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Article on Back Pain from The Guardian

Dec 10, 2018 12:20 AM

The hard truth about back pain: don’t rely on drugs, scans or quick fixes
by Ann Robinson, theguardian.com
March 22, 2018 11:20 AM
Most treatment is wasteful, wanton and wrong, says the Lancet. The key is to try to keep walking and working

‘Concentrate on core muscle strengthening with pilates
Photo by: pictured
Back pain is the biggest cause of disability globally, and most of us will have at least one nasty bout of it. But treatment is often wasteful, wanton and wrong, according to a series of papers in the Lancet . “Worldwide, overuse of inappropriate tests and treatments such as imaging, opioids and surgery means patients are not receiving the right care, and resources are wasted,” it says.

It’s perfectly understandable to want a quick-fix solution to make the pain go away and maybe a scan to set your mind at rest. But there isn’t a reliable instant solution. Scans don’t make you better, and painkillers can be harmful. The vast majority of low back pain is musculoskeletal – caused by damage to ligaments, joints and muscles surrounding the spine. A tiny percentage is due to a serious or dangerous underlying cause that needs specific diagnosis and intervention – such as cancer, infection or a fracture.

An underlying cause is more likely if you have so-called red-flag symptoms; previous or current diagnosis of cancer, fever, unexplained weight loss and sweats, night pain, pain in the middle of your back rather than lower, inability to stand, urinate or open your bowels, or severe and unremitting pain that is getting worse.

The good news is that if your backache is musculoskeletal – and it usually is – 90% of cases will be better within six weeks. And that is irrespective of what you do. There’s no good evidence that interventions, ranging from Tens machines (which use a mild electric current), acupuncture, physio, osteopathy and chiropractic to epidural injections and surgery, significantly affect the outcome. Prolonged bed rest – still advocated in some countries – is positively dangerous, as it can cause blood clotting (thrombosis) and makes recovery from back pain less likely.

‘The evidence may not be great but it’s cheap, safe and happens to work for me.’ A Tens machine. Photograph: Alamy Stock Photo
It’s tempting to want a scan or special investigations if you develop back pain. But scans don’t correlate well with symptoms; you can have a dire-looking scan with no symptoms or a fairly normal-looking one with dreadful pain. A scan is useful for surgeons if you need an operation, and other imaging is important if an underlying fracture is suspected. If your back pain is associated with an underlying inflammatory condition like Crohn’s, ulcerative colitis or psoriasis, you will need investigation and referral to a rheumatologist.

The key to recovery is to try to keep walking and working. Different approaches help different people; it’s good to find the least risky option that suits you. My own favourite is a Tens machine: the evidence may not be great, but it’s cheap, safe, and happens to work for me.

Painkillers can be useful in the short term, if that’s the only way you can keep moving. There are two main groups of effective painkillers, and they both come with health warnings: non-steroidal anti-inflammatories, (NSAID) such as ibuprofen, and opioids such as tramadol. There is already an epidemic of opioid overuse and addiction in the US, with Europe and lower-income countries catching up fast. NSAIDs are less addictive but can cause heart, kidney and gut damage if used for more than a few days at a time.

Prof Nadine Foster of Keele University, one of the authors of this series of papers, says: “In many countries, painkillers that have limited positive effect are routinely prescribed for low back pain, with very little emphasis on interventions that are evidence-based, such as exercises. As lower-income countries respond to this rapidly rising cause of disability, it is critical that they avoid the waste that these misguided practices entail.”

One in three people who has an episode of low back pain will have a recurrence in the following year. So it is important to look at adaptations to the workplace, avoiding heavy lifting and concentrate on core muscle strengthening with pilates, swimming and some types of yoga once you recover from the acute attack.

Prof Jan Hartvigsen, of the University of Southern Denmark, who also contributed to the Lancet series, says: “Millions of people across the world are getting the wrong care for low back pain. Protection of the public from unproven or harmful approaches to managing low back pain requires that governments and health-care leaders tackle entrenched and counterproductive reimbursement strategies, vested interests, and financial and professional incentives that maintain the status quo ... Funders should pay only for high-value care, stop funding ineffective or harmful tests and treatments, and importantly intensify research into prevention, better tests and better treatments.”

He’s right, of course, but there is no point withdrawing funding without any explanation. Healthcare professionals need to take the time to explain to patients that it’s not vindictive cost-cutting that is behind the restriction of access to scans and drugs. It’s in everyone’s best interests that we stop pursuing bad medicine and invest in finding better and safer solutions to this global problem, which is likely to affect all of us sooner or later.

• Ann Robinson is a GP

Dec 10, 2018 5:40 PM

Wow! Is this a “peer reviewed” article? Proven with analysis and data backed studies or someone writing a informational/opinion based article? I agree that a great deal of cases “may” be caused by soft tissue damage. I do not agree that everybody be dumped into one class. There are many who do have medical conditions that warrant more than exercise/work. I would like to see further studies on this subject before I will concur with the authors views.🌸

Dec 14, 2018 5:58 PM

There are several studies out there that reiterate this.

Dec 15, 2018 10:06 AM

If you know a couple Zetarlov I’d like to read them.

Dec 17, 2018 11:41 AM

I will see if I can find them, they are posted on one of the support groups for my disease.

Dec 17, 2018 11:34 PM

The report that was easiest for me to get ahold of is The Psychological and Physical Side Effects of Pain Medications from the national safety council. You have to sign it and then search. But a good word to search is "Hyperalgesia". I know from personal experience that after 2 weeks no pain meds my pain was so much less, even tolerable.

Dec 19, 2018 8:23 PM

Thanks Zetarlov for your work. Merry Christmas to you if appropriate.🎄

Dec 19, 2018 10:11 PM

Good articles thank you Zetarlov it clarifies the topic for me.

Dec 20, 2018 8:56 PM

Marry Christmas is great! Back at you.

Dec 22, 2018 5:54 PM

I’ve had back pain since I was a child and I can’t explain to you how much osteopathy helps me to live a more normal life rather than laying awake at night because the pain is too bad to sleep. Unfortunately it so far hasn’t been anywhere near a cure but it certainly improves me quality of life. That’s all the evidence I need.

Jan 01, 2019 1:11 AM

I’ve read that article and while there are truths, it’s totally unhelpful and doesn’t take genetics, trauma, or reality into account. Duh, opiates won’t fix a thing, injection won’t, ablation won’t, surgery might b worse...meanwhile you’re unable to work, have no $$, burden on family, no way to get therapy or afford to invest in holistic approaches, you try for ssdi and get rejected cuz you’re “not disabled” cuz you can use Facebook n ride a bus or make a sandwich. The system sucks but these articles pointing out all the problems is easy to write but adds false value. Prevention could range from addressing childhood adversity to complete lifestyle changes which would be great but not realistic but we could hope

Jan 17, 2019 10:03 AM

There are lots of studies on how opiods only work meaningful for around 7 days, and how the Neuro blockers are doing more harm mentally than good. On one of my support groups we have a person who seems to be a researcher and the in dept articles he finds are great for this. But ultimately it is up to the patient if they want to try natural methods or keep 'trying' different things and possible hurt them selves more, especially if we are talking spine. From my experiences after getting pissed about betold to increase my morphone and take antidepressants and then add shots into my spine, then reading several articles about the above i just sd hell no more. I was introduced to Wahls protocol to reduce inflamation, ease the fibromyalgia, and now the only time I take meds is after I am bed rested. I have constant pain in my lower back and can not sit for longer than 15 mins but my pain is just now a discomfort.

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