5 predictions for the future of back pain treatment

Brighton chiropractor examines backBack pain is a global menace. It is the biggest cause of disability worldwide; it affects whole economies, individuals’ health and makes lives a misery. Back pain contributes to obesity, diabetes, osteoarthritis and mental health issues as those with back pain cannot exercise as much as they would wish. The 2020s should see major advances in back care.

Despite not getting the attention or funding that conditions like Alzheimers and cancer receive, there are exciting developments in treatment, policy and back research which will change how we approach back pain over the next decade.

 

 

 

1. Artificial discs 

Once a thing of science fiction, man-made discs are looking like a reality. As we get older the discs of the spine wear and although this is mostly painless, in some people it can cause extensive osteoarthritis, nerve or spinal cord entrapment and pain. Not nice!

The standard treatment, if people are beyond chiropractic care, is an operation to remove the old disc and then the adjacent vertebrae are fused together. It doesn’t have a great success rate and complications are high not least of all by accelerating the wear on the other discs in the area.

Primitive artificial discs and cages have been tried surgically but don’t have the strength and mobility that a healthy spine requires. The latest innovation is to inject stem cells into an artificial polymer gel matrix in the lab and top and tail it with foam – mimicking a real disc. These discs have been transplanted into goats successfully and initial reports are that they perform as well as normal discs. You can watch the video – click here.

Whilst the researchers have yet to carry this out in humans it is a huge step in the right direction.

2. Stopping ineffective and dangerous drugs to treat back pain

A class of painkilling drug is increasingly being prescribed, including for back pain despite being ineffective for this sort of pain and is so dangerous that it can kill. In the USA, where the problem is much worse, more than 70,000 people a year are dying from a prescribed opioid class drug. In recent years Tom Petty and Prince died from these legal drugs which are often many times more powerful than heroin. In the UK, figures are harder to come by but in 2018 one drug alone, tramadol, was implicated in 220 deaths. There are many others which go by names such as dihydrocodeine, codeine, oxycodone and morphine. 

Doctors are often pressured by patients to prescribe more powerful painkillers when the standard drug treatment of anti-inflammatory medication, such as ibuprofen, is not effective. Most doctors are well aware of the problem so if you have been prescribed these drugs or are taking them without a prescription then talk to your GP.

The chiropractic profession, particularly in the US and Canada, has been proactive in raising awareness of this problem. Research has shown that opioid use is much lower amongst back sufferers who go to a chiropractor than those who go to medical doctors alone. People who saw a chiropractor were 64% less likely to use opioids than people who didn’t, researchers report in the journal Pain Medicine.

As the problem becomes more widely recognised, the next decade should see a steady reduction in opioid prescriptions for back pain and the devastating harm associated with them.

3. Chiropractors on the NHS

Physiotherapy in the NHS is not keeping pace with the levels of back pain. Waiting times are huge in some areas, and when you do finally get to see a physio’ you are often given a sheet of exercises and told to go home and do them. Part of this is due to funding but it is also due to the fact that most NHS physiotherapists are not back experts and most doctors are not back specialists either.

The incidence of back pain is likely to rise over the next decade, in line with the ageing population. If the latest government promises are to be believed, then funding on the NHS should rise. But spending more on services where the skills are poor is not going to be the solution. 

In a handful of locations around the UK chiropractors and osteopaths are employed by the NHS in a variety of diagnosis and treatment roles, often as first contact practitioners. Such a system also works in the USA, Canada, Switzerland and Denmark. If the NHS is going to improve back care then it will have to look at existing expertise and use chiropractors and others embedded in hospitals, GP surgeries and in community practices, many of which are up and running already. This sort of approach exists already with NHS and private dentists and podiatrists (thank goodness they changed their name from chiropodists!).

4. Back sufferers finally given a diagnosis

Chiropractic consultation with Brighton chiropractorIf you go to a doctor with a pain in your back, if you don’t have any serious disease or injury, you are most likely to be told that you have non-specific back pain. What this means is that they don’t know which bit of you back is causing the pain and are just going to treat the pain, not the cause. This is a non-diagnosis.

As chiropractors become more common within the NHS patients should be told what the cause of their back pain is likely to be. Differentiating a muscle spasm from sciatica, a disc problem from a pelvic problem is straightforward if you have the training and experience to do so. This improves access to the right treatment and helps people get better faster.

Chiropractors have these diagnostic skills and have been shown in study after study to provide effective back pain treatment. Access to MRI and other imaging techniques directly for the few who need them will speed up diagnosis and free up the GPs to do what they do best – treating things other than back pain. 

5. Ending these dangerous exercises

DeadliftDeadlifts, touching toes and leg press exercises are amongst the drills that will be recognised by the fitness industry as contributing to back pain and will be phased out. Currently, there is a mismatch between most, but not all, spine care experts and gym and yoga instructors. As more up to date research makes its way to the courses for these professions practise will change and fewer back injuries will result.

