TalkBack, spring | 2021 (BackCare)

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

SPRING n 2021

It’s never too late to take action on your bone health

FREE TO MEMBERS

also in this issue: Special focus Chronic back pain: an overlooked symptom of MS Practitioner Treating a herniated disc without resorting to surgery www.backcare.org.uk

Management New national NHS programme to drive lifelong MSK health


2 TALKBACK NEWS

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Lifting the lid on chronic pain EAMONN Holmes’ recent revelations about his mystery chronic pain inspired a breakfast show “pain clinic” phone-in as well as attracting widespread attention in the national press and across social media1. The broadcaster explained how prolonged and severe pain had caused him many sleepless nights and resulted in a visit to a hospital for an MRI scan (a dislocated pelvis later being identified as the source of his problem). Sharing his experiences with viewers – and his social media following – Eamonn called attention to a complex and debilitating problem which can blight and destroy lives. Medical experts taking part in the segment looked at the life-limiting impact of persistent pain and the oftenfrightening symptoms that can accompany it, and suggested ways of achieving better outcomes. Daytime television has extraordinary influence when it comes to raising awareness on important health issues, although the prevalence of chronic pain is reason enough for GPs and other health professionals to persevere with patients to help lessen it. The assessment and development of care and support plans for all types of chronic pain is covered in a new NICE guideline2, which can be used alongside its standing guidance on many related conditions including headaches, lower back pain and sciatica. It recommends that a “person-centred assessment” be adopted to identify factors contributing to the pain and how the pain affects the person’s life. There are two types of chronic pain. If there’s a known cause, this is defined as chronic secondary pain, whereas if there’s

no clear underlying cause – or the pain is out of proportion to the injury or disease – this is called chronic primary pain. Individuals can present with both and it is not always easy to distinguish between the two, making it all the more important to understand the disease mechanisms and ensure that patients are offered the right treatment and support to help them manage their condition – which may include alternative, safer and more effective options. Whatever the type, an individual’s chronic pain is unique to them, not least in how it affects their life, including their work and leisure time, relationships with family and friends, and sleep. The management of chronic pain is central to much of BackCare’s work. In this edition of TalkBack, we examine how chronic back pain can be a frequently overlooked symptom of multiple sclerosis and explore the growing interest in cannabis medicines and their use in treating back and spinal pain.

Richard Sutton Editor

Contents

Strategy on women’s health – a call for evidence 5

Preserving wellbeing for the chronically ill 10

Treating neck pain after a skiing accident 14

LETTERS TO THE EDITOR:

richard.sutton@backcare.org.uk

Cover image: Sports England / This Girl Can

1) This Morning, ITV, 5 April 2021 2) Chronic pain (primary and secondary) in over 16s: assessment of all chronic pain and management of chronic primary pain

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 Executive Chair. 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

BackCare BackCare, Monkey Puzzle House, 69-71 Windmill Road, Sunbury-on-Thames TW16 7DT Tel: +44 (0)20 8977 5474 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.

Gold standard for moving and handling 22

MSK technique helps where and how to treat 25 TALKBACK l SPRING 2021


4 TALKBACK NEWS

ONE in three 18-24 year-olds have experienced new symptoms of back, neck or shoulder pain since March 2020 and 80% of this group are experiencing them every week, according to new research investigating the impact of long-term lockdown restrictions. The study, conducted by OnePoll on behalf of the British Chiropractic Association, revealed that young people have noticed the biggest impact to their physical wellbeing in this period, experiencing more symptoms of back pain than over-55s. Findings revealed that only 12% of 18-24 year-olds had sought support from their GP, and 7% had consulted a chiropractor. As many as 40% of young people also reported experiencing poor sleep quality, again worse than any other age group. Catherine Quinn, president of the BCA, said: “The results showed that all ages have been impacted, with routines like exercise being unanimously the hardest to stick to. We were surprised to find that 18-24 year-olds have been more impacted than any other age group, particularly in areas such as frequency of back pain,

Image: yanalya/freepik

Young people report the biggest impact on wellbeing in lockdown

exercise and sleep quality. Traditionally, back strain or injury most commonly occurs through wear and tear as we age,

or injury. What this data suggests, is that there’s been a sharp rise in the prevalence of back pain among younger people.”

