TalkBack, Issue 4 | 2013 (BackCare)

f u l l r e p o rt : b a c kca r e awa r e n e s s w e e k 2 0 1 3

TalkBack Quarterly magazine of BackCare, the UK’s National Back Pain Association

■ NEWS

■ EVENTS ■ COMMUNITY autumn 2013

£2.95 • FREE TO MEMBERS

Burnout Are you burning out?

Menopause Back pain in the menopause Pain language BackCare adopts the Pain Exchange

The Charity for Back and Neck Pain www.backcare.org.uk

2 Talkback news

BackCare Events Calendar 2013/14 BackCare Christmas Carol Concert 2013 18 December 2013 at 6.30pm – Queen’s chapel at the Savoy, Strand, London

Join us at The Queen’s Chapel of the Savoy for a rich tapestry of choral masterpieces brought to you by the Tredici Choir directed by one of Britain’s leading choral conductors, Richard Thomas. Tickets £20; refreshments available.

Box office: 020 7766 1100, www.smitf.org.uk Proceeds go to the charity.

Virgin London Marathon 2014 – Application Deadline 24 January 2014 (Race day: 13 April 2014)

Join the BackCare team at the world’s largest marathon. We have 40 guaranteed places but they won’t last long! Minimum pledge: £1,300. Registration fee: £50. Contact events@backcare.org.uk or telephone 020 8977 5474.

Moving and Handling People’s Conference 30 and 31 of January 2014 - Business Design Centre, Islington, London

Moving & Handling People: Empowering Practitioners, Inspiring Improvement. With ‘Pre-Conference New Products Evaluation Workshops’ on 29 January. Delegate rates held at 2010 prices + 3 for 2 offer and early booking discounts available, www.movingandhandlingpeople.co.uk

BUPA London 10K Challenge 25 May 2014 – London

The BUPA London 10,000 will take place at 10am on Sunday, 25 May, 2014. It starts and finishes in St James’s Park and uses Green Park as its assembly area. Team BackCare has 10 places available. Contact events@backcare.org.uk or telephone 020 8977 5474.

The Back Pain Show at London Olympia 4–6 July 2014 – Olympia Exhibition Centre, London

Proudly sponsored by BackCare, the 2014 Back Pain Show brings together the latest in back care products, techniques and technologies in an exciting three-day event. Grab your two free tickets in the preceding issue of TalkBack!

Prudential Ride London 100 10 August 2014 – London

One of London’s newest mass-participation challenge events. As many as 70,000 people are expected to participate, riding 100 miles from the Queen Elizabeth Olympic Park into central London through the scenic Surrey Hills before finishing on The Mall. Applicants must be confident cyclists who can ride safely in large groups. Find out more at info@backcare.org.uk or 020 8977 5474.

BackCare Awareness Week 2014 6–11 October 2014 – Nationwide

Back pain in office workers will be the theme of our 2014 awareness week. Campaign packs and details of media activities will be released closer to the event.

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Talkback news 3

Welcome

Contents

Welcome to the last issue of 2013. Can you believe it? The festive season is upon us once again and another year comes to a close.

They say time flies, so we must have been having a great time at the BackCare head office because the year has whizzed by! But 2013 has not been without its catalogue of accomplishments.

The launch of the new Simply Health Back Care app on national television in September was tremendously successful, sparking great public interest and a surge in applications to join Team BackCare at the 2014 London Marathon.

BackCare Awareness Week in October reached out to nearly six million people through more than a dozen live BBC radio interviews, and our Caring for Carers campaign saw great support from clinics and carer support centres across the country who hosted local events for their communities. Read the full report which starts on page 18.

I hope you enjoyed the evidence-dense “Rethinking chronic pain” in the last issue. Our educational series, “Prevention is better than cure”, continues with the fourth instalment focusing on burnout syndrome. It’s more common than you thought, more harmful than you’d believe and its treatments present us with a powerful insight into medicine’s future.

I bumped into a representative from the Complementary and Natural Healthcare Council at an exhibition back in March. They’ve just been awarded approval by the Professional Standards Authority for Health and Social Care, so what better time to interview them for TalkBack. We’ve also got a fascinating contribution from the Society for Teachers of the Alexander Technique on page 6.

As always, we do welcome contributions from our members – whether you have back pain or treat people with back pain, if you can inform and inspire others, we’d like to hear from you. Just drop me an email at yourstory@backcare.org.uk or send us a letter to the usual address.

Before I go, let me take this opportunity on behalf of everyone at BackCare to wish you all a very merry Christmas as well as a happy, healthy and productive New Year. Enjoy the magazine and I’ll see you in 2014.

News

4-5

Alexander Technique

6-7

A regulator’s role

8-9

The menopause

The Pain Exchange

10-11

12-13

Dr Adam Al-Kashi Head of Research & Editor of TalkBack

We welcome articles from readers, but reserve the right to edit submissions.

Paid advertisements do not necessarily reflect the views of BackCare. Products and services advertised in TalkBack may not be recommended by BackCare. Please make your own judgement about whether a product or service can help you.

Where appropriate, consult your doctor. Any complaints about advertisements should be sent to the Head of Information and Research.

All information in the magazine was believed to be correct at the time of going to press. BackCare cannot be responsible for errors or omissions. No part of this printed publication may be reproduced, stored in a retrieval system or transmitted in any form or by any means without permission of the copyright holder, BackCare. ©BackCare

Burning out?

14-17

Awareness report

18-22

BackCare 16 Elmtree Road, Teddington, Middlesex TW11 8ST Tel: +44 (0)20 8977 5474 Fax: +44 (0)20 8943 53318 Helpline: +44 (0)845 130 2704 Email: info@backcare.org.uk Website: www.BackCare.org.uk Twitter: @TherealBackCare Registered as the National Back Pain Association charity number 256751.

Talkback is designed by Pages Creative www.pagescreative.co.uk and printed by Severn, Gloucester.

Chronic pain

24

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4 talkback news

Brain scans show lower grey matter density in areas that process pain In recent issues, we reported on the discovery that chronic lower back pain (CLBP) can be detected by brain scan.

In December 2012 (PMID: 23246778), researchers from Stanford University compared 47 CLBP patients with 47 healthy people and found that CLBP patients displayed “cortical re-structuring” (physical changes to the brain). Almost a year on, several research groups have published their own findings in this new field.

In September 2013 (PMID: 23392554), researchers from the University of Cologne compared brain scans and psychometric tests of 14 CLBP patients with 14

healthy people. Their results confirmed the hypothesis of a “brain signature” in chronic pain conditions, showing CLBP patients had significant decreases in grey matter density in the areas of the brain involved in pain processing and modulation (i.e. the dorsolateral prefrontal cortex, the thalamus and the middle cingulate cortex). They also confirmed that CLBP

patients had significantly higher scores for depression and anxiety.

Meanwhile, researchers from Harvard Medical School and Pittsburgh University noted that the studies associating chronic back pain with “grey matter thinning” had not controlled for important clinical variables which might actually influence the changes in the brain.

They published a pilot study in October 2013 (PMID: 24135900) suggesting that depression, anxiety and medications such as opioids (e.g. morphine or tramadol) and benzodiazepines (e.g. diazepam) may contribute to the brain re-structuring seen in CLBP patients.

Tough course no obstacle for Rebecca Congratulations to Rebecca Fargie who raised £635 for BackCare by competing in a ‘Tough Mudder’ event on September 7.

Rebecca braved 12 miles of obstacle courses designed by the Special Forces to test strength, stamina, mental grit and camaraderie. On her JustGiving fundraising page (www.justgiving.com/ Rebecca-Fargie), Rebecca explains her motivation: “To make this challenge worthwhile I have decided to raise money for the BackCare. This is very close to my heart and I would

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love if one day a cure could happen for all those that suffer daily. I run because I can. When I get tired, I think of my Dad and those who can’t run, what they’d give to have this simple gift I take

for granted, and I run harder for him/them. I know they would do the same for me.”

Many thanks from BackCare and on behalf of those in pain for your courageous effort.

researching recovery BackCare is collaborating with Professional Member Georgie Oldfield of SIRPA (www.sirpauk.com) to investigate the phenomenon of chronic pain recovery.

Conventional care for chronic pain does not result in recovery but focuses on helping patients to manage their pain and quality of life.

However, through the work of SIRPA, it has become clear that chronic pain recovery can indeed result from a deliberate medical intervention, which warrants further study.

With hundreds of millions of people locked into disabling chronic pain worldwide, this collaboration could be a vital step into the future of pain medicine.

Conference debate The National Back Exchange – the national association for manual handling professionals – held its annual conference in Leicestershire from 30 September to 2 October.

