Professor David Peters on Back, neck and joint pain

The usual cause of simple back pain?

Most of us have had backache at some time: a careless overstretch or a clumsy lift and “we feel something go”. “Feeling something go” is usually what a sudden muscle contraction feels like. Acute back pain usually happens when back muscles get into a vicious circle of pain and tension. Back muscles do this to protect you from overdoing it (and weak or over-sensitive muscle do this too easily), but the trouble is this “protective spasm” ends up being painful in itself! To understand this just make a tight fist and squeeze as hard as you can. The muscles soon start to ache and may even get cramp as the tension reduces blood flow into the muscles. Stop as soon as you feel what I mean; let the fist go and give your hand a good shake. Feel the ache fade away as the muscles relax again and the circulation returns to normal.

Similarly, after unaccustomed activity – a workout maybe or a heavy day’s gardening – your back might feel a bit sore, then over the next day or two become so painful that you feel you really must to lie down until it gets better. The build-up is caused by a gradually increasing tension in the over-used muscles. You can imagine that if they get caught up in a cycle of tension, pain and more tension, that this vicious circle could become a painful problem!

What can you do about your back problem?

It’s important to get the right advice and help if you have acute low back pain and to take longer term back pain very seriously indeed, especially if it has caused you to stop working! Because although about 70% of people who take sick leave due to low back pain return to work within 1 week (and 90% return within 2 months), the longer the sick leave, the less likely return to work becomes. Less than half of people with low back pain who have been off work for 6 months will return to work.

Almost all acute low back pain settles on its own, so you should see your doctor (either for a first visit, or for a follow-up) if your pain has been going on for more than 4-6 weeks. However, most people who have had a bout of back pain find they get another one within a year. Early treatment and advice about recovering your back strength can be an investment in prevention.

Red flags, or warning signs

These symptoms may suggest something more serious than simple mechanical back pain could be going on. See a doctor for investigation and treatment if any of them applies to you:

You have severe pain that is getting worse instead of better over time

If you have pain that doesn’t settle down when you’re resting at night
If in addition to your pain you feel quite unwell
If you have difficulty passing or controlling urine or your bowels
Numbness around your back passage or genitals
Numbness, severe pain, or pins and needles or weakness in your legs
You are unsteady on your feet.
The pain follows a violent injury, such as a road traffic accident.
You have had cancer in the past or at present.
You are on steroids.
You are an IV drug user, or have HIV.
You have lost significant weight without trying to.
You continue to have great difficulty bending forwards after a week.
You have developed an obvious deformity of your spine.

Repeated episodes of back pain

Yet even though quite painful episodes usually get better after a few weeks with little or no treatment other than some pain killers, further bouts are very common. 50-80% of people who have had a bout of acute low back pain say another one follows within a year. You may have found from your own experience that you got better but within a year the pain came back again. Whereas this sort of relapsing back pain is very common, persistent disabling long-term back pain is much more unusual. Only around 27% go on to have continual longterm pain problems. But even this will often respond to the right exercise and stress management approaches.

Long-term back pain

Many people who have longterm back problems think their pain is due to “arthritis of the spine”. As we get older it’s true that the spinal joints develop signs of wear and tear, and that XRays commonly show this kind of osteoarthritis. Whats interesting though is that if the back XRays of people who don’t have back pain very often show the same wear and tear. And very often the XRays of most people who do have back pain don’t show any signs of osteoarthritis. Its tempting to conclude then that the wear and tear revealed by an XRay may not be the actual cause of the pain. Though arthritic joint stiffness can contribute to the problem, in my experience long-term back pain happens when the back muscles have “forgotten” how to relax.

A muscle can get sore simply from being tense. Try this if you don’t believe it: take a firm grip on one thumb with the other hand and keep squeezing hard. Notice how the gripping hand and forearm quite quickly start to ache. Stop as soon as you feel it, but learn from this demo that when a muscle works hard without relaxing, it gets sore and crampy. Another demo: stand up and exaggerate the curve in your low back by sticking your bottom out. Stop as soon as you notice how quickly this makes your low back or buttocks ache!

So what’s going on in that sore back, and why are these muscles working so hard? Probably your back muscles, having become weak- perhaps after a bout of acute back pain – are having to overwork just to do their normal job. After only a few weeks of acute back pain some back muscles will have been underused (and so lose some of their strength and fitness), while others become extra tense. You may be familiar with the sort of lop-sided feeling that can be part of acute and long term back pain. This may be because your back muscles began working in an unbalanced way as they tried to adapt your posture to avoid pain.