£11m funding for healthy ageing research projects

Image: pressfoto/freepik

SEVEN research projects designed to support the government’s healthy ageing agenda will share £10.7 million in funding provided by UK Research and Innovation. The projects will run for 36 months and will work with people with lived experience and with business and industry partners to deliver the evidence needed to develop better products and services for us all as we age.

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These include identifying scalable and sustainable design improvements to homes that provide support for healthy cognitive ageing, allowing people to continue living in their homes for longer, to be more active, independent and socially connected. Further schemes include supporting over-50s to remain in work for longer by creating commercially viable products to assist the less visible aspects of older workers’ health and wellbeing, including menopause and dementia, financial health/wellbeing, and working carers. Another area to be addressed is the design, delivery and evaluation of digital resources to facilitate structured activity programmes for “health connectivity” in older age. Professor Alison Park, from the Economic and Social Research Council, which runs the programme, said: “The projects will provide an evidence base and timely insights about internal and external environments of relevance to ageing – for example, people’s homes and workplaces, and their urban and natural settings. They will also shed light on how social and digital connectivity can support physical and mental wellbeing through arts and cultural participation.”


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Rehab should be first option for pelvic floor disorders

committed to multidisciplinary maternity teams that include physiotherapists who can advise women after childbirth on strengthening pelvic floor muscles, through exercise. Rachel Newton added: “This level of support needs to be available to women of all ages with pelvic health issues and women should be referred for pelvic rehabilitation before surgical options are considered.” The deadline to submit evidence for the Women’s Health Strategy is 31 May.

Advice function set up to improve efficiency of NHS e-Referral Service will only be able to convert the advice and guidance conversation into a referral with the agreement of the referrer, where both agree it is in the best interests of the patient to do so. Image: pressfoto/freepik

NHS Digital has improved the NHS e-Referral Service (e-RS), to make referring smoother and easier. Provider clinicians can now turn an advice conversation directly into a referral, making it easier and quicker for busy clinicians to use the e-RS. Further changes will also allow the advice and guidance function to be integrated into provider systems so that conversations can be directly embedded into the patient’s medical record and clinicians do not have to switch between systems to seek advice from each other. Martin O’Keeffe, senior clinical lead from NHS Digital, said: “By making it easier for primary and secondary care clinicians to talk to each other, we know that GPs can get the advice they need at their fingertips while hospital consultants can have greater confidence that a referral is appropriate before a patient is referred to them.” Consultants and other provider clinicians

aims to smash record

LACE UP your running shoes and take part in something iconic. While 50,000 people will be running the Virgin Money London Marathon 2021 in London, another 50,000 people will have the opportunity to run the same marathon virtually over the course of 24 hours. From midnight on 2 October until 23:59:59 on 3 October you will be able to take part in one of the World’s greatest marathons, from wherever you are on the planet – and attempt to smash a Guinness World Record for the most runners participating in a remote event. This year we have 15 virtual, Virgin Money London Marathon places available and we hope our supporters will run for BackCare (or maybe you know a friend or relative who can). All virtual runners will receive their running numbers before the event as well as their coveted official finisher medal – and if the Guinness World Record is broken you can also claim your Official World Record certificate. Registration is £50 (+vat) and all we ask is that you raise as much money as you can to help us to help people living with back pain.

