Back pain is so common it is not so much a disease as a condition of life. Virtually, all of us will suffer from it at some point. It is the single commonest cause of lost working days.
Before, we outline a generalised conservative care programme below, it is important to understand the mechanisms of back pain and sciatica.
There are many causes of chronic back pain though by far the commonest is ‘degenerative disease’. This degeneration is the normal process of wear and tear that occurs with life. It affects the discs, bones, joints and ligaments of the spine. If it arose anywhere else in the body, it would be called arthritis, though medics tend to call it ‘spondylosis’. There is more to it than just ‘wear and tear’ as whilst it is more common amongst those who do heavy manual work or play heavy spinal sports such as rugby, there are many sedentary sufferers. Thus, the random mix of our genetic lottery comes into play too.
Wear and tear of the spine arises earlier than in any other joint of the body. This is not surprising when one considers the complexity of the spine, its mobility and the amount of weight that the lower segments take.
For more information regarding wear and tear of the spine, please press here.
Back pain arises when inflammation occurs in these worn joints and discs. Thus, back pain really may be thought of as inflammation arising on a long-term background of wear and tear in the joints and discs of the spine.
For more information regarding the different types of back pain, please press here.
Sciatica or leg pain occurs when the nerves servicing the legs are compressed by the swollen joints or bulging discs or irritated by inflammation in these joints and discs. Sciatica is therefore called a ‘referred pain’ and arises because the pressure excites the nerve and the brain thinks anything that comes from that nerve, comes from the leg.
For extended information about sciatica, please press here.
For extended information about referred pain, please press here.
In broad terms, nerve root pressure pain is best treated with rest and passive gentle treatments, whereas back pain is best treated with active exercise-based treatments.
The measures below are generally found helpful, though they will need to be tailored for the individual. We will discuss aspects specific to your case at The Spine Surgery London.
In principle, you need to do exercises and stretches whilst modifying some aspects of life-style. They will not have an immediate effect though in the long-term may bring benefit and are essential if the process of progressive pain is to be halted. Even for those of you who ultimately require injection therapy or surgery, it is very important that the underlying programme of back care is optimised if the long-term results are to be good.
None of the suggestions outlined below are effective in their own right. However, when effectively combined, they are often a sufficient gust to knock over much spinal pain. The strategy is to allow you to become more active without increased levels of pain and then to help the pain ease.
Whilst you may well gain benefit from sessions with a professional physiotherapist or a manipulative therapist – such as an osteopath or chiropractor – it is essential that you develop your own programme.
The aim is to maintain the range of movements in your spine – of the discs and of the multiple joints. It will loosen the spine so that the movements are freer. Stretching the hamstrings and the rest of the body will then reduce the amount of movement required of the spine.
The simplest programme and one which may be adequate for the majority, is a follows:
Stand up straight, relax and take a few deep breaths in and out Bend slowly forwards breathing out, running the hands down the front of the legs as far as you wish to go. Do not force yourself to touch your toes. Then, breathing in slowly return to the upright position, perhaps bringing the hands straight up above your head. Take another breath in and out and then lean backwards. Next slowly return to the upright position with the hands to your side. Take another slow breath in and out and run one hand down the side of the leg, again as far as you wish to go. Return to the upright position and perform the same thing with the other hand on the other leg. You will probably get your hand as far as the knee in these sideways movements. Two cycles of these four movements are quite sufficient if performed often enough.
You should aim to do these exercises 10 or 12 times a day – when you first emerge from bed, after cleaning your teeth, after breakfast, after getting to work, at coffee, lunch etc.
These movements ‘oil the spine’ and will prevent repeated ‘micro-injuries’ occurring throughout your normal day.
The strength of the spine comes from the muscles. These are the stomach, back and upper thigh muscles all of which attach to the pelvis. They are your own internal corset which protects the spine from injury in whatever position you assume and during movement. For the majority, what is required are light, frequent toning exercises that will maintain your muscles in a state of alertness throughout the day. They will then also protect the spine from the multiple micro-injuries of the day.
You will be taught specific strengthening and toning exercises by your physiotherapist and these are likely to focus on the weaker oblique muscles, which you are likely to be unaware of. Joseph Pilates, a German by birth, developed a particular set of exercises, whilst interred by the British during World War 1, which he later taught from his studio in New York from the 1920’s until his death in the 1960’s. Pilates is currently very popular and works.
The physiotherapist McKenzie and Keisner all developed specific exercises to help with core stability.
Whatever system you use, developing your core muscle strength is perhaps the most important element of rehabilitation and back pain prevention.
Your program needs to be individually tailored and progressive which is why you need an instructor to help you start. For a sure start, you need one to one instruction.
In addition, many of you could benefit from being physically fitter and others may be provoking the situation by doing inappropriate forms of exercise or gym work. Exercise is best done each day and at least a few times each week. Certain forms of exercise are particularly easy on the back – the stationary exercise bike, the cross trainer and smooth step machines. Swimming, particularly back stroke is also very good, as is simply walking navel deep in water or stationary running in water approaching shoulder height.
Other forms of exercise are hard on the back – you should avoid repeated impact and forced flexion or extension (bending) of the spine. Do not jog or use the treadmill to keep fit. Keep off the rowing machines in the gym. Tummy crunches are good but full sit-ups are bad. Leg raises are a better alternative.
You should think about your daily activities both at home and at work. Include how you travel and any physical hobbies. Rather than sacrificing some activities, you should aim for perhaps 10-15% reduction in the amount that each activity irritates the spine by modifying it, rather than reducing it. This may bring the amount of strain the spine sustains below the threshold for the onset of inflammation.