BackCare’s Head of Research and Education, Dr Adam Al-Kashi chaired the plenary sessions on the final day and presented a talk on the need to integrate challenging evidence in order to evolve the profession.

The exhibition area showcased new technologies in manual handling and patient care – these included innovations in health-promotion such as the YouBike™ (www.youbike.co.nz), a cardiovascular workout machine for wheelchairbound and bed-bound people.

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Long-standing BackCare member recalls charity founder’s inspiration We’ve had some great responses to the special birthday feature in the last issue. Here’s one such letter from long-standing BackCare member, Mary Scheu: Great Anniversary issue! I was especially interested to read the obituary of Stanley Grundy whose kindness I will never forget.

In the early 1980s, I was a 30-year-old postwoman who – through carrying two 35lbs delivery bags daily, heavy with mail – was suffering from debilitating back pain. First, I damaged a ligament and was unable to work (stand, walk, sit, etc.) for several months. Back to work – no rehabilitation in those days, straight back to carrying heavy bags – and I suffered a slipped disc.

As the obituary rightly states, treatment for back pain was shared between many disciplines and that was if the patient was lucky! I was offered x-rays, which apparently

Tribute to a pioneer

confirmed diagnoses, and thereafter painkillers increasing to such strength that I became a zombie.

In desperation I wrote to Mr Grundy at the National Back Pain Association, as it was then, and I received a lengthy hand-written reply from him in which he reassured me and gave me the first hope I’d dared to have of a full recovery,

which, in time, did happen.

I have never forgotten that letter and Mr Grundy’s kindness which came at a time when I had no hope. His kindness and inspiration is reflected throughout his life.

Good luck to TalkBack. I’m already looking forward to the next edition!

Best wishes, Mary Scheu

Thousands download app According to latest figures, downloads of the new Simplyhealth Back Care app have now reached 40,849 – that’s an average of around 750 downloads a day since the launch back in September.

For every download, BackCare receives £1 from Simplyhealth so we’d like to give a huge “Thank You!” to those who download the app and share it with friends and family. The television adverts have now ceased after several weeks of prime-time appearances, but they will resume in the New Year to boost downloads once again.

The target is to reach 120,000 downloads by Easter to secure the maximum donation of £120,000, so please continue to download and share the app! (www.backcare.org.uk/backcareApp)

Somewhat belatedly, we’d like to acknowledge the passing away of Valeria Crook, pictured, who was a driving force at the BackCare Hull and East Riding Branch for many years. Her friend and colleague Beryl Kelsey wrote the following statement for us.

“Valerie Crook joined BackCare Hull and East Riding Branch in its early days and became involved in the administration and development. She started a Listening Ear group. This was a morning meeting where people could go for advice and meet other people with back pain. This developed into an easy line dancing session, which is still flourishing.

“Perhaps Valerie’s main contribution was to the social side. Over the years she organised dinner dances or lunch parties at Christmas and Easter bonnet parades. The annual auction was started to raise money, but quickly developed into a hilarious social event. In 2004, Valerie received a Pioneer of the City award for her services to the community.

“Valerie battled with ill health for many years and died on 28 December 2012.

She is greatly missed by us all.”

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6 Talkback the alexander technique

Benefits beyond the physical There is strong evidence showing that the Alexander Technique provides significant and sustained benefit to chronic back pain sufferers.

The improvement in pain and disability was not only sustained long after completion of the course of lessons, but continued to grow over time. Given that the development and remission of chronic pain appears to be governed by psychosocial factors, we wondered whether there was indeed a psychosocial dimension to the Alexander Technique. The article that follows is the result of a conversation that took place between BackCare and the Society of Teachers of the Alexander Technique (www.stat.org.uk).

A

recent randomised controlled trial has found that Alexander Technique lessons are an effective intervention for back pain (Little et al 2008). Participants reported a reduction in their pain and talked about feeling more in control and gaining positive benefit from the support and advice of their Alexander teachers (Yardley et al 2010). Both these factors, and the fact that the Alexander Technique made sense to them, are likely to provide more holistic benefits than just simple pain relief.

In 2009, Armitage interviewed people who were learning the Alexander Technique about the psychological benefits they experienced from taking lessons for a variety of reasons (not just pain relief). They reported an increase in self-awareness and presence in the world, benefits which are similar to those acquired through practising mindfulness which has been shown to help with depression and stress. Like the participants in Yardley et al’s study, the Armitage group reported a greater sense of control and with it increased confidence.

They cited the student/teacher relationship as positive and found that after learning the technique they had feelings of lightness and improved balance. Further evidence for the psychological benefits comes from a survey carried out in 2010 by the Society for Teachers of the Alexander Technique

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(STAT). The survey found that Alexander Technique lessons benefit people with psychological difficulties, including depression and panic attacks, and 52.68% reported that lessons helped them lower their stress levels.

People with Parkinson’s disease have been found to benefit from Alexander Technique lessons, not only increased ability to carry out daily activities, but through a reduction of depressive symptoms (Stallibrass et al 2002). Anyone experiencing long-term back pain is also likely to feel under stress and depressed at times. Learning and applying the Alexander Technique may alleviate these symptoms, not just as a consequence of reduction of muscle tension and of pain, but also through a direct beneficial influence on attitude and emotion.

The Alexander Technique doesn’t distinguish between the functioning of mind and body; individuals are seen as a psychophysical whole so any work will have effects that spread throughout the whole person. Recent research suggests that emotions are primarily experienced through bodily sensation and then translated into feelings and brought into consciousness (Philippot et al 2004). We feel with our whole self and so it makes sense that releasing bodily tension and bringing about better overall functioning will

affect us in all ways, not just physically but emotionally as well.

Quite often people’s habitual ways of holding themselves, of being in their bodies, resemble the kind of startle patterns that we adopt when frightened or under threat. These muscle patterns convey stress to the whole person. By applying the Alexander Technique and with the help of a teacher, people can reduce their tendency to be in a startle response and change to a way of being that is more at ease and neutral; this can have a positive effect on mood.

The technique is usually taught in oneto-one lessons which typically last 30-40 minutes, and consist of exploring the way the individual goes about their daily activities. Lessons involve spoken advice and skilled touch, the teacher using his or her hands to communicate with the student, to listen to their neuromuscular activity and provide feedback. This is a gentle, non-demanding touch which has been described as nurturing and reassuring. One participant in a study of touch in Alexander lessons said: “It’s such a lovely feeling when somebody gives your body the opportunity to let go and expand” (Jones & Glover 2012). Touch is also known to stimulate secretion of oxytocin which reduces physiological stress responses and increases a sense of calm.

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The Alexander Technique doesn’t distinguish between the functioning of mind and body

Quite often people’s habitual ways of holding themselves, of being in their bodies, resemble the kind of startle patterns that we adopt when frightened or under threat Alexander Technique lessons provide a gentle one-to-one approach with the teacher alongside, supporting and helping an individual to bring about change in him/ herself. Positive benefits can come directly from pain reduction but also through stress reduction and an increase in self-control and presence. One final thought is that people generally enjoy the process of learning the technique; this experience in itself is likely to add to the benefits which extend beyond the physical.

A woman who went for Alexander Technique lessons to improve her horse riding said: “…However, it is not just my riding that has improved, I simply didn’t realise that I was full of tension and how this was affecting me in day-today life. I no longer lose my temper at the drop of a hat and I feel full of confidence. I can honestly say that AT has changed my life”

References Little P, Lewith G, Webley F et al.

Randomised controlled trial of Alexander Technique lessons, exercise and massage (ATEAM) for chronic and recurrent back pain. BMJ 2008; 337: a884.

Yardley L, Dennison L, Coker R et al.

Patients’ views of receiving lessons in the Alexander Technique and an exercise prescription for managing back pain in the ATEAM trial. Family Practice 2010; 27: 198–204.

Armitage J. Psychological change and the Alexander Technique. Unpublished ClinPsyD thesis. University of Hull; 2009.

Stallibrass C, Sissons P, Chalmers C. Randomised, controlled trial of the Alexander Technique for idiopathic Parkinson’s disease. Clinical Rehabilitation 2002; 16: 695–708.

Philippot P, Baeyens C, Douilliez C, & Francart B. (2004). Cognitive regulation of emotion: application to clinical disorders. In: Philippot P, Feldman RS (eds.) The regulation of emotion. New York: Laurence Erlbaum Associates; 2004.

Jones T, & Glover L. Exploring the psychological processes underlying touch: Lessons from the Alexander Technique. Clinical Psychology & Psychotherapy 2012; online early view.