Contact details: events@ backcare.org.uk

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Image: katemangostar/freepik

A NEW women’s health strategy is examining ways to tackle health inequalities. The government is welcoming written submissions from individuals and organisations who have expertise in the area. Despite living longer than men, women spend a greater proportion of their lives in ill health and disability. Secretary of State for Health and Social Care Matt Hancock said the “male by default” problem of the past must be put right. “It can lead to poorer advice and diagnosis and, as a result, worse outcomes. Symptoms can often differ between men and women, and studies show some conditions, like coronary blockages, are more likely to be misdiagnosed among women than men.” The spotlight on women’s health has been welcomed by healthcare professionals. Rachel Newton, head of policy at the Chartered Society of Physiotherapy, said: “Women tend to have poorer access to rehabilitation services to prevent deterioration or help manage a whole range of long-term health conditions.” A key area where action is needed is in pelvic rehabilitation. The NHS Long Term Plan is

Image: katemangostar/freepik

New strategy on women’s health Virtual marathon – a call for evidence


6 TALKBACK PRACTITIONER

Treating a herniated disc –

Image: freepik

“Herniated disc” is not a phrase we tend to learn about in biology classes at school. Patients usually come across it for the first time from a therapist or doctor, just after they have found themselves with excruciating pain in their neck, back or legs, wondering what on earth they have done to themselves. STEPHEN HAYNES reports.

OUR spines are like a stack of cotton reels, with sponge-like cushions between them surrounded by soft tissues. The cotton reels are the bones and the cushions are the discs. When the centre or nucleus of a disc pushes out and even passes through the wall of the disc, this is what we refer to as a herniated disc. The good news is that the majority of herniated discs can be treated without surgery using manual therapy and exercise or with IDD Therapy disc treatment. It is only a small percentage of cases which go on to have surgery. This article helps to explain what causes a herniated disc and how the non-surgical treatments aim to resolve this debilitating condition.

Healthy discs before herniation A spinal disc or “intervertebral disc” sits

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between the bones of our spines. In the spinal column, each bone (vertebra) is a solid structure. In order to bend our spines and cushion the vertebrae which are stacked on top of each other, the discs act as shock absorbers sandwiched between the vertebrae. The discs are very strong, slightly spongy and provide cushioning. They consist of an outer wall made of collagen and the centre of the disc is made of a toothpaste like substance, called the nucleus pulposus. At birth, the nucleus is made of 80% water and this percentage reduces as we age. When a disc is healthy and hydrated it is bouncy like a well-inflated bicycle tyre, this is called hydrostatic pressure. The most important thing we can do to look after our discs is to move, have good posture and to drink plenty of water.

Movement, posture and hydration The reason movement and good posture are so important is because discs help to support the pressure of our body. If we don’t move, the constant pressure pushes the nucleus of the disc against the outer wall and, over time, weakens it. The discs absorb water from their surroundings and if they are under constant pressure (compression) they cannot do so. Without water the discs lose some of their hydrostatic pressure and shock-absorbing properties. Additionally, the walls of the disc can dry out and weaken, making them less able to keep the nucleus inside. We talk about posture with our patients. Sitting and slouching squashes the life out of our discs. This is because if we slouch we put a lot of pressure on the discs at the base of the spine.


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without resorting to surgery The majority of herniated discs can be treated without surgery using manual therapy and exercise or with IDD Therapy disc treatment.

Pressure can also be exerted on the body when the surrounding muscles are weak, meaning there is less support for the discs, and they are squashed even more. The muscles in our back and our “core” muscles provide essential support to keep the spine supported and strong, which takes excess pressure off the discs. We are recommended to drink two litres of water a day. Our discs are made of collagen, the same material as in our skin. We moisturise our skin to keep it from drying it out. Water in the body is essential for the collagen in our discs and without enough water, the disc walls will dry out and weaken.