Think ‘Active Office’. There is no such thing as a perfect chair. You were just not designed to sit down all day. You were designed to potter about, picking berries and occasionally run away from lions!
If you are working it is vital that your chair and desk are correctly paired so that your spine can remain upright and with healthy curves. If you use a PC, this will need to be high and near – the screen will determine the position of your head. Your chair should have a high back so that the shoulders may be referenced against it. The back should be at right angles to the base and the base high enough to have your knees at right angles. If the chair has wheels, they should run smoothly on the floor. Even when perfectly positioned, you should not sit down uninterrupted for more than half to one hour. Get up a lot.
If you are on the telephone a lot, use a wire free headset so that your position does not slump to one side or alter when taking a call. A wire free set means you can get up (and stretch) whenever the phone goes.
Design your tasks so you are obliged to get up a lot. Put the envelopes on the other side of the room.
At home, you should break up physical tasks into small parts, i.e do not vacuum the entire house in a day or dig the whole garden or mow the entire lawn. Do half an hour and then something light for half an hour.
Break up your car journeys. Ensure that the seat in the car is high and upright and relatively near to the steering wheel. Let others drive when you can.
Avoid lifting and carrying where possible – suitcases with wheels, no hand luggage. Have your physiotherapist teach you the correct way to lift – bend at the knees.
Most sports can continue. Squash, long distance jogging, fast bowling and rowing pose particular problems and should be avoided if possible. Tennis, cycling, badminton, golf, weight-training, football and even rugby are often fine. You should, however, plan to have a relatively restful day before and an easy day afterwards. Have a coach teach you how to serve or tee off with a ‘bad back’.
It is important to remember that you will often pay with pain the day after you abuse your back, rather than at the time. It is important to avoid a cycle of activity followed by pain and inactivity. If you are suffering from chronic back pain, you should aim to gradually, in small steps, increase the amount of exercise you take each day.
The problem we are trying to solve is the build up of inflammation in the worn joints and discs. As such anti-inflammatory medications are appropriate. Apart from steroids and immune-suppressants, these are all derived from aspirin and include Ibuprofen (Nurofen), Diclofenac (Voltarol), Misoprostol (Ponstan), Indomethecin (Indocid) etc. They have a different mechanism of action from standard pain killers which themselves all relate to opium and include; Paracetamol, Codeine, Dihydrocodeine, Paramol, Co-proxamol, Solpadene, Tramadol etc.
These drugs may be taken together in a full dose but you cannot take two different types from the anti-inflammatory family at the full dose.
If you take these medications regularly they will give you side effects, most commonly gut related (indigestion or constipation) or drowsiness, and they will also stop working as your body downgrades its own anti-inflammatory and analgesic mechanisms. Thus you will get the most out of them on a continued basis if you take these medications intermittently. They will also be more effective if you take them before events or activities which exacerbate the pain (long drives, physical exercise, the end of the working week etc). If you find that the pain is worse when you wake up in the morning you should take them at night before you go to bed. By contrast if it tends to worsen towards the end of the day you should take it mid-morning or at lunchtime before it starts.
If there is no particular pattern to your pain, then sprinkle them throughout the week to cover the days you would most like to be free from pain. If it is to cover a particular activity, take them half to one hour beforehand. If your symptoms persist after the activity into the next day, take another dose.
If you are taking the medications two or three days a week, and therefore not taking the medication four or five days a week, and you plan the doses to occur before the times when the pain usually peaks, you will get the most out of the medications on an on-going basis. This may not be all the relief you wish for but it is the maximum that can be maintained.
You will usually find slow release preparations more effective. Ibuprofen is as good as any of the anti-inflammatories and comes as an 800mg slow release tablet. Less than the normal full adult dose is usually effective when taken in the way described. The full dose is 1600mg, taken as four 400mg doses in a day or two 800mg slow release ones.
Paracetamol is usually effective enough as a pain killer. Remember regular daily stronger ones will give you no better relief, can be addictive, and will cause side effects. Paracetamol usually come in 500mg tablets and you can take two of these four times in a day. For ongoing symptoms, we suggest you use one, once on the days you most need them.
NB - if you have suffered peptic symptoms (hiatus hernia, ulcers, stomach ulcers, duodenal ulcers, etc) you should discuss the taking of these tablets with me or another doctor beforehand. You should probably avoid the anti-inflamatories. In addition, certain of these drugs are now known to cause heart problems (though aspirin in low doses prevents them!)
Please go to our Medications section to read more about this section – it is best to read this before you take any medications.
Acute attacks: If your pain is intermittent and severe then a different regime is needed. Again, Paracetamol and Ibuprofen should do the trick for most of you especially if you are not taking analgesics and anti-inflammatory drugs regularly. For these isolated episodes, it is better to take a high dose of each, regularly for perhaps 5 days to a week before tailing it down. By “high” I mean 400mg of ibuprofen and 1000mg of paracetamol four times a day each. Providing you are normally drug free you should find this combination very effective It is permissible to take twice this amount but side effects will then be more common. You can replace the paracetamol with a stronger combination pain killer tablet – you can readily buy tablets with 500mg of paracetamol and 8mg of codeine of which you can take up to two four times a day.
The advantage of sticking to these drugs for ongoing and one off attacks is that you are independent. Available over the counter at many shops and in all countries, you need not worry about forgetting your medications or take time out to go to the doctor. Their side effect profile is lower than other drugs in their groups and if one day it gets out of hand you can subsequently up the regime to prescription only medications.