I hope that these predictions are more than my benign, post-Christmas fug and that they will come to pass. They are all feasible but some are more likely than others. All will improve the lives of the thousands suffering from back pain. 

 

Matthew Bennett

Sundial Clinic Principal

 

Opioid references:

https://www.physiciansweekly.com/chiropractic-care-for-back/

https://www.independent.co.uk/voices/opioid-crisis-addiction-drugs-prescription

https://fpm.ac.uk/opioids-aware-clinical-use-opioids/current-uk-data-opioid-misuse

 

Bare as you dare – how sunbathing prevents back pain

The sun is shining; it’s warmed up; time to take your clothes off!

If you are suffering from ongoing back pain, then you could be deficient in Vitamin D. This hormone is responsible for a wide range of processes in the body including bone and muscle function. A commonly missed cause of back pain is Vitamin D deficiency, especially over a long winter. At least 50% of people in the UK show signs of vitamin D deficiency and many will have increased back pain as a result.

Common signs of vitamin D deficiency

  • muscle and bone aching
  • pain sensitisation, lower pain threshold
  • fatigue
  • depression
  • weakness
  • muscle soreness after exercise

Vitamin D is essential for bone formation as it helps your body absorb calcium from food. If you don’t have enough Vitamin D you can get a condition called osteomalacia. The dull, aching pain associated with osteomalacia most commonly affects the lower back, pelvis, hips, legs and ribs. This pain can be worse at night, or when you’re weight bearing. Vitamin D deficiency may cause morning back pain in some people too.

How much Vitamin D is enough?

There are various ideas about what the minimum blood levels for Vitamin D are required. This is a measure in nanomoles per litre of blood (nmol/L). Severe deficiency is anything below 25nmol/L, but anyone below 50nmol/L is considered deficient. Optimum health is often thought of a being above 85 nmol/L although more than 125nmol/L can be required for some people.

How can you get enough Vitamin D?

Fortunately, it is easy to get enough Vitamin D for free as you make it in your skin. Sunlight contains ultraviolet (UVB) rays that stimulate Vitamin D production. UVB rays also cause sunburn, however, so it is important to avoid over-exposure. If you cover up or use sunscreen, you will not produce Vitamin D so only aim for short exposure.

A sensible approach is to aim for 10-30 minutes exposure on as much bare skin as you dare, depending on how sensitive your skin is, several times a week when the sun is strong enough; in the UK that is from April to September. Full body sun exposure with no sunscreen will produce up to 20,000iu (500 μg) in 30 minutes. More importantly, once you have made enough Vitamin D your skin stops producing it so you can’t get too much.

Vitamin D supplements

Over the winter or for if you are severely deficient then supplements are the only way to go. In your diet oily fish such as salmon, mackerel and sardines provide some vitamin D but you would, for example, need to eat 20 tins of salmon a day to get 5000iu.

Here at Sundial we recommend a liquid Vitamin D supplement which is highly absorbable and inexpensive. The chewable calcium based supplements from ordinary shops are often too low in Vitamin D to help much.

Summary

  • Vitamin D deficiency is common and can cause back pain
  • Safe sun exposure on bare skin from April to September is beneficial
  • Taking a good quality supplement over the winter prevents deficiency

For more information and references:

https://www.nhs.uk/live-well/healthy-body/how-to-get-vitamin-d-from-sunlight/

https://www.skincancer.org/prevention/uva-and-uvb

https://www.hsph.harvard.edu/nutritionsource/vitamins/vitamin-d/#new-vitamin-d-research

https://www.healthline.com/nutrition/9-foods-high-in-vitamin-d#section2

 

Can arthritis of the spine cause back pain?

Does arthritis, specifically osteoarthritis, cause low back pain? In this video Brighton chiropractor and back pain expert, Matthew Bennett, reveals the answer and explains what osteoarthritis of the spine actually looks like.

New study slams medical treatment for back pain

backsA new study on back pain in the prestigious medical journal, the Lancet, roundly criticises medical treat of low back pain. Researchers from all over the world took part and looked at how back pain is treated and they concluded that there is “inappropriately high use of imaging, rest, opioids, spinal injections, and surgery.”  They go on to say that “Doing more of the same will not reduce back-related disability or its long-term consequences.”

Back pain is now the number one cause of disability globally and rates have continued to rise in spite of increased spending on treatment. The authors make a plea for more sense and evidence based treatment. They call for a new direction which encompasses emerging treatments alongside effective solutions that exist already.

