Paracetamol Ineffective For Back Pain And Osteoarthritis

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!

What Triggers Low Back Pain?

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.

MBT: To Wear Or Not To Wear?

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.”

Is Back Pain Genetic?

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.

Chronic Pain And Emotion

Professor Apkarian has studied chronic pain for over 20 years. In a recent study looking into people with recent back pain, he was able to predict with 85% accuracy those that would go on to develop chronic back pain! How? By noticing an increased level of cross-talk between two specific parts of the brain…suggesting that the more emotionally the brain reacts to the injury…the greater the likelihood of developing chronic pain. The researchers also found that the subjects that developed chronic back pain lost grey matter density…this is in accord with earlier studies that have measured brain atrophy in people with chronic pain. These changes can be compared to those that occur with aging.

Acupuncture Awareness Week

This week the British Acupuncture Council is launching the very first Acupuncture Awareness Week and their website is full of useful information. Of all the treatments I use, acupuncture is by far the one that most clients are curious about. Acupuncture has been used in China for over 2000 years. Fine needles are inserted into the skin to stimulate the body. Obviously, the needles are sterile and disposed of after use. Acupuncture can help with all sorts of muscle or joint pains like back pain for instance. The most common question is; how does it work? Let’s use back pain as an example (the following information was provided by the British Acupuncture Council).

“Acupuncture can help back pain by:

• Providing pain relief – by stimulating nerves located in muscles and other tissues, acupuncture leads to release of endorphins and other neurohumoral factors and changes the processing of pain in the brain and spinal cord (Pomeranz 1987; Zhao 2008).
• Reducing inflammation – by promoting release of vascular and immunomodulatory factors (Kim 2008, Kavoussi 2007;Zijlstra 2003).
• Improving muscle stiffness and joint mobility – by increasing local microcirculation (Komori 2009), which aids dispersal of swelling and bruising.
• Reducing the use of medication for back complaints (Thomas 2006).
• Providing a more cost-effective treatment over a longer period of time (Radcliffe 2006;Witt 2006).
• Improving the outcome when added to conventional treatments such as rehabilitation exercises (Ammendolia 2008; Yuan 2008).”
• Releasing tight bands in muscles

Following research into the effects of acupuncture on low back pain, the National Institute for Health and Clinical Excellence (NICE) now recommend that GPs offer a course of 10 sessions of acupuncture as a first line treatment for persistent, non-specific low back pain.

Low Back Pain: When To See Your Doctor?

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)
• Osteoporosis
• Prolonged use of corticosteroids
• History of cancer
• Unexplained weight loss
• Fevers
• 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!

I Wouldn’t Sit For That (Part 2)

Here are my tips to help prevent back pain, obesity, heart disease, cancer and death from over sitting:

• Stand whilst on public transport…there’ll be more than enough time to sit when you get to work
• Get up from your desk at least 1-2 times an hour (less than 5 minutes standing and walking around is sufficient)
• Drink more often, you’ll have to get up more frequently…to get a drink…and to go to the toilet
• Rather than send an email, why not walk over and speak to someone? (research has shown that walking at a leisurely pace is enough to reverse the metabolic changes caused by prolonged sitting)
• Don’t have lunch at your desk…go for a short walk…get some fresh air
• Organise your work tasks so that they involve frequent movement
• Here’s a little exercise you can do when you stand (breath in whilst you reach upwards and hold the position for about 5 seconds)…it will help your back

• Don’t use your car when your feet will do just as well

The clear message is that health can be maintained by including frequent short periods of standing and walking in our normal daily activity…little and often is the way forward!

I Wouldn’t Sit For That

Most of us spend the overwhelming majority of our waking hours seated. We sit down to have breakfast. Then we sit in our cars or on the train or bus on the way to work. When we arrive at work, we sit at our desks until lunch and then sit a little more to enjoy lunch. After work, we once again sit in our cars or on the train or bus. As soon as we get home we rush in to “take the load off” and collapse into our sofas, from where we surreptitiously pretend to read the paper…until dinner is ready! We then sit down to savour our meal, after which we promptly return to our sofas to digest…whilst watching a little TV…sound familiar?

Unfortunately for us, sitting is a major risk factor in the development of low back pain and it has even been associated with disc herniation. I naïvely assumed that was the worst of it until I stumbled upon a thought-provoking article…

Can sitting too much kill you? Wow, talk about getting your attention! Research has shown that spending excessive periods of time sitting can lead to obesity, heart disease and cancer. This can happen even if we take part in regular exercise. As Dr Marc Hamilton says, “sitting too much is not the same as exercising too little”. One of the culprits may be an enzyme called lipoprotein lipase. It allows muscles to uptake fat thereby decreasing the levels of fat circulating in the blood stream…and preventing arteries from becoming clogged up. Sitting markedly decreases the secretion of lipoprotein lipase. A large study conducted by Dr Peter Katzmarzyk found those who sit more are at higher risk of death than those who sit less.

Shocking isn’t it? I bet you won’t complain the next time you don’t get a seat on the train or underground! Before you sell your sofa and chairs or hand in your notice in search of that coveted job as a parking attendant or postman…things may not be as bleak as they seem…check out my next post for some life saving tips!

Yoga and Stretching Ease Back Pain

Something I read with interest in the news this week. A large randomised controlled trial in the US has shown that both yoga and stretching can lead to better function and decreased symptoms from chronic low back pain. Although this was no surprise to me, it’s always good to have evidence to back up our practice…I believe they call it evidence based practice…

If you would like to read the entire article, please follow the link below:

Largest US Yoga Study to Date Finds Yoga Eases Back Pain