When a disc herniates At any given time, we may have discs bulging out of shape. When the nucleus of a disc pushes out and even passes

through the walls of the disc, this is called a herniated disc or disc herniation. Pain can strike immediately. The spinal column houses the spinal cord and, at each level of the spine, nerves branch off from the spinal cord. The discs separate the vertebrae and allow space between them for these nerves to travel to the different parts of our body. If the disc herniates, the nucleus can press against one of the nerves and this pressure can cause pain. Additionally, the material of the nucleus causes a chemical irritation to the nerve and pain. When there is an injury to the disc, the body has a natural inflammatory response to heal an injury. Inflammation is a good thing, but, if pain persists, the inflammation can be a source of pain in itself. This is why we often take anti-inflammatories to dampen down the inflammation.

For discs in the neck, this can lead to shooting pains in the arms. In the lower back, it can cause pain in the buttocks or legs as pressure is put on the sciatic nerve, “sciatica”. The lower back has five discs and, depending on which disc has herniated, the pain is felt in different parts of the leg or buttocks as different nerves control different parts of our lower limbs. The body guards itself when the disc herniates. To stop further injury, the body goes into spasm. This is where the muscles contract rigidly to stop any further movement which may risk damage, and this causes intense pain in itself. The herniation can be caused by an injury such as falling or a collision, where the impact pushes the nucleus violently against the disc wall causing it to rupture (herniated). Or more commonly, where continued on p8 >

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8 TALKBACK PRACTITIONER

How to treat a herniated disc to relieve pain and create a platform for long-term healing. IDD Therapy is suitable for most patients with an unresolved herniated disc. The exceptions being if people are pregnant, have metal implants in their spine or they have severe osteoporosis. If a patient has severe weakness in their legs or the herniated disc is causing incontinence, then we would refer them immediately to a consultant.

< from p7

a disc wall has been weakened over time, a twisting movement, poor bending posture, or improper lifting can force the nucleus against the disc wall which is unable to contain it. Herniation results.

How to treat a herniated disc The good news is that the body will repair itself, provided the conditions are right and the injury is not too severe. However, if the pain persists, the spinal segment is not moving and over time it can become stiff and immobile and prevent the healing mechanism from working normally.

Manual therapy and exercise Manual therapists work with patients in a number of ways. When someone presents with a herniated disc, we look at the overall function of the body. We can use stretching techniques to ease the muscle spasm and then we use our hands to move the joints, to mobilise them. This mobilisation is important to free the movement and allow the body’s natural healing mechanisms to operate. A herniated disc is not purely about the spine. As an osteopath, I look at the hips and the whole body. If one part of the body is not moving properly, this can mean that certain movements and thus additional forces pass through the back, eg if the hips are not moving, a twisting motion which would normally be a combination of hip and lower back movement can pass primarily through the back. That puts excessive forces on the discs, and they can herniate. So we look at those

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Life after a herniated disc Image: kjpargeter/freepik

If the disc herniates, the nucleus can press against one of the nerves and this pressure can cause pain imbalances and work on them. Once we get movement back in the spine and start to address structural imbalances, simple exercises to strengthen the muscles will help to support the spine and ease pressure on the disc.

IDD Therapy disc treatment Disc herniation usually occurs at a specific level. The two discs at the base of the spine, called L5/S1 and L4/L5 are the most common to suffer herniation. The spinal segments are extremely strong and if they become stiff over a long period of time, it can be difficult to take pressure off the disc and get the segment moving again. IDD Therapy is a mechanical tool which allows us to decompress and mobilise targeted spinal segments. Patients are connected to the Accu SPINA machine with ergonomic harnesses. Then, using computer controlled pulling forces, IDD Therapy directs a pulling force to a targeted level to gently

open the space between two vertebrae and to relieve pressure on the disc and nerves. At the same time, the system gently oscillates the forces, meaning the soft tissues are both stretched and mobilised. The combination of decompression and mobilisations helps to take pressure off the disc and restore mobility. The treatment forces applied are progressively increased as the body adapts. IDD Therapy is combined with manual therapy and exercise and patients have a course of treatments over a six-week period, the aim being

If weakness and a lack of movement contributed to the disc herniation, certain lifestyle changes will make a big impact on preventing a recurrence of the problem. Gentle activity like walking helps, or specific exercise classes to stay flexible and strong, such as Pilates may benefit. Of course, we want people to be more aware of their posture and hydration. Most people fully recover from a herniated disc. The goal of registered practitioners is to help people out of pain and onto a path of long-term wellbeing. l Stephen Haynes is an

Osteopath and IDD Therapy provider, and Clinical Director of Active Therapy Clinic in Cirencester, Gloucestershire.

