just on that general point about the, if you like, the warning sign that pain might be that you are doing damage, you seem to be taking the view that the pain - if you feel pain it's something to be worked through, it's not really - it may be hurting but not necessarily doing any damage, is that a general point that you would put across Stephen ?
LONGWORTH
There are some things that we call red flags with back pain, certain circumstances where we would say well actually this possibly isn't straightforward back pain, maybe 1% of people that go and see their doctor might have something seriously wrong with them. So the sorts of things which would make me concerned, as a GP, would be somebody who started to develop back pain at a much older age than usual, so say somebody in their 70s, 80s getting back pain for the first time, you're thinking well that's not normal and would want to look into that one a bit more carefully. Somebody who was feeling ill with their back pain - losing weight, not sleeping, no appetite, maybe fevers or chills or sweats. Somebody who had a past history of a significant - of a cancer somewhere, so let's say you had lung cancer or breast cancer and then developed back pain because this is the sort of place where secondary cancers can go. These sorts of things are not common but they're important and so if you fall into one of these sort of red flag type categories then worth talking to you doctor about, about your back pain.
MYERS
Okay thank you very much. Douglas is joining us now with ...
DOUGLAS
Good afternoon.
MYERS
... hello Douglas, well you tell us what the problem is in your case if you will.
DOUGLAS
I've suffered back pain for about 12 months. I did slip a disc about three years ago. Now I wake up with terrible stomach ache and I've been put on diclofenac ...
LONGWORTH
Diclofenac.
DOUGLAS
... and it seems to help, yeah, it seems to help. I've still got stomach ache, I've still got backache but how long can I [indistinct words]...
MYERS
It's rather a poor mobile phone line I think we've got there Douglas, sorry about that, but I think we got the point - so it's backache and terrible stomach ache and taking diclofenac.
DOUGLAS
I'm told it's a consequence of the backache.
LONGWORTH
No it's a consequence of the tablet I think. One of the commonest side effects of anti-inflammatory tablets, of which diclofenac is one of the most commonly prescribed, is that they can upset your stomach.
DOUGLAS
But I've had this pain [indistinct words]...
MYERS
Really sorry, we're having a real breaking up on the line there. So maybe we can just get on the evidence that we've got an answer from Stephen as to whether it's perhaps a question of stopping that particular medication then.
LONGWORTH
As a piece of general advice to anybody who's taking an anti-inflammatory tablet for anything if you start getting stomach ache stop it and go and talk to your own doctor about it because we see a significant number of people every year who get stomach ulcers and might even bleed from their stomach which can be quite significant as a side effect from anti-inflammatories.
MYERS
Okay and there are other types of medication to ease the pain.
LONGWORTH
Yes absolutely.
MYERS
Quick call from Ruth who's got a new baby, if you've got pain - bad pain I wouldn't be surprised, is that the case?
RUTH
That is the case yeah. I've got a three month old baby and I strained my back since I've had her, I think I just don't have any strength in my stomach muscles and so the back is doing all the work. My problem is that I'm still breastfeeding her so I can't take any painkillers, other than paracetamol, and obviously I can't rest it in any way - I can't stop it - the same action happening again and again.
MYERS
It's a real dilemma and I think a lot of us have been there and can sympathise with you. In my case it did get better once the baby got older. But Stephen something right now for Ruth to work with if you will.
LONGWORTH
This is another common scenario but I think the most important thing is to be very reassuring that sooner or later this is going to settle down and particularly you'll probably swap carrying the baby around for running after - probably in the next few months. But if you really want to find something helpful have you got somebody that can massage your back, have you got a partner that you can perhaps have a nice rub down from?
RUTH
Yeah.
LONGWORTH
And so some local treatments like some local heat, some local massage, these are the sorts of things which folk often find very helpful when you're having a bad time with this, just to keep you going through it.
MYERS
Okay, well we wish you well with that and like all these things it does tend to improve as time goes on, although as Stephen has just said you'll end up with other problems running around after your toddler.
Well thank you very much to everyone who's rung today and e-mailed with your questions. Thanks to Dr Stephen Longworth for his answers. If you missed anything you can go to our website, that's bbc.co.uk you can follow the prompts to Check Up. You can also download this programme as a podcast. And then of course if you want to speak someone about sources of information you can call this number: 0800 044 044.
So finally, and sad to say, this is the last edition of Check Up, for the past 10 years it's been my privilege to be here to take your health questions and to try to find answers that I hope have been helpful to everyone who has called and e-mailed and the many more of you who are out there listening. So thank you very much for your interest, from Check Up goodbye and good health.
ENDS
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