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8 talkback interview

Complementary healthcare

John Lant, Chairman of the Complementary & Natural Healthcare Council, outlines the role and vision of his organisation

What is the CNHC and what do you do?

CNHC is the UK voluntary regulator for complementary healthcare practitioners that was set up with government funding and support to protect the public. We provide a UK register of practitioners who have met national standards.

Our role is to: n set the standards that practitioners need to meet to get on to and then stay on the register n require CNHC registered practitioners to keep to our code of conduct, ethics and performance n investigate complaints about alleged breaches of the code n impose sanctions or remove practitioners from the register when necessary.

CNHC has recently been approved by the Professional Standards Authority for Health and Social Care (PSA) as the holder of an Accredited Voluntary Register (AVR). PSA is the independent government appointed body that oversees the work of the nine statutory medical, health and care regulators. It also accredits registers of health and care occupations that are not regulated by law and this is the process we have completed.

This marks the next step for CNHC as the voluntary regulator for complementary therapists. I’m delighted that CNHC has met the PSA’s rigorous standards and practitioners on the CNHC’s register can now use the new CNHC AVR quality mark.

This reinforces the confidence that the public, employers and healthcare

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commissioners can have in choosing CNHC registered practitioners.

What constitutes an infringement of CNHC’s Code?

Breaches of the Code could include a breach of professional boundaries such as an inappropriate personal relationship with a client. It could include fitness to practise issues such as practising when ill with any condition that puts the patient or client at risk. Or there could be an abuse of trust in terms of financial exploitation. In terms of performance it could be failure to provide care that meets the national standards for safe and competent practice.

All practitioners on the register must abide by CNHC’s Advertising Guidance and the Advertising Codes as set out by the Committee of Advertising Practice (CAP). We have received complaints about advertising when practitioners are in breach of these Codes.

Which professional groups do you regulate?

We regulate people who practise the following therapies: 1. Alexander Technique teaching 2. Aromatherapy 3. Bowen therapy 4. Craniosacral therapy

5. Healing 6. Hypnotherapy 7. Microsystems acupuncture 8. Massage therapy 9. Naturopathy 10. Nutritional therapy 11. Reflexology 12. Reiki 13. Shiatsu 14. Sports therapy 15. Yoga therapy Descriptions of each of these therapies can be found on our website (www.cnhc.org.uk) under ‘Clients, patients & the public’ then ‘Complementary therapy descriptors’.

How do you define complementary medicine and how do you categorise its basis?

CNHC regulates the groups it does as a result of a report about complementary therapies by the House of Lords Select Committee of Science in 20001. This report included a statement which said that the public interest would best be served by improved regulatory structures of many complementary therapy professions.

This was in recognition of the wide use of these therapies and that they were largely unregulated in terms of training and practice.

The Lords grouped the therapies into three categories. The first (Group 1) included therapies such as acupuncture and herbal medicine which the Lords described as claiming to have an individual diagnostic approach. The second group

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watchdog sets out standards of practice 70% of people we asked did not know that anyone could set up as a complementary therapist in the UK without any training, qualifications or insurance (Group 2) were those “therapies which are most often used to complement conventional medicine and do not purport to embrace diagnostic skills2”. The third (Group 3) were those therapies which the Committee considered to be “alternative” therapies and which included a diagnostic and treatment element.

The Lords recommended statutory regulation for the therapies described in Group 1. These disciplines were either already regulated by statute (osteopathy and chiropractic) or they began a process to develop statutory bodies (acupuncture, herbal medicine and homeopathy).

The disciplines registered by CNHC are primarily those which the Lords categorised as Group 2.

Subsequently, government invested in the development of National Occupational Standards (NOS) for each of the disciplines. The NOS define the relevant knowledge base and the requirements for safe and competent practice. These are the benchmarks that protect the public.

Is complementary medicine simply a placebo effect or faith based?

CNHC does not make any claims or statements about the efficacy of the disciplines on the register: this is not our role. CNHC was set up to protect the public due to the widespread use of the therapies. However, we do of course support the need for a robust evidence base. We encourage our registrants to take part in research and we liaise with

the Research Council for Complementary Medicine (RCCM) which co-ordinates research in this field.

What’s interesting is that complementary therapies are already provided in a range of healthcare services such as in cancer and palliative care and mental health services.

They are also widely used in the sporting arena and many of our practitioners were involved in providing massage and sports therapy to athletes during the Olympics and Paralympics.

What proportion of UK complementary practitioners does CNHC register?

There are no reliable statistics about the numbers of UK practitioners, let alone how many might be eligible to register with CNHC. The register has opened incrementally to new disciplines since it opened in 2009 so growth has come in stages and we currently have just over 5,000 practitioners on the register.

We work with more than 50 professional associations across the sector which either require or recommend their members to be registered with CNHC. Some include categories of membership which fall below CNHC’s standards and so, of the people calling themselves practitioners, not all would meet the standards.

Of course as a voluntary register, practitioners do not have to sign up to CNHC and it takes time to raise awareness of a voluntary code among the public. People tend to assume that their practitioner is already registered with a reputable body and in a recent CNHC

survey we found that 70% of people we asked did not know that anyone could set up as a complementary therapist in the UK without any training, qualifications or insurance.

CNHC was set up to address this by providing a UK register of insured practitioners who have met national standards.

What is the CNHC vision for the future?

We plan for CNHC to grow and we continue to work hard to get the message out to the public. We are pleased to have this opportunity here in TalkBack.

The PSA is also publicising its AVR scheme among the public as well as with NHS commissioners, employers and others. AVR status has been acknowledged as providing additional assurance for standards of patient safety and service quality in the Any Qualified Provider (AQP) scheme in England.

Our vision for the future? That anyone looking for the complementary therapies we register knows to look for the CNHC quality mark in the same way that they might look for Gas Safe when fixing their boiler or ABTA when booking a holiday. n For further information or to find a CNHC registered practitioner visit www.cnhc.org.uk

Footnotes 1 2000, House of Lords Select Committee on Science & Technology Report, Complementary & Alternative Medicine 2 ibid

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10 Talkback research

Back pain and the menopause A

s with pregnancy, ageing is not a disease and can be navigated healthily without clinical symptoms. Despite the common myth, there is actually no convincing evidence that back pain increases with age once you account for lifestyle.

Healthy older people are at no greater risk of back pain than healthy younger people. So why might women aged 40-60 experience more back pain than women of other ages?

Given the title of this article, we can safely assume you’ve guessed the culprit. Indeed, the menopause is part of the puzzle, but it goes a little deeper than that. The menopause syndrome is experienced differently by different women. Around 15% of women suffer severe symptoms, but a similar figure will transition without any symptoms.

In 2001, researchers in America analysed the menopause symptoms of 15,000 women across five ethnic groups1. The analysis showed that different classes of symptoms were significantly more common among different ethnic groups. For example, Caucasian women reported significantly more stressinduced symptoms than other groups and African-American women reported more vasomotor symptoms (such as hot flushes and night sweats).

So how does this relate to back pain? To understand that we’ll have to consider what has been perhaps the most important finding in back pain research. Almost all of us (96%) will experience a headache at some point in our lives – it is, after all, the single most common painful ailment. Not far behind is back pain with a lifetime prevalence of 84%.

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What back pain has in common with headache is that 90% of cases are stress-induced.

In fact, the most consistently evidenced independent risk factor for back pain is acute psychological distress, which affects around a third of women during menopause.

“Stress-induced” means that the physical processes causing

power to cause painful muscle tension or activate pain nerves in the body without injury or defect, consider that the brain automatically breathes for you while you sleep, automatically raises your pulse rate in response to fear, and automatically increases blood flow through the face (blushing) in response to embarrassment.

If you are experiencing an acute episode of back pain, it’s important to understand that – like the common cold – it’s unlikely to be serious the pain (e.g. muscle tension) are themselves being caused by the brain (as part of a maladaptive stress response) rather than by any actual physical problem in the back.

However, while we seem to appreciate that most headaches are stress-induced and generally don’t visit our GP requesting a brain scan, the same is not true of back pain.

The general assumption is that back pain must be caused by a physical problem, such as a slipped disc, and people will commonly request an MRI scan. Studies have now made it quite clear that slipped discs, prolapses and other forms of spinal degeneration seen on MRI scans are very common in people with and without back pain, and are now considered a normal part of ageing-related wear and tear.