Surgery is a last resort Surgery is a last resort to treat a herniated disc. When the pain is so severe and unresolved, or if the nerve pain is causing weakness in the leg, then surgery can be carried out to remove the part of the disc pushing on the nerve. Surgery can relieve leg pain. However, it is not given routinely because there are risks and it does not address the underlying causes of the compression, immobility in the spine and weakness. Hence it is so important to have full rehab when a patient undergoes surgery for a herniated disc. http://iddtherapy.co.uk/


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Image: bedneyimages/freepik

Growth in NHS activity

Redefining integrated MSK delivery and crossboundary working

NHS activity has grown every year since records began (at an average of 3.3% a year). Over the last nine years (between 2009/10 and 2018/19), the number of attendances in A&E increased by 4.3 million; the number of GP appointments have risen from 222 million in 1995 to 308 million in 2018/19; and outpatient attendances have increased by almost 36 million since 2009/10. www.gov.uk/government/ publications http://arma.uk.net

New national NHS programme to drive life-long MSK battle A new programme from NHS England, which aims to deliver evidence-informed, personalised, high-quality integrated healthcare, is expected to increase the resource to support MSK service delivery. The initiative, part of the Pathways for Better Health Programme, covers the breadth of MSK including orthopaedics, rheumatology and pain. The programme has 10 workstreams, each led by a relevant clinical specialist: diagnostics; orthopaedics; rheumatology; primary and community MSK provision; spinal services; falls, fragility fractures and osteoporosis; data, validation and coding; communications and developing MSK networks; supporting those with long-term MSK conditions; outpatients. The primary and community workstream is expected to be vital to the success of the programme overall. The other workstreams all depend on effective support in primary and community services, and having all the pieces of work in one programme will enable co-ordination and help break down some of the boundaries in the NHS.

NHS reform The delivery of this programme will happen

There’s help on the way for MSK sufferers, spanning primary, secondary and community services. as the NHS starts thinking about new structures in response to the NHS White Paper, Integration and Innovation: Working together to improve health and social care for all, published in February. This sets out proposals for changes in legislation with the aim of enabling integration within the NHS in England and between the NHS, local government and other health system partners. Every part of England will be covered by

a statutory integrated care system (ICS). These will be made up of an ICS NHS body and a separate ICS Health and Care Partnership, bringing together the NHS, local government and partners. The ICS NHS body will be responsible for the day-to-day running of the ICS, while the ICS Health and Care Partnership will bring together systems to support integration and develop a plan to address the systems’ health, public health, and social care needs.

Do you live with chronic pain? Newcastle University is looking into connections between adult relationship styles, thoughts about pain and the impact on everyday life. If you are over 18 and live with chronic pain (lasting three months or more), please consider taking part in this research project. Claire Borthwick, primary researcher.

Email: C.Borthwick2@newcastle.ac.uk http://nclpsych.eu.qualtrics.com/jfe/ form/SV_cwpHJuAcAbifzpA

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10 TALKBACK COVID UPDATE

Aiding wellbeing among people with Chronic pain populations can be disproportionately impacted by public health restrictions during a pandemic. Consequently, it is important to maintain access to essential non-urgent support services during periods of lockdown in order to preserve wellbeing in this population, a new study recommends. ZOË ZAMBELLI reports.