Effective treatment for back pain

Guidelines exist for doctors to follow on the most effective sorts of treatment but often these are ignored or not implemented properly. Here in the UK, NICE has issued guidelines and these are mentioned in this study as being helpful and they echo the findings in this paper.  The evidence points to a biopsychosocial model of care which looks at the behavioural, psychological, and social factors as well as the anatomical structures which play a role in the persistence of pain and disability. What does this mean for you if you have back pain?

It means that there is greater emphasis on self-management, physical and psychological therapies, and some forms of complementary medicine, and less emphasis on pharmacological and surgical treatments. So staying active, doing gentle exercises, getting some manual therapy as well dealing with stress, anxiety and depression, especially negative feelings around pain and disability, are very helpful. Some guidelines also recommend massage and acupuncture. One thing the guidelines in the US Denmark and UK agree on is that spinal manipulation is helpful. Which is good news because that’s what we do here at Sundial.

The report goes on to highlight the differences in standards of care throughout the world and it is clear that there is huge variance in practise and approach. For instance in the USA only half of back sufferers are prescribed exercises and in Sweden, USA and Australia electrical modalities like ultrasound are routinely used in spite of being ineffective.

Back pain is not one condition

This review is an excellent summary of the worldwide management of low back pain but has its limitations. Back pain is not one condition but several conditions causing a similar group of symptoms. A muscle spasm, disc derangement and a spinal joint dysfunction all cause low back that can refer pain down to the buttock and leg and a skilled clinician can tell which problem it is likely to be. Whilst several conditions can co-exist it is clear that an accurate diagnosis is important because the treatment is different for all three. Here at Sundial we make sure we make an accurate diagnosis and agree a treatment plan that is the most likely to get the best results.

If you would like a free check up to see if we can help your back pain please give us a call or book online above

 

Reference:

Prevention and treatment of low back pain: evidence, challenges, and promising directions

Foster, Nadine EBuchbinder, Rachelle et al.
The Lancet , Volume 0 , Issue 0 ,

21 March 2018

Back pain treatment needs a rethink

photo (1)Back pain patients in Brighton and Hove might be able to access chiropractic and osteopathy on the NHS next year. The local Clinical Commissioning Group is currently considering this option. This will give local residents access to a wider range of treatments than are available currently.

An article in the British Medical Journal two years ago suggested that back pain treatment needs to be changed. The opinion piece, entitled We Need to Rethink Front-Line Care for Back Pain was authored by a team including Dr Nadine Foster, Professor of Musculo-skeletal Health in Primary Care at the Arthritis Research Centre at Keele University. I saw Dr Foster speak at the recent BCA conference on this topic.

Dr Foster says that patients with back pain are not well managed by GPs who get little training in common muscle and joint problems. We know from other areas such as North East Essex that uses chiropractors and osteopaths alongside physiotherapists to provide back care, that given a choice more than half of back pain patients would prefer to go to a chiropractor or an osteopath rather than to the physiotherapist.

This echoes recommendations from the new Harvard Medical School booklet entitled Low Back Pain: Healing Your Aching Back, which endorses chiropractic care as one good option for back pain treatment. The booklet says chiropractic care ’improved short and medium-term pain more than other treatments including exercise physical therapy and medication’. People who saw chiropractors also reported being less disabled compared to people who received standard medical treatment. The report also states that chiropractic care tends to be satisfying and effective for acute low back pain.

Many patients now demand access to treatment not widely available on the NHS, including chiropractic. As more areas commission chiropractors and osteopaths to provide specialised spine care around the UK is clear that chiropractors and osteopaths can help treat back pain safely, effectively and cost effectively. Hopefully the back pain patients of Brighton and Hove won’t have to wait too much longer to be able to access this care themselves.

Eliminate muscle pain with dry needling

Dry needling specific areas in muscles called trigger points is an evidence based technique for relieving and often eliminating pain coming from muscles such as back pain, neck and shoulder pain. Muscle pain can come in many forms from just being tender to touch, to a consistent ache to an excruciating spasm. Dry needling with acupuncture needles can help.

How effective is dry needling at relieving back muscle pain?

The 2009 NICE guidelines recommend that dry needling as a useful adjunct for health practioners for the treatment of low back pain .  One famous study showed that the needle caused immediate back pain relief in nearly 86% of needle sites. In over 31% of cases the pain relief was permanent;  20% had several months of pain relief and  22%, were better for several weeks.

What is dry needling?

Dry needling uses a very fine acupuncture needle to “deactivate” or “shut down” painful or knotted areas in your muscles. Many of us have areas in our body that feel tense all the time or feel like a hard ball in the muscle. By inserting fine needles into these tight areas, we elicit a “twitch response” or a brief contraction followed by an immediate and long lasting relaxation. Because the needle can treat very deep parts of the muscle it can often reach deeper muscles that other techniques such as massage can not reach.

How does dry needling work?

Based on pioneering work by Dr Jay Shah colleagues at the National Institutes of Health we know that inserting a needle into a trigger point can cause favourable biochemical changes which assist in reducing pain.  It is most effective when there is a local twitch response and this can be described as a “deep aching”, “pressure”, “releasing” or “soreness”. The needle is left in for a very short period of time, just long enough to relax the muscle. The procedure is repeated in different areas until the muscle returns to its normal, relaxed state.

What can it help?

Essentially any postural problem or injury where the pain is primarily from a muscle.  Most commonly it can be used with

So problems such arm and shoulder pain from mouse and keyboard overuse respond very well.

One last thing, dry needling is just one way of relieving muscular pain.  If you have a needle phobia or just don’t like the idea of the technique there are other effective techniques we use at Sundial to help relieve your muscle pain such as laser therapy, massage and chiropractic.

References Dry Needling In Orthopaedic Physical Therapy Practice, Jan Dommerholt, Orthopaedic Practice, Vol16, 3:04

X-rays reduce cancer risk says latest research

Arthritis x-ray explainedUsing x-rays to see inside the body has been around since 1895 and chiropractors were amongst the first to use this wonderful new technology. The first x-ray machine to be installed in a chiropractic college was in 1910 in Davenport, Iowa. Since then x-ray use fallen in and out of favour in both medical and chiropractic circles. Everyone assumes that all x-rays pose a risk to health but latest research puts this to the test.

Recently NICE recommended against the routine use of x-rays for simple low back pain. As far back as 1976 studies(1) showed that ordinary x-ray films don’t show the cause of the pain. Further arguments showed that in most cases and doesn’t improve care or the clinical outcome.  Whilst that may be true for medicine where the first treatment is medication and then, after a while, physiotherapy exercises, chiropractors use x-rays differently.

The 1976 study was limited to the 18-50 age group so the same conclusion cannot be drawn for older back sufferers. Chiropractors take films standing up which shows such things as leg length differences far more accurately than measuring the legs or eyeballing differences at the feet or ankles. Hospitals take back x-rays lying down which show disease but mask postural changes like spinal curvature (scoliosis)  and disc compression with instability.

Chiropractors main form of treatment is manipulation or adjustment of the spine. Whilst this is a safe procedure in most people, if you have a hidden spinal birth defect, x-ray can show if it safe to adjust. Chiropractors feel for individual spinal bone movement and it is the loss of this movement which is thought to cause many forms of back pain. If there is a spinal defect where 2 vertebra have not  grown properly and have fused, which is not uncommon, then that segment will move abnormaly. Without an x-ray a chiropractor might conclude that this was 2 bones locked together causing the pain and start treatment to unlock them. In a review of 847 x-rays form new borns to 85 year olds, 68 % had observable anomalies (2).  These ranged from common wear-and-tear arthritis to tumours and fractures. It is good to know so that the right treatment can be applied.

Are X-rays Safe?

We are exposed to x-rays every day, about 2.4 mSv a year. In Cornwall the rock emits more radiation so it is bit higher here ( no Cornish jokes please). When we fly the exposure is higher still. It has been assumed that any exposure is harmful. This has not been based on research but an assumption that the effects are linear down to zero. This theory means that even small doses have a small adverse effect.

But is this true. In 2008 Rodgers and Holmes (3) went to Chernobyl to find out. Astonishingly they found that at small doses of up to 15 mSv, x-rays were actually beneficial! Up to this level people had lower levels of cancer than a normal un-exposed population. So x-rays are good for you, within reason. A set of 2 low back x-rays is about 1 mSv (4) and the maximum safe dose is 20 mSv a year (5).

The British Chiropractic Association insists on a strict code of practice to ensure even higher safety standards. Regular site inspections and equipment maintenance is carried out to make the best use of a valuable resource in the chiropractors diagnostic options.

References

1. Nachemson, A. L. (1976). The lumbar spine an orthopaedic challenge. Spine,1, 59-71.

2. Beck, R. W., Holt, K. R., Fox, M. A., &  Hurtgen-Grace, K. L. (2004). Radiographic anomalies that may alter chiropractic intervention strategies found in a New Zealand population. Journal Manipulative Physiological Therapeutics, 27, 554-9.

3. Rodgers, B. E., &  Holmes, K. M. (2008). Radio-adaptive response to environmental exposures at Chernobyl. Dose Response, 6, 209-21.

4. Wall, B. F., &  Hart, D. (1997). Revised radiation doses for typical X-ray examinations. Report on a recent review of doses to patients from medical X-ray examinations in the UK by NRPB. National Radiological Protection Board. Br J Radiol, 70, 437-9.

5. World Nuclear Association (2009). Radiation and Nuclear Energy. Dec 2009 from  http://www.world-nuclear.org/info/inf05.html