Posture and work position

Another factor could be your work posture. Does the way you stand or sit or work mean putting your back muscles under extra strain? Do certain areas get stiffened up or have to overwork? For instance, tight muscles in the back of the thighs will tilt the pelvis so that the back has to flatten out, which affects overall spinal movement. Weak stomach muscles do the opposite, allowing the low back to tilt the other way, exaggerating your low back curve. These postural habits play can be really significant, so if you’re a desk-worker sitting for hours at time, the layout of your desk, filing system, VDU and chair become like the railway track on which you move. Its essential to make sure these “tracks” don’t force you into uncomfortable repetitive movements.

Does your work involve movements or positions that put strain on your back or force you to adopt tense and awkward postures? Employers are anxious to prevent back pain so get Health & Safety to check this out!.

Not all in the mind, but

The fact that mental tension triggers patterns of tightness in the neck shoulders back and hips helps explain why back or joint pain so often accompanies stress, anxiety and depression. Think about how your body expresses the way you’re feeling: for instance does your body slump when you feel sad, fearful or angry? All sorts of phrases and sayings remind us of the connection between emotions and the body. When we are proud we hold our head high; at other times we may feel we’re going through a bit of a slump and feel things are weighing us down or that life is a burden. When we’re anxious we will almost certainly talk about feeling tense. This tension is in the muscles as well as the mind! So it’s clear that our emotions are in the body as well as the mind, and that persistent emotional stress – not just physical strain – can cause muscles to tense up in the long term.

Use it or lose it!

We all know that being active and taking regular exercise is good for us; that it reduces the risk of serious health problems like heart disease, diabetes and stroke. We know that it helps us to lose weight or stay at a healthy weight. But it’s also a great stress reliever, makes you feel more energised and helps you sleep better; and exercise is a very effective cure for moderate depression. But how exactly does being active benefit you if you are prone to long term back pain?

Your back is built for movement. But if you’re getting lots of back pain of course you’re likely to feel you ought to avoid exercise in case it causes pain. This is understandable, but wrong. if your back doesn’t get the exercise or stretching it needs it will lose the strength and flexibility required for normal movement. Then it will need to use a high proportion of its reduced strength just to do everyday jobs. What’s more, a stiff back makes fewer of the sorts of movements that keep good circulation going in the muscles and joints. And once it gets more tense and stiff, and more irritable, your back is more likely to set off the alarm system that triggers muscle spasm and pain. Its especially important to grasp this idea if you’ve a long term back problem.

Working with the new model of back pain

The idea that low back pain is due to tissue damage or inflammation is misleading. If your muscles were torn or inflamed then of course you would need to stop and rest, probably for days until it healed. So, if you are getting one bout of back pain after another, and probably without doing much to provoke it, the notion that there’s some sort of injury happening makes no sense. What’s likely to be happening is that the part of your back that originally got irritated has become over-sensitive. When this happens it will be too easily provoked into protective tension; which the back muscles do when they feel overloaded or over-stretched. So, the question is what can you do to make your back less sensitive and less prone to irritability? Several things can be done once you realise that your back’s oversensitivity has to do with a loss of strength and stretchiness, and with an increased tendency to clench up. Then the answer becomes obvious: if you want to make the sensitive areas stronger and more flexible, then exercise will be the answer. If you want to reduce the tension-tendency, learning how to relax could also be crucial.

Preventing back pain and recovering from it

When muscles in the back get overused or overstretched they tend to tighten up. So when you start to move you feel them protesting, or perhaps even spasming – a sudden extreme muscle contraction that can make you feel like you daren’t move a muscle. It’s as if these muscles have become too “irritable” and don’t want to be disturbed, and so they over-react if you demand anything of them! If you were to go along with this perfectly normal aching and oversensitivity, the obvious next step would be to lie down and wait for the muscles to calm down; and indeed this was what doctors used to advise. But we realised only quite recently that people who took bed rest, got better more slowly that people who kept moving! That’s because unless irritable back muscles are encouraged to move, they easily get into a vicious circle of immobility, tension and pain that causes more immobility, tension and pain! Its these pain-tension cycles that cause most back pain.

To rest or not to rest?

Though you might feel bed-rest is the obvious option, resist this temptation or at least keep it to a bare minimum; and if you really have to lie down then make sure you do some gentle mobilising exercises to maintain muscle flexibility and blood flow. The best position for you is the one in which you feel the least uncomfortable. You might need pillows to hold you in that position while you let your body’s alarm systems settle down. For instance you might find that lying flat is only ok if you have a pillow under your knees, because that can help to relax the lower back; side lying may feel a lot easier if you have your uppermost knee bent with a pillow underneath to support it and prevent your having to twist at the waist.

Carry on with normal life, but take it easy and definitely don’t do things that hurt a lot.

What should I do?

Mild pain killers are very helpful if you’ve got acute back pain, because they damp down this over-sensitivity and take the edge off the pain so that you can gradually get going with your mobilization routine. Some people find a cold pack – like a big pack of frozen peas wrapped in a single layer of bath towel – placed on or under their back helps them relax their back when it’s acutely painful. Using a relaxation technique to encourage tension to let go as you slow your breathing down and focus on a remembered sense of ease and comfort can be very valuable thing to do.

Its important to allow your back muscles to loosen up and relax as often as you can. Do this by using a few easy relaxation and stretching exercises every hour or two.

A set of easy back exercises I recommend for acute as well as longterm back pain (as well more information on what you can do about stress and wellbeing) are available as podcasts and downloads from bhma.org

How I treat back pain

Conventional treatment
I always advise that people try to keep going unless the pain is getting worse. Use rest and painkillers carefully to take the edge off acute pain. Sometime anti-inflammatory and muscle relaxant drugs are helpful. I have found that acupuncture can sometimes relieve disc pain. Start active relaxation and stretching exercise as soon as they are bearable. Never more than 2-3 days in bed!! Manual therapies early on and definitely if not improving within six weeks.

If there are any “red flag” symptoms I would want to let your GP know straight away and possibly get specialist opinions. I might order diagnostic tests (usually an MRI scan or blood tests) particularly if there is referred pain and any loss of power suggesting a significant disc prolapse or another cause. Advice from an orthopaedic or neurosurgical specialist is occasionally needed. I prefer to work closely with your GP wherever possible.

Depending on the cause, I might use techniques ranging from gentle massage to ease muscle tension, to deep soft tissue massage involving pressure and stretching to encourage greater joint mobility. Manipulation always includes expert relaxation and stretching of soft tissues, but it does not always mean having to make joints “crack” – something that although it is not painful some people find disagreeable. When I do think a specific manipulation would help free a stiff joint, I only use it if my patient says they want me to do so.

Several studies have shown that osteopathy can aid recovery from acute low back pain. Its effectiveness for long-term back pain is less well established, though in my experience, when coupled with an effective exercise programme and sometimes alongside acupuncture and relaxation techniques, remarkable recovery is possible.

Acupuncture has proved so effective in relieving both acute and chronic back pain that many British pain clinics now use it routinely. Studies at the University of California, Los Angeles (UCLA) showed that different styles of acupuncture, Chinese and westernised, were equally effective in restoring blood flow, relaxing muscle spasms and strengthening weak muscles. In several trials in the US, patients receiving acupuncture for back and neck pain showed more improvement than control groups.

Alexander Technique involves becoming more aware of how you move. This will help you realign and correct your posture, thereby easing areas of muscle tension and nerve pressure. I work closely with Alexander teachers when recommending this approach for preventing long term back pain.

Qigong: These exercises combine movement, breathing and mindfulness into a form of meditation in which people focus on breathing and body awareness. Research at the Maryland School of Medicine has shown they can form an effective part of a programme for managing chronic lower back pain.

Yoga: Most yoga postures help stretch and release tense muscles and encourage suppleness and flexibility. Breathing exercises (pranayama) gently work the muscles of the upper back. Check first with your doctor and avoid positions that hurt. Better still, ask a qualified teacher to tailor a yoga programme to your individual requirements. The corpse position (lying flat on your back) is good for releasing tension and relieving pain; shoulder rotations ease tension in the upper back; back rolls massage the spine. Of readers responding to a questionnaire in an American magazine, 96% of those using yoga reported chronic back pain relief, compared to 23% seeing neurosurgeons (Klein, Backache Relief 1985)

Relaxation and breathing

Several researchers have shown that relaxation training reduces pain and muscle tension better than placebos or biofeedback. Learning to breathe well and relax reduces muscle tension. I teach various approaches and have produced CDs and podcasts to support these lessons.

Visualisation

Guided imagery is one of the methods. For instance someone might be taught how to relax their whole body and then imagine their pain as something that they can see or feel shrinking, melting or otherwise disappearing.

Rolfing is a hands on approach to releasing deeply held tensions. It involves powerful strokes which cause muscles and connective tissue to lengthen out so that joints become less stiff. Even old and habitual patterns of tension can be released so that the body aligns itself more comfortably.