mental health. The pandemic brings risk and burden to chronic pain populations regarding disease management, as well as the potential to impact social and health behaviours. Evidence also suggests that socioeconomic status (SES) may influence self-management outcomes as those with low SES may have access to fewer resources than those with high SES. Additionally, access to healthcare greatly impacts an individual’s health journey as those with chronic pain rely on a combination of assessments, diagnostics, and interventions, involving frequent interaction with the health system. The objective of the study was to explore changes in wellbeing outcomes as related to sleep, anxiety and depression within a community sample of adults living with chronic pain between the start of the Covid-19 outbreak, pre-lockdown and during a period of lockdown in the UK. Respondents’ chronic pain conditions were grouped into seven types, including chronic widespread pain (eg fibromyalgia; 34%), musculoskeletal (eg osteoarthritis; 37%), headache (eg chronic migraine; 10%), visceral (eg pelvic pain; 3%), neuropathic (eg trigeminal neuralgia; 15%) and other (1%). Nearly all participants reported co-existing physical health conditions (95%), and more than half reported a mental health condition (55%). The results demonstrated that individuals who felt less dependent on others had fewer sleep problems, anxiety, and depressive symptoms compared to those who reported feeling more dependent on others for practical and emotional support during this time. Chronic pain poses a threat to individuals’ perceived independence, and research shows the importance of retaining independence in order to carry out activities of daily living and social interactions.

AMONG chronic pain populations, the decreased ability to self-manage pain, restricted access to healthcare and increased dependence on others are found to be associated with negative wellbeing outcomes related to sleep, anxiety and depression. A study funded by the Economic and Social Research Council examined the experiences of these individuals during recent periods of lockdown with a view to mitigating risk in future waves where possible. There is clear evidence that selfmanagement strategies play an important role for psychological coping and management of chronic pain. These strategies include adhering to prescribed medication or physical activity regimen, identifying treatments jointly with a health practitioner, in addition to managing the impact on mood and relationships due to pain interference. Losing the ability to self-manage or restricting healthcare access for prolonged periods may have a significant impact on wellbeing, including sleep behaviours and

Image: freepik

Recommendations

The ability to self-manage for individuals with chronic pain has been shown to reduce psychological distress and disability

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The study highlights implications related to psychosocial wellbeing, workforce and healthcare practice along with practical recommendations which should be considered in the current climate. Firstly, it is clear that the lockdown measures implemented during the first wave


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chronic pain during the pandemic

The study’s findings highlight the importance of maintaining access to health and care services as part of the wider care management plan for many with chronic pain of Covid-19 have impacted communities and support for special populations. The research shows the importance of retained independence on mental health in chronic pain populations. It is foreseen that future lockdowns would cause a social disconnection and a threat of increased loneliness. Thus, it is recommended that considerations are made for allowing social “bubbles” and social cohesion to continue in support for chronic pain communities during future public health restrictions. Secondly, a significant proportion of the UK workforce is affected by chronic pain and disability across all sectors and skills bases who contribute greatly to the economy. It is therefore vital to ensure this portion of the workforce can continue their contribution while managing the increased risk of disease severity as a result of Covid-19. Workplace managers (supported by policies to protect workers’ rights) should carry out necessary risk assessment and ensure that individuals most at risk can contribute via adaptable working plans, whether through remote working or redeployment, before taking steps to prevent individuals from working in any capacity. Thirdly, there is evidence that closure of non-urgent health services has impacted waitlists as they begin to reopen. It is

therefore recommended that services which begin to triage backlogs of cases based on clinical need ensure referral pathways to psychological and mental health services are in place. There is evidence that mental health has suffered because of halted health and social care services and it is reasonable to assume that once financial assistance programmes come to an end (such as furlough schemes), many more will be in need of these services. Identifying factors which could impact wellbeing in this population may help health and social care services dealing with the pandemic’s response and recovery process. Research and learnings from the Covid-19 outbreak should be used to inform policy and emergency planning responses for future pandemics. Policