Last month Groessl et al., from the San Diego School of Medicine, published the results of their study examining the benefits of yoga on military veterans with chronic low back pain. Of the 150 participants in the study, 35% were unemployed or disabled and the mean back pain duration was 15 years. The mean age was 53 years. The group was generally thought to have “fewer resources, worse health, and more challenges attending yoga sessions than community samples studied previously”.
Hatha yoga classes, designed specifically for people with low back pain, were held twice a week for 12 weeks. They were led by an experienced certified instructor. Home practice (15-20 mins/day) was encouraged. The classes consisted of yoga postures, movement sequences, breathing exercises and brief meditation.
The veterans that completed the study had less disability and less pain. Although the decreases in pain were small, they happened in spite of reduced opioid use.
Most of us have us have used paracetamol at some point in our lives, whether to bring down a fever, for a headache, joint pain or some other painful condition. In fact, if we have a look in our medicine cabinets we’ll probably find a box…or two! Machado et al. from George Institute for Global Health at the University of Sydney recently reviewed the scientific literature with the aim of investigating the efficacy and safety of paracetamol (acetaminophen) in the management of spinal pain and osteoarthritis of the hip or knee. They included 13 randomised controlled trials in their review and the results were published in the BMJ.
They found that for low back pain, paracetamol was ineffective at reducing pain or disability and at improving quality of life. It’s important to point out that by “ineffective”, they mean that paracetamol did not provide more benefit than a placebo. For hip and knee osteoarthritis they found that there was a significant, although not clinically important, effect on pain and disability in the short term. Adverse events were not more likely with paracetamol than placebo but patients taking paracetamol are 4 times more likely to have abnormal results on liver function tests.
Although the clinical importance of the last finding is uncertain, paracetamol has been linked to increasing incidence of mortality, increased risk of cardiovascular, gastrointestinal and renal disease. This study has prompted the BMJ to release an editorial discussing the use of paracetamol for back pain and osteoarthritis. One of the problems for GPs is that the National Institute for Clinical Excellence (NICE) recommends paracetamol as the first port of call for low back pain and arthritis. Taking this option away leaves NSAIDS and opioids which both present even more health risks… Non-pharmalogical options should be pursued and developed i.e. physical activity and exercise, weight loss, nutritional supplements and physiotherapy of course!
A study published this month in Arthritis Care and Research by Daniel Steffens et al. from the University of Sydney has looked at the risk factors that could lead to acute low back pain. Acute low back pain is back pain that comes on suddenly and resolves after a few days or weeks as opposed to chronic low back pain which is long-standing.
They surveyed close to 1000 people and asked them about the presence of 12 physical and psychosocial factors up to 4 days before the onset of back pain. The results revealed that a number of triggers were linked to acute low back pain:
- moderate to vigorous physical activity increased the risk by 3
- manual tasks involving awkward postures increased the risk by 8
- being distracted during an activity increased the risk by 25
- age decreased the effect of exposure to heavy loads
- risk was highest between 7 am and mid-day
Over the years, I’ve noticed that the parents of young children have an increased incidence of low back pain. Having seen some of the risk factors high-lighted in this study, it becomes evident how sleep-deprived, fatigued and distracted parents that often lift their children in awkward positions can dramatically increase the risk of low back pain. It’s also interesting to note that distraction seems to massively increase the risk of low back pain and therefore underlines the importance of mindfulness.
Ever wondered whether MBT shoes really work? Well, a study was commissioned by companies that manufacture rocker sole shoes. The research was carried out by a team of physiotherapists from King’s College London. 115 people with chronic low back pain (CLBP) were randomly split into 2 groups; one was asked to wear rocker shoes for a minimum of 2 hours a day and the other was asked to wear flat soled shoes for the same duration. The subjects were followed for a year. At the end of the study the researchers concluded that “rocker sole shoes appear to be no more beneficial than flat sole shoes in affecting disability and pain outcomes in people with CLBP. Flat shoes are more beneficial for LBP aggravated by standing or walking.”
Last week I picked up a copy of Metro and came across an article entitled “Back pain ‘cured with a £114 dose of antibiotics'”. The story has also been covered by theguardian, The Times and the NHS. It’s based on the results of 2 studies published in the European Spine Journal by Hanne B Albert et al. from the University of Southern Denmark. It appears that oedema (swelling) of the vertebrae is observed in 6% of the general population and in 35-40% of people with low back pain. In their first study, Albert et al. examined 61 patients that had MRI-confirmed disc herniation and were undergoing surgery to address this. The disc material was analysed and it turned out that anaerobic bacteria were present in 43% of patients. Of those with anaerobic bacterial infections, 80% presented with oedema of the vertebrae next to the disc prolapse. Whereas only 44% of patients with negative cultures had bone oedema of adjacent vertebrae. The association between anaerobic bacterial presence and bone swelling was highly statistically significant. It’s thought that bacteria reach the inside of intervertebral discs via newly formed blood vessels that penetrate the damaged discs. The flow chart below shows how the process takes place.
In their second study, Albert et al. conducted a double-blind randomised controlled trial with 162 patients whose only known illness was chronic low back pain of greater than 6 months duration occurring after a previous disc herniation. They also had bone edema in the vertebrae next to the previous herniation. The patients were split into 2 groups. One group was given antibiotics for 100 days and the other group was given a placebo for 100 days. The patients were evaluated at the start of treatment, at the end of treatment and 1 year after the end of treatment. The patients given antibiotics improved on all measures; they had less low back pain, less leg pain and better function and the changes were highly statistically significant.
Although these results are extremely encouraging, they should be confirmed with larger groups. Additionally, it’s worth bearing in mind that this form of treatment only applies to a subgroup of people with low back pain and that the indiscriminate use of antibiotics for low back pain should be discouraged as it could lead to decreased efficacy of antibiotics through the spread of drug-resistant bacteria.
There’s been a lot of talk in the press (BBC, The Telegraph, Yahoo, Medical News Today, etc.) this week about finding the gene that causes back pain. So now back pain can be added to a host of other inherited conditions such as obesity, depression, cancer and diabetes. Before I give my opinion, I’d like to specify exactly what recent research has found. The study was carried out at King’s College London and was published this month in the Annals of Rheumatic Diseases. They found an association between the PARK2 gene and lumbar disc degeneration (LDD). The PARK2 gene switches off in people with LDD. LDD is the progressive dehydration of lumbar discs leading to disc space narrowing and osteophyte (bony spurs) growth. It is thought to be a common cause of low back pain (LBP).
It’s interesting to note however, that only 5 % of the population is affected by LDD but over 80% of people will have an episode of LBP at some time in their lives. Also, lots of people diagnosed by MRI scan with LDD have not experienced low back pain…strange? The obvious conclusion is that most LBP is not caused by LDD. Now, let’s look more closely at the relationship between the PARK2 gene and LDD. Does having the PARK2 gene automatically lead to disc degeneration? No! The PARK2 gene has to be switched off for that to happen. What switches it off? That there is the million dollar question, and it hasn’t been answered to satisfaction. The researchers have alluded to environmental factors such as lifestyle and diet. This is starting to sound familiar…could this be the old ‘nature vs nurture’ debate again?
Epigenetics explains how genes can be switched on and off. It’s the study of mechanisms by which the environment controls gene activity. “These mechanisms can enable the effects of parents’ experiences to be passed down to subsequent generations eg. paternal grandsons of Swedish men who were exposed during preadolescence to famine in the 19th century were less likely to die of cardiovascular disease, if food was plentiful, then diabetes mortality in the grandchildren increased” (Wikipedia).
Being told that we have a gene for x, y or z disease can lead to a helpless condition where we believe we have no control over what happens to us and so we gloomily go down a predestined path. “I can’t do anything about it, it’s in my genes.” Incidentally, self-fulfilling prophecies can come into play here. On the other hand, epigenetics puts us firmly in the driver’s seat. We can control our environment by controlling what we do, how we think, what we eat, drink, etc. It empowers us to write our own scripts. Gattaca is a beautiful example of this…I know it’s only a film but wasn’t it good!
Coming back to LBP, nothing has changed. Acute back pain is often caused by physical factors such as poor lifting technique, twisting, and prolonged sitting. Whereas with chronic back pain, there is the added contribution of mental, emotional and social factors. The good news is that whether it is acute or chronic, there are lots of things that can be done to prevent, treat and manage low back pain.
An article in Medical News Today reviews a study in The Journal of Alternative and Complementary Medicine on the treatment of low back pain. A combined program of complementary and conventional therapies was found to be more helpful than the usual care provided by the primary care physician. The benefits of the program were a decrease in pain and an improvement in function. The complementary therapies provided included physiotherapy, acupuncture, massage, mind-body techniques, chiropractic and nutritional advice. Healing in Motion in St Albans aims to treat musculoskeletal disorders using a holistic, integrated approach.
The BBC News-Health webpage currently links to the BBC Health site. The title of the link is “Back-pain danger signs, Symptoms to take straight to your doctor”. I followed it, read through the information and found it incomplete. In my opinion, a few things could be added to the list, but before adding anything…it’s important to bear in mind that the vast majority of low back pain is trivial and usually disappears after a couple of days or weeks. In a very small minority of cases the low back pain is a sign of something more serious. You should make an appointment to see your doctor if your back pain is associated with:
- Significant trauma (such as RTA or a fall)
- Prolonged use of corticosteroids
- History of cancer
- Unexplained weight loss
- History or high risk of decreased immune response (AIDS or HIV, recreational drug use, steroid or immunosuppressant use)
- Unremitting pain (even when lying down)
- Neurological symptoms (urinary incontinence or retention, fecal incontinence, loss of sensation in the genital region, weakness or loss of sensation in the lower limbs)
Please note that the signs and symptoms listed above don’t automatically mean that something sinister is at hand but simply that further questioning and examination is required. Lastly, remember that the overwhelming majority of low back pain is insignificant…apart from the inconveniencing pain obviously!