Even among spinal pain sufferers with spinal degeneration, the location and degree of MRI findings do not actually correlate to the location and severity of the pain. And if you have any doubt that the brain has the

So what can be done if you have back pain? If you’re experiencing an acute episode of back pain, it’s important to understand that – like the common cold – it’s unlikely to be serious and swift recovery is normal and natural. And just as we may use symptomatic relief for the common cold to make that natural recovery more comfortable, over-the-counter painkillers (such as ibuprofen, paracetamol or a combination) can be quite effective. These can be combined with the local application of heat or cold, depending on preference, to ease back pain while you stay active to promote recovery.

Bed rest is a big no-no as we now know it prolongs and can even prevent recovery. Many people also opt for manual therapies such as osteopathy or chiropractic which can effectively dissipate acute pain and aid recovery through joint and soft tissue manipulation.

Now, when it comes to preventing back pain and promoting health, it all starts with stress. According to the World Health Organisation,

stress and lifestyle are the big killers in modern industrialised countries. Psychological stress accounts for more physical pain than any other factor, so it’s vital that you learn how your subconscious mind responds to different triggers and pick up the tools that mitigate your risk of stress-induced symptoms.

Programmes such as CBT (cognitive behavioural therapy), MBSR (mindfulness-based stress reduction) and ISTDP (intensive short-term dynamic psychotherapy) have proven effective for stress-reduction and for resolving the physical symptoms of stress.

The second most important factor for health promotion relates to how you use your body. Sitting uncomfortably can become painfully uncomfortable, but contrary to popular belief, research shows that posture is not associated with back pain once you account for psychosocial factors.

So, if not posture, what are we recommending? Well, there’s nothing new about the prescription of exercise for health, but going for a brisk walk or even for a jog is not sufficient if you want to protect and build your health longterm. Subjecting your muscles to “progressive overload” by safely lifting heavier and heavier weights over time to build and strengthen the entire body confers profound health benefits (including reversing osteoporosis and improving memory and cognitive function) that cannot be reached through aerobic exercise. It’s a common myth that resistance training (lifting weights) is not for women and certainly not for older people. In fact, the many thousands of elderly women – many well into their 80s and

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It’s a common myth that resistance training is not for women

90s – who have participated in the hundreds of research studies at dozens of universities across the world over the last two decades, have conclusively proven quite the opposite (see p20-21, TalkBack, Spring 2013).

This kind of prescription may be shocking to many, but the breakthrough evidence speaks for itself: in 2011, researchers at the Buck Institute for Age Research in California performed genetic age marker profiling on the muscle tissue of a group of elderly men

and women (average age 71 years) and a group of 21 year olds. Within just six months of resistance training (twice per week), the genetic age markers of the elderly group had reversed to match the levels of 21 year olds2.

The final of the big three for health promotion and disease prevention is adequate nutrition. Here we’re talking about a diet that is adequate for repair, recovery and renewal. There’s more to healthy eating than getting your “5-a-day”. There are also many

dangerous misconceptions such as avoiding fat to avoid getting fat. Our bodies actually need dietary fat to make our hormones – a very low fat diet can cause tremendous health problems. We also tend to neglect protein and don’t eat enough for growth and repair.

In general, we either consume in excess or deficit rather than striking that adequate balance.

As a general direction, you can taper up your caloric intake to support the increasing frequency and intensity of your physical activity in your journey

towards a healthier, stronger and younger you.

References 1) Avis NE et al. “Is there a menopausal syndrome? Menopausal status and symptoms across racial/ethnic groups.”

Soc Sci Med. 2001 Feb;52(3):345-56.

PMID:11330770.

2) Melov S et al. “Resistance exercise reverses aging in human skeletal muscle.” PLoS One, 2007:465.

PMID:17520024.

Adapted from an article written by BackCare for The Menopause Exchange newsletter

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12 Talkback campaigns

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te my lif H E LP S !!

O T H IN G e.

THE PA I N TODAY

U N BELI IS EVand ABUK BackCare’s chairman Dr Brian Hammond takes the buzz wire The launch team: representatives from Pfizer LE.pain life and

am gru

challenge

lps. I've

no

charities

Website registers sufferers’ Pain in kneloud es, all n levels of pain ight, and clear taken

M

ore than five million people develop chronic pain in the UK every year. A third of them will never escape it and will live in pain for the rest of their lives. For many, this pain is highly disabling, destroying lives and livelihoods – a quarter will lose their jobs, three quarters will get divorced, half develop depression and one-in-10 attempt suicide.

A quarter of people with chronic pain have been accused of using pain as an excuse not to work. There is a feeling of isolation and loneliness as they realise many cannot understand what they’re going through. Half of those living with chronic pain say their pain is not adequately managed and around half have to wait more than a year before receiving a diagnosis or explanation.

There is a real need to equip people with the confidence

Talkback l autumn 2013

every p

ainkiller

I can

fin d, no relief.

I'm exh

austed

and

Pfizer in collaboration with several UK pain charities, including BackCare. It was

launched in January 2013 at an event on London’s South Bank that saw a flurry of media

allows chronic pain sufferers to to acknowledge and attention. share how they feel today by communicate their pain. People Since its launch, it’s had simply scoring their pain out of do not need to suffer in silence

more than 3,000 visitors across 10 and providing a description. and it can be tremendously the UK and there has been They use their own unique empowering they realise I haveonce

b e e significant positive feedback n to describe how the in cothe that many others are feeling nstanlanguage c h t r with many users reporting

o pain feels and affects them, same way.nThis guiding ic pwas ainthe

f o I

r that it is a valuable community a

so tired principle the creation9 ofyearand this is what makes itm pa inbehind s

. a

T n i s h d

e s w resource. o

ant to s bad I fe powerful. Examples are shown The Pain Exchange. lee2013, el so sonicthe next page. Every move aOn 19 November p. jThe ustPain waExchange n k d . I

nt to cu t u r n W

i s a BackCare’s Head of Research

i p ting for a in f rl up an The Pain Exchange website is a website (www.

and tabEducation dwas diecreated lets to kDr Adamul. . and funded thepainexchange.co.uk) that that by ick in so I can se Al-Kashi took part in a radio

e thoug h

t h e day with GP and media medic

d

ay.

Dr Roger Henderson to discuss the impact of chronic pain and raise awareness of The Pain Exchange website. Pfizer will soon be donating The Pain Exchange to BackCare who will take on the management and further development of this valuable community initiative.

The Pain Exchange was launched on London’s South Bank

just wa

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My pain aches all the time, no day is free of pain, some days campaigns are more 13 Talkback

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14 talkback research

Prevention is better than cure Part 4

Are you burning out?

“Prevention is better than cure”, or so the old adage goes. And it’s perhaps not surprising to find that when it comes to safeguarding our future health and preventing illness, a lot of what’s important for healthy backs is also beneficial for our overall health.

Burnout is traditionally considered to be a psychological term relating to long-term overwork that results in fatigue and withdrawal. In this episode, we’ll be exploring how burnout influences your health and what you can do if you are burning out.

The 12 phases of burnout The term burnout was coined by German-born American psychologist Herbert Freudenberger (1926-1999) in his 1974 book Burnout: The High Cost of High Achievement.

He defines burnout as “the extinction of motivation or incentive, especially where one’s devotion to a cause or relationship fails to produce the desired results’’.

Freudenberger and colleague Gail North went on to organise their observations of burnout in their patients and fellow staff members into 12 phases:

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1 Compulsion to prove oneself: Driven by ambitions or ideals. Desire to prove oneself turns to determination then compulsion.

2 Working harder: High personal expectations. Focus only on work.

Taking on more. Obsessed with doing everything alone.

3 Neglecting own needs: All time and energy devoted to work.

Friends and family, eating and sleeping perceived as obstacles to work.

4 Displacement of conflicts: Aware that something is not right, but cannot see the problem. This conflict brings the first physical symptoms.

5 Revision of values: Values now only include work and job. No time for family, friends or hobbies. All energy is consumed by work. Denial of basic physical needs. Emotional blunting.

6 Denial of emerging problems: Intolerance of social interaction.

May appear aggressive and sarcastic to others. Increasing problems blamed on time pressure, instead of on the ways they have changed.

7 Withdrawal: Social contact is minimal and soon turns into isolation.

Feelings of being without hope and direction. May use alcohol or drugs to provide release.

8 Obvious behavioural changes: People within one’s immediate social circles (e.g. co-workers, family and friends) cannot overlook the behavioural changes.

9 Depersonalisation: Losing sense of humanity. May no longer see value in self and others. Life becomes just a mechanical sequence.

10 Inner emptiness: Feelings of inner emptiness. Maladaptive coping behaviours may arise, such as binging or dependency on food, sex, alcohol or drugs.

11 Depression: Exhaustion, hopelessness and indifference. No future.

No meaning of life. Typical depression symptoms arise.

12 Burnout Syndrome: Physical and emotional breakdown requiring immediate medical attention. Few commit suicide but it may become viewed as a viable escape route.

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The three dimensions of burnout

Understanding how burnout can influence health has required a scientific way of measuring burnout. Perhaps the most studied measure of burnout is the Maslach Burnout Inventory (MBI), developed by psychologist Christina Maslach and colleagues in the 1970s, and which has since been used in more than 60 clinical trials.

The MBI is a self-report questionnaire.

Patients are asked to rate statements relating to three dimensions: emotional exhaustion, depersonalisation and personal accomplishment.

More common than you might think

Burnout affects personal health, but because it also affects how you relate to other people, a lot of the research has focused on burnout in occupations that involve a duty of care to patients or students. In brief, burnout is often very common among doctors, nurses and teachers.

Around 25-35% of schoolteachers in Europe test positive for burnout1. Studies of doctors and nurses in Europe and America typically reveal that between half and three quarters suffer burnout – 56% of hospital doctors in Baltimore2; 68% of gynaecologists in Barcelona3; and 75% of paediatricians in Boston4. This latter study in Boston found that a third of their paediatricians with burnout also had depression and, while burnout was not associated with medical errors, doctors with depression were six times more likely to give a child the wrong dose of medication or the wrong medication altogether.

Another study of more than 50,000 nurses from six countries linked burnout to a lower quality of hospital care5. What this tells us is that burnout is not only very common in occupations involving a duty of care, but is also linked to poorer performance with potentially disastrous consequences.

Burnout, illness and death

Clearly, burnout affects one’s ability to do one’s job, but how does it affect the health of sufferers themselves? Over the last decade, several studies have shown an association between burnout and ill health.

In 2003, researchers at Maastricht University measured burnout in more than 12,000 Dutch workers using the

Emotional exhaustion measures feelings of being emotionally overextended and exhausted by one’s work, for example: n “I feel used up at the end of the workday” n “I feel I’m working too hard” n “I feel fatigued when I get up” Depersonalisation measures an unfeeling and impersonal response toward recipients of one’s service, care treatment, or instruction, for example: n “I don’t really care what happens to some [clients/colleagues/students]” n “I feel I treat some [clients/colleagues/students] like impersonal objects” n “I’ve become more callous towards [clients/colleagues/students]” Personal accomplishment measures feelings of competence and successful achievement in one’s work, for example: n “I can easily understand how [clients/colleagues/students] feel” n “I feel exhilarated after working closely with [clients/colleagues/students]” n “I feel I’m positively influencing [clients/colleagues/students]”

Maslach Burnout Inventory. They found that people with burnout were twice as likely to develop gastroenteritis and those with gastroenteritis were more than three times as likely to test positive for burnout6.

In 2006, a study of more than 800 service sector workers showed that those with burnout took more than twice as many sick days a year than those with the lowest burnout scores on the Copenhagen Burnout Inventory7.

In 2009, a study of nearly 400 Japanese middle managers found that burnout (MBI assessed) was associated with risk factors for cardiovascular disease five years later.

Those who initially tested positive for burnout had significantly greater increases in waist circumference, body weight, and nearly three times the risk of high blood cholesterol8.

In the last couple of years, studies have also demonstrated an association between burnout and back pain. In 2012, a study of 58 hospital nurses in Egypt found that burnout is directly associated with back pain severity9. In 2013, a study of 348 hospital doctors in Saudi Arabia showed that burnout is directly associated with back pain incidence10.

But perhaps most alarming is the relationship between burnout and death.

In 1996, researchers in Finland measured burnout in 7,396 people. Ten years later, 199 of the original volunteers had died.

In workers aged under 45, burnout was statistically linked to a high all-cause mortality rate. The risk of dying during the 10-year study increased by 35% for each increase of 1-unit on the Maslach Burnout Inventory.11

Evidence-based treatments for burnout Mindfulness-based stress reduction

Mindfulness-based stress reduction (MBSR) is a behavioural medicine programme developed in 1979 by Professor Jon Kabat-Zinn at the University of Massachusetts Medical School. Mindfulness is a capacity of the mind that anyone can cultivate through ongoing practice.

Mindfulness brings awareness and choice to our otherwise automatic reactions to life, allowing us to respond in newly effective and creative ways.

Over the last 15 years, mindfulness-based interventions, such as MBSR, have been the subject of some 200 clinical trials. One of the largest areas of mindfulness research has been in psychiatric medicine, where it has been found to improve treatmentresistant major depression12, and prevent

relapse in patients with depression13, schizophrenia14 and drug addiction15.

Another popular area of investigation has been in cancer patients and cancer survivors. Mindfulness promotes immune system recovery after cancer treatment16 and reduces side-effects of breast cancer drugs17. It has also been found to reduce side-effects from anti-HIV medication18 and improve symptoms in not-yet-medicated HIV patients19.

The relationship between mindfulness and pain is rather interesting. While it does not appear any more effective than usual care at reducing pain scores20, it does improve patients’ perceived control over their pain.21 It also reduces hospital care costs in people with medically unexplained symptoms22, and 80-90% of back pain is classified as non-specific and thereby

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Prevention is better than cure: are you burn from p15 medically unexplained23 24. Intriguingly, mindfulness appears to separate pain from disability and suffering, such that physical disability and psychological suffering are reduced without dramatic reduction in the level of pain.

Mindfulness-based interventions are among the few effective, evidence-based treatments for burnout. In 2012, researchers at the University of Virginia enrolled 93 healthcare workers in an eight-week MBSR course with a seven-hour retreat. The course comprised 2.5 hour weekly classes including training in four types of formal mindfulness practices (‘body scan’, ‘mindful movement’, ‘walking meditation’ and ‘sitting meditation’), as well as discussion focusing on the application of mindfulness at work.

The course significantly reduced burnout

scores in before-after comparisons25.

Another study compared an MBSR course for nurses to a waiting list control (i.e. people taking the course were compared with people on a waiting list). The mindfulness training reduced two of the three subscales of the Maslach Burnout Inventory in nurses, and this change lasted as long as three months26. Variations between studies suggest that the duration, design and application of the MBSR programme may be critical to outcome. Indeed, a seven-week MBSR course failed to improve burnout in medical and psychology students 27.

Overall, the research suggests the fully-effective MBSR course significantly improves burnout and that these benefits are best sustained through sustained engagement.

References

sickness absence among human service workers: prospective findings from three year follow up of the PUMA study. Occup. Environ. Med. 63, 98–106 (2006).

8 Kitaoka-Higashiguchi K, et al. Burnout and risk factors for arteriosclerotic disease: follow-up study. J. Occup. Health 51, 123–131 (2009).

9 Sorour AS, El-Maksoud MMA. Relationship between musculoskeletal disorders, job demands, and burnout among emergency nurses. Adv. Emerg. Nurs. J. 34, 272–282 (2012).

10 Aldrees TM, Aleissa S, Zamakhshary M, Badri M, SadatAli M. Physician well-being: prevalence of burnout and associated risk factors in a tertiary hospital, Riyadh, Saudi Arabia. Ann. Saudi Med. 33, 451–456 (2013).

11 Ahola K, Väänänen A, Koskinen A, Kouvonen A, Shirom A. Burnout as a predictor of all-cause mortality among industrial employees: a 10-year prospective register-linkage study. J. Psychosom. Res. 69, 51–57 (2010).

12 Chiesa A, Mandelli L, Serretti A. Mindfulness-based cognitive therapy versus psycho-education for patients with major depression who did not achieve remission following antidepressant treatment: a preliminary analysis. J. Altern.

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Quattrin R, et al. Burnout in teachers: an Italian survey. Ann. Ig. Med. Prev. E Comunità 22, 311–318 (2010).

Sargent MC, Sotile W, Sotile MO, Rubash H, Barrack RL. Quality of life during orthopaedic training and academic practice. Part 1: orthopaedic surgery residents and faculty.

J. Bone Joint Surg. Am. 91, 2395–2405 (2009).

Castelo-Branco C, et al. Stress symptoms and burnout in obstetrics and gynaecology residents. BJOG An Int. J. Obstet. Gynaecol. 114, 94–98 (2007).

Fahrenkopf AM, et al. Rates of medication errors among depressed and burnt out residents: prospective cohort study.

BMJ 336, 488–491 (2008).

Poghosyan L, Clarke SP, Finlayson M, Aiken LH. Nurse burnout and quality of care: cross-national investigation in six countries. Res. Nurs. Health 33, 288–298 (2010).

Mohren DCL, et al. Common infections and the role of burnout in a Dutch working population. J. Psychosom. Res. 55, 201–208 (2003).

Borritz M, Rugulies R, Christensen KB, Villadsen E, Kristensen TS. Burnout as a predictor of self-reported

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The herbal adaptogen, Rhodiola rosea

Rhodiola rosea is a species of succulent plant native to the cold mountainous and coastal regions of Europe, the Arctic, and Central and Eastern Asia. Rhodiola is not a food plant and has no horticultural history as a crop, but ethnobotanical records document its prized position in Siberian, Mongolian, Chinese and Scandinavian folk medicines.

It has been known by many vernacular terms throughout these folk records but the few surviving common names include Arctic root, Golden root, and Rose root. In recent years, Rhodiola rosea has become popular among health consumers for its evidenced and purported health-giving properties. Rhodiola rosea is one of a handful of plants which fit the criteria for being an “adaptogen”, promoting nonspecific resistance to a wide range of potentially harmful stressors, including psychological, biological, chemical and physical. Effective stress reduction has enormous implications for health, as stress has been linked to many illnesses and even to death itself. In fact, over the last five years, longevity studies have revealed life extension properties of Rhodiola: extending

Complement. Med. N. Y. N 18, 756–760 (2012).

13 Kuyken W, et al. Mindfulness-based cognitive therapy to prevent relapse in recurrent depression. J. Consult. Clin.

Psychol. 76, 966–978 (2008).

14 Chien WT, Lee IYM. The mindfulness-based psychoeducation program for Chinese patients with schizophrenia. Psychiatr.

Serv. Wash. DC 64, 376–379 (2013).

15 Witkiewitz K, Bowen S. Depression, craving, and substance use following a randomized trial of mindfulness-based relapse prevention. J. Consult. Clin. Psychol. 78, 362–374 (2010).

16 Lengacher CA, et al. Lymphocyte recovery after breast cancer treatment and mindfulness-based stress reduction (MBSR) therapy. Biol. Res. Nurs. 15, 37–47 (2013).

17 Hoffman CJ, et al. Effectiveness of mindfulness-based stress reduction in mood, breast- and endocrine-related quality of life, and well-being in stage 0 to III breast cancer: a randomized, controlled trial. J. Clin. Oncol. 30, 1335–1342 (2012).

18 Duncan LG, et al. Mindfulness-based stress reduction for HIV treatment side effects: a randomized, wait-list controlled trial.

J. Pain Symptom Manage. 43, 161–171 (2012).

19 SeyedAlinaghi S, et al. Randomized controlled trial of

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ning out? the life span of fruit flies by 24%28 and nematode worms by up to 20%29. Such medicinal properties relate to a complex cocktail of chemical compounds found in the rhizome roots of the plant. Extracts of the root material are commercially available in capsule and tincture form, often standardised to contain certain percentages of certain active compounds.

In 2000, researchers in Armenia conducted a trial of a standardised Rhodiola extract (SHR-5) to assess the effect on night duty fatigue in 56 doctors.

They found a significant improvement in mental fatigue, associative thinking, shortterm memory, concentration and speed of audio-visual perception30. The same Armenian group conducted a subsequent trial of the SHR-5 extract with 91 patients suffering mild to moderate depression (aged 18-70). In this latter study, they demonstrated significant improvements in insomnia, emotional instability and somatisation (the tendency to express psychological stress as physical symptoms such as back pain) using a dose regimen of 340mg of the SHR-5 Rhodiola extract given either once or twice a day, for 42 days31.

A study of 161 Russian cadets (aged 19-21) in 2003 using the SHR-5 Rhodiola extract observed “pronounced anti-fatigue effect on capacity for mental work against a background of fatigue and stress”32.

In 2009, researchers at Uppsala University in Sweden published a study looking at the effect of Rhodiola SHR-5 extract on 60 patients (aged 20-55) suffering from stress-related “fatigue syndrome”, as designated by the Swedish National Board of Health33. Thirty patients received Rhodiola (576mg a day) for 28 days, while the other 30 patients received placebo pills for the same period. On day 1 and day 28 they measured mental health (SF-36), burnout

(Pines’ Burnout Scale), depression (MADRS), attention (CCPT II) and the salivary cortisol response to awakening (a stress hormone response which some studies have linked to burnout). Interestingly, there was a pronounced placebo effect in this study as patients receiving the inactive placebo pills showed significant improvements in scores for burnout, mental health and attention at day 28. However, the patients receiving the Rhodiola extract showed improvements in burnout and attention scores that went above and beyond the placebo effect to a statistically significant degree.

mindfulness-based stress reduction delivered to human immunodeficiency virus-positive patients in Iran: effects on CD4+ T lymphocyte count and medical and psychological symptoms. Psychosom. Med. 74, 620–627 (2012).

Plews-Ogan M, Owens JE, Goodman M, Wolfe P, Schorling J. A pilot study evaluating mindfulness-based stress reduction and massage for the management of chronic pain.

J. Gen. Intern. Med. 20, 1136–1138 (2005).

Brown CA, Jones AKP. Psychobiological correlates of improved mental health in patients with musculoskeletal pain after a mindfulness-based pain management program. Clin.

J. Pain 29, 233–244 (2013).

Van Ravesteijn H, et al. Mindfulness-based cognitive therapy for patients with medically unexplained symptoms: a costeffectiveness study. J. Psychosom. Res. 74, 197–205 (2013).

Kent P, Mjà sund HL, Petersen DH. Does targeting manual therapy and/or exercise improve patient outcomes in nonspecific low back pain? A systematic review. BMC Med. 8, 22 (2010).

Krismer M, van Tulder M. Low Back Pain Group of the Bone and Joint Health Strategies for Europe Project. Strategies for

prevention and management of musculoskeletal conditions.

Low back pain (non-specific). Best Pract. Res. Clin.

Rheumatol. 21, 77–91 (2007).

Goodman MJ, Schorling JB. A mindfulness course decreases burnout and improves well-being among healthcare providers. Int. J. Psychiatry Med. 43, 119–128 (2012).

Cohen-Katz J, et al. The effects of mindfulness-based stress reduction on nurse stress and burnout, Part II: A quantitative and qualitative study. Holist. Nurs. Pract. 19, 26–35 (2005).

De Vibe M, et al. Mindfulness training for stress management: a randomised controlled study of medical and psychology students. BMC Med. Educ. 13, 107 (2013).

Schriner SE. et al. Extension of Drosophila Lifespan by Rhodiola rosea through a mechanism independent from dietary restriction. PloS One 8, e63886 (2013).

Wiegant FAC, et al. Plant adaptogens increase lifespan and stress resistance in C. elegans. Biogerontology 10, 27–42 (2009).

Darbinyan V, et al. Rhodiola rosea in stress induced fatigue – a double blind cross-over study of a standardized extract SHR-5 with a repeated low-dose regimen on the

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Balance as a goal of medicine

Our response to stress involves the coordinated activity of several parts of the brain and several glands in the body. Stress itself begins with the interpretation of events as being stressful – this takes place in the amygdalae, two small structures deep within the brain that are involved in processing memories and emotional reactions.

From there, neurones carry signals to the hypothalamus which links the brain and nervous system to the hormone-secreting glands of the endocrine system via the pituitary gland. The pituitary gland is a pea-sized structure located at the base of the brain which releases a variety of hormones into the bloodstream, including adrenocorticotropic hormone (ACTH; which communicates stress to the body) and betaendorphin (which is involved in pain relief).

The adrenal glands, located at the top of the kidneys, respond to ACTH from the pituitary gland by releasing their own cocktail of hormones including cortisol and adrenaline which put the body into an emergency state, commonly referred to as the “fight or flight response”.

From an evolutionary perspective, we

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can understand that acute stress and the body’s emergency state is an important survival mechanism. Most people are now fortunate enough never to have to fight for their physical survival, but even in our modern democratic societies, the fight or flight response can be appropriate to “social survival” – for example, in situations requiring the need to assert your point of view and demonstrate your social value. Indeed, studies show that people with pituitary hormone deficiencies are less assertive, less sociable and more neurotic34.

So a functional stress response is vital, but when it becomes maladaptive and persistently active, the stress response is associated with the onset and perpetuation of many chronic illnesses. This means that an effective anti-stress remedy should not interfere with normal stress functioning by simply dulling or suppressing the mind and body, like a traditional sedative or tranquilizer, but rather should promote adaptation, balance and harmony.

We can better understand this notion of balance by considering how it compares with the conventional treatment. While conventional palliative pharmacotherapy would treat insomnia and fatigue as opposites, perhaps prescribing a sedative for one and stimulant for the other, mindfulness practices and herbal adaptogens are effective treatments for both conditions.

By targeting medicine at the level of the underlying imbalance and disharmony, rather than at the symptoms of imbalance, we can access forms of medicine that are paradoxically more gentle yet more powerful. Through today’s examples of burnout, mindfulness and adaptogenesis, we can harvest deep insights into a medicine beyond the popular.

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mental performance of healthy physicians during night duty.

Phytomedicine 7, 365–371 (2000).

Darbinyan V, et al. Clinical trial of Rhodiola rosea L. extract SHR-5 in the treatment of mild to moderate depression.

Nord. J. Psychiatry 61, 343–348 (2007).

Shevtsov VA, et al. A randomized trial of two different doses of a SHR-5 Rhodiola rosea extract versus placebo and control of capacity for mental work. Phytomedicine 10, 95–105 (2003).

Olsson EM, von Schéele B, Panossian AG. A randomised, double-blind, placebo-controlled, parallel-group study of the standardised extract shr-5 of the roots of Rhodiola rosea in the treatment of subjects with stress-related fatigue. Planta Med. 75, 105–112 (2009).

Stabler B, Turner JR, Girdler SS, Light KC, Underwood LE. Reactivity to stress and psychological adjustment in adults with pituitary insufficiency. Clin. Endocrinol. (Oxf.) 36, 467–473 (1992).

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backcare awareness week 2013 backcare

Research challenges everyday opinions This year’s awareness week was a tremendous success with BackCare’s authorship of new research, a far-reaching radio day and more than a dozen local events at clinics and carer support centres across the country.

As ever, the emphasis was two-fold. The first goal of BackCare Awareness Week is to educate people on the risk and impact of back pain in general. However, each year we also focus on a different at-risk group of people to raise awareness around their unique and unmet needs.

This year’s theme was unpaid and familial carers – those who look after a family member, friend or neighbour without remuneration or formal training – and this theme comprised the second goal of this year’s awareness week.

BackCare research survey

Science is forever evolving our knowledge and understanding. Knowledge, as they say, is power but out-of-date knowledge can be downright dangerous and more needs to be done to ensure the general public is up to date on medical matters.

Case-in-point, many people with non-specific back pain still seem to be routinely referred for an MRI scan despite the fact that numerous studies, some dating back nearly 20 years now, have long debunked the association between back pain and signs of spinal degeneration (such as slipped discs and prolapses). So, in September 2013, BackCare conducted a national survey to examine public perceptions of back pain. We asked two thousand men and women from England, Wales, Scotland and Northern Ireland about back pain.

The power of misinformation We first asked people to identify the leading cause of back pain. Perhaps unsurprisingly, around 70% of people believed that most back pain is caused by bad posture (e.g. in the office, car or bed) or by physical injuries (e.g. from lifting, falling or car accidents).

Clinical evidence tells us that the most consistent predictor of back pain is not physical factors such as posture or lifting

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but actually psychological stress.

Around 90% of back pain is classed as “non-specific” and does not relate to any damage, disease or dysfunction in the back itself. Only 6% of people correctly identified stress as the leading cause of back pain – interestingly, this belief was twice as common in adults under 25 years than in those over 55 years.

In 2001, Professor Sir Simon Wessely at King’s College London ran a study looking at the diagnoses given to 550 patients across seven medical specialities at two London hospitals. On average, more than half of patients (52%) were diagnosed with “medically unexplained symptoms” (i.e. symptoms cannot be explained by any physical damage, disease or dysfunction).

Patients were also extensively profiled to understand why some people develop medically unexplained symptoms – what they found was that believing your symptoms have a physical cause actually increases your risk and “patients who believed their illness to be the result of lifestyle factors were approximately 40% less likely to have medical unexplained symptoms”.

Keeping in mind that around 90% of back pain is “medically unexplained”, what this important study tells us is that beliefs built on misinformation are dangerous and would be expected to increase your risk of back pain. Our survey showed that 70% of people hold beliefs built on misinformation about causes of back pain.

The full impact of chronic back pain Chronic pain is defined as pain which persists for longer than physical injuries would reasonably be expected to heal (typically taken as three months). It is estimated that a third of adults in the UK and America suffer from chronic pain, and around one in 10 of us suffer highly disabling chronic back pain. This is very relevant for BackCare because back pain constitutes half of all chronic pain. Over the last two decades, we’ve learned a lot about the full impact of chronic pain on people’s lives, but through our survey we wanted to understand how much of that

information had reached public awareness. So, we asked our survey panel to review which of a series of statements about chronic pain were true or false. Here are eight such statements along with the percentage of people who believed they were true: ■ Chronic pain increases your risk of losing your job 25% ■ People with chronic pain are more likely to commit suicide 24% ■ Chronic pain increases your risk of psychiatric problems 20% ■ People with chronic pain are more likely to get divorced 17% ■ Chronic pain increases your risk of fatal heart attack 10% ■ Chronic pain can actually be detected by brain scan 8% ■ Chronic pain increases your risk of dying from cancer 5% ■ Chronic pain increases your risk of dying from a lung disease 1% In fact, these statements are all true. Half of all marriages in the UK end in divorce – this divorce rate rises to three quarters if one partner has chronic pain. A quarter of people with chronic pain will lose their job; one in five will consider suicide and one in 10 will attempt it. Only one in 10 people believed that chronic pain could increase your risk of heart attacks. Clinical evidence tells us that chronic pain sufferers have a 67% higher risk of fatal heart attack. If the pain is highly disabling, the risk is doubled.

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backcare awareness week 2013

In fact, people with highly disabling chronic pain have more than three times the risk of fatal lower respiratory diseases and more than four times the risk of fatal coronary heart disease.

Pain experience influences pain beliefs We have a lot of estimates of how many people have experienced back pain. Here, we wanted to understand how common different severities of pain were and how these experiences of pain might influence people’s beliefs about back pain. So, first, we asked people to rate their worst experience of back pain: ■ Never had back pain 7% ■ Noticeable but can be ignored 27% ■ Cannot do anything strenuous 29% ■ Struggle to focus and concentrate 14% ■ Limited ability to take care of self 17% ■ Cannot cope. Completely disabled 6% Our survey showed that 93% of UK adults report having experienced back pain. This is a bit higher than the 84% statistic commonly quoted – there is evidence that back pain is becoming more prevalent, but it’s important to also note that our panel of 2,007 UK adults was answering an online survey so it doesn’t entirely represent people who don’t use Radio Station BBC Cambridge BBC Northampton BBC Kent BBC Leicester BBC Gloucestershire BBC Scotland BBC Solent BBC Lancashire BBC Jersey BBC Ireland (Foyle) BBC Sheffield BBC Hereford & Worcester BBC Wiltshire BBC Merseyside All FM U105 Sunrise radio Gem 106 Real Radio Yorkshire Magic 1161 96.4 Eagle Radio Mix 96 96.4 The Wave 107.6 Juice Liverpool

computer technology who may well experience less back pain for reasons we don’t fully appreciate.

However, whichever way you look at it, back pain is extremely common, but our survey suggests most people haven’t experienced really bad back pain. Perhaps

Area Covered Listener Reach Cambridge Northampton Kent Leicester Gloucestershire Scotland Southampton Lancashire Jersey Ireland Sheffield Hereford & Worcester Wiltshire (South Central) Liverpool Manchester Ireland Yorkshire East Midlands Yorkshire Hull Surrey Buckinghamshire Wales Liverpool

109,000 111,000 223,000 162,000 108,000 948,000 271,000 226,000 30,000 543,000 255,000 236,000 112,000 357,000 14,000 196,000 227,000 404,000 396,000 59,000 145,000 39,000 188,000 221,000

because mild back pain is so common, there is a public misunderstanding of just how disabling back pain can be.

Nonetheless, a quarter of UK adults have had back pain that made it hard to perform basic self-care tasks (cook, eat, wash, dress). And more than one in 20 have been completely disabled by back pain, unable to cope or function at all.

We also found that the experience of being completely disabled by back pain correlated to certain beliefs about back pain. Compared to people who have never had back pain, those who have been completely disabled by back pain are twice as likely to believe that pain could lead to job loss (17% versus 32%), mental health problems (13% versus 28%), and suicide (16% versus 33%).

Radio day reaches millions

Whenever we conduct medical research that has the potential to evolve medical policy and practice, it’s vitally important to broadcast it as widely as possible.

So, with our survey results in hand, we organised a radio day at the start of the awareness week. Our startling figures attracted significant attention and the story was bought up by the General News Service, an organisation that supplies news to the BBC. From a studio in central London, BackCare’s Head of Research continued on p20

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backcare awareness week 2013 backcare

and Education was interviewed by 14 BBC radio stations, including two nationals, as well as a further 10 commercial stations to reach an estimated 5,580,000 listeners.

It’s important we learn from each awareness week. What seemed to make this report so newsworthy to radio editors was that it challenged their own beliefs.

As we highlighted, 70% of UK adults believe that physical factors (e.g. posture or injury) represent the leading cause of back pain. This belief certainly seemed to be held by the majority of radio presenters themselves.

Sadly, when the gap between research and public perception grows too large – as has occurred in medicine – scientific evidence is often perceived as laughable, or even offensive, and met with significant resistance.

However, once we grasp that these health beliefs profoundly impact people’s health status (including whether or not you’ll succumb to illness and whether or not you’ll recover), the work of raising awareness becomes all the more vitally important.

Caregiver Strain Index Sleep is disturbed (e.g. because ____ is in and out of bed or wanders around at night) It is inconvenient (e.g. because helping takes so much time or it’s a long drive over to help) It is a physical strain (e.g. because of lifting in and out of a chair; effort or concentration is required) It is confining (e.g. helping restricts free time or cannot go visiting) There have been family adjustments (e.g. because helping has disrupted routine; there has been no privacy) There have been other demands on my time (e.g. from other family members) There have been emotional adjustments (e.g. because of severe arguments) Some behaviour is upsetting (e.g. because of incontinence; ____ has trouble remembering things; or ____ accuses people of taking things) It is upsetting to find ____ has changed so much from his/her former self (e.g. he/she is a different person than he/she used to be) There have been work adjustments (e.g. because of having to take time off) It is a financial strain Feeling completely overwhelmed (e.g. because of worry about ____; concerns about how you will manage)

Caring for Carers

In keeping with BackCare’s tradition, each awareness week gives us the opportunity to highlight a specific at-risk group of people.

This year’s theme was carers who are exposed to very real health risks through their role and responsibilities. While the role of carer can provide great satisfaction, stress levels among caregivers are high – between a third and a half of carers experience significant psychological distress.

Most at risk are familial caregivers who look after a spouse, parent, child or other close family member. Those who receive care are necessarily dependent upon their caregiver.

This inevitably changes the underlying emotional relationship, often raising difficult personal issues about duty and responsibility, adequacy and guilt [from Assessment of carers’ psychological needs

by Jan Oyebode, 2003].

BackCare created an educational pack for carers during the awareness week which included strategies and resources to empower effective prevention.

Here, we feature some excerpts from the pack for our general readership as part of our report on the campaign and awareness week.

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Caregiver Strain Index The Caregiver Strain Index is one of several validated measures used to assess the impact of being a caregiver. Take a moment to tick the boxes that apply to you.

A score of 7 or higher indicates that you have a high level of stress and your physical and mental health is at risk.

Hopkins Symptoms Check List (somatisation sub-scale) The Hopkins Symptoms Check List is a validated clinical tool for assessing

non-specific symptoms in adults.

If you are an adult carer, take a moment to tick the symptoms that you have experienced recently or regularly. If you score more than 7 on the Caregiver Strain Index it indicates you are at risk of developing physical and psychological health problems.

If you have also recently or regularly been experiencing symptoms described on either of the somatisation tests, it indicates you are expressing psychological stress in

Hopkins Symptoms Check List (somatisation sub-scale) Feeling low in energy or slowed down Pain in the lower back Headaches Soreness of muscles Hot or cold spells Difficulty in breathing Numbness or tingling in parts of the body Faintness or dizziness Pains in the heart or chest Heavy feeling in arms or legs Weakness in parts of the body A lump in the throat

talkback campaign 21

backcare awareness week 2013

the form of physical symptoms and are at risk of symptom related disability.

Factors correlating to high caregiver stress A number of factors have been found to be associated with the higher levels of caregiver stress [from Assessment of carers’ psychological needs by Jan Oyebode, 2003].

By learning to spot these factors and choosing to address them openly without denial or blame, caregivers and care recipients can consciously work together towards remedying the situation.

■ Disturbed behaviour in the care recipient ■ Withdrawal in the care recipient ■ Being a wife rather than a husband ■ Being a daughter rather than a spouse ■ Having conflicting roles and responsibilities ■ Having no support from a partner ■ Having no social support ■ Having a narrow range of coping strategies ■ Not using active, problem-solving coping strategies ■ Rating the current relationship as poor ■ Reporting no satisfactions from caring.

Most helpful carer strategies The nine most popular strategies, found to be very helpful by more than 50% of carers [from Understanding family care by Michael Nolan et al, 1996] are: ■ Realising the person you care for is not to blame for his or her position ■ Taking life “one day at a time” ■ Finding out as much as you can about the problem ■ Keeping a little free time for yourself ■ Realising that there is always someone worse off than yourself ■ Realising no-one is to blame for things ■ Keeping one step ahead of things by planning in advance ■ Getting as much help as you can from professional service providers ■ Talking over your problems with someone you can trust.

Written Emotional Disclosure Written Emotional Disclosure (WED) – also

known as expressive writing or therapeutic journaling – refers to a variety of techniques designed to diffuse subconscious emotional burden through writing. Several studies have trialled writing techniques for reducing psychological and physical symptoms.

WED improves mental health scores in chronically stressed caregivers and significantly reduces scores on the Hopkins

Symptoms Check List. It has also been shown to reduce the severity of irritable bowel syndrome (a stress-induced disorder characterised by stomach cramps, diarrhoea and constipation).

The evidence suggests that people benefit from guidance in both the content and manner of writing. People who write continued on p22

It is estimated that a third of adults in the UK and America suffer from chronic pain, and around one in 10 of us suffer highly disabling chronic back. This is very relevant for BackCare because back pain constitutes half of all chronic pain Talkback l autumn 2013

22 talkback campaign backcare awareness week 2013

chronologically and include optimistic future-facing language as well as reflective language (such as “I realise...”) achieved the most significant results.

The “unsent letter” is a popular writing format where you write with complete and raw honesty to a person with whom you share an emotionally charged relationship (perhaps the person you care for). Acute emotional upheaval should be expected, followed by a reduction in symptoms thereafter.

Local events

The carers’ theme proved very popular this year and we had several inquiries from supporters who needed resources to help run local events in their own communities.

The Putney Clinic held a free advice day with talks and demonstrations We distributed campaign supporter packs to 15 health clinics and carer support centres – many of whom reported back on

the successes of their local events. BackCare would like to commend and thank all of those who opted to support the campaign and awareness week in this way.

Beryl Kelsey and fellow members from the BackCare Hull and East Riding branch created displays in their library and carer centre during BackCare Awareness Week and aboard the carers’ bus

during Carers Rights Day in November.

GP and patient liaison Janette Fordyce and colleagues from Nuffield Health Tees created a BackCare awareness stand at the Cleveland Centre shopping mall in Middlesbrough. Osteopath Clive Lathey and colleagues from the Putney Clinic in London held a free advice day with talks and demonstrations.

The BackCare awareness stand at the Cleveland Centre in Middlesbrough

Talkback l autumn 2013

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Why Back Pain?

There is a disease spreading across the UK, claiming 7,000 new victims every day. It increases your risk of fatal heart attack and terminal cancer. It causes structural changes to the brain and increases your risk of suicide. It’s also resistant to conventional NHS treatments.

Sounds like a horror movie, right? Actually, we’re talking about highly disabling chronic back pain, which now affects around 1-in-20 people and millions more every year.

Because back pain is so common, most people have no idea how serious it can be.

Yes, most back pain is not serious and goes away by itself just like headaches and the common cold. But for hundreds of millions of people worldwide, the pain becomes chronic and never goes away. For many it is torture, all day, every day, forever.

Not only can back pain destroy lives, but it also costs huge amounts of money in NHS treatments, disability benefits and sickness absence – more than £50 million a day. In fact, the amount of money the UK spends on back pain in just one year would solve the entire water crisis in Africa where 4,000 children die each day from contaminated water. Makes you think, doesn’t it?

Why BackCare?

BackCare is the UK’s national back pain charity. Our mission is to turn the tide on back pain through our research, education and outreach initiatives. We are a unique charity and no one else is doing the same work.

Just by reading and sharing this magazine, you are helping to support our work – thank you.

Why Not Donate?

Back pain is a major global health problem. By donating to BackCare you are helping a very worthy cause. We are very grateful for all donations and people can donate their time, effort or money in many different ways – whether that’s volunteering your skills, organising a fundraiser, running the marathon or simply popping a cheque in the post.

Why not get in touch to find out how you can get involved?

Call us today on 0208 8977 5475 or email yourstory@backcare.org.uk

www.

The Charity for Back and Neck Pain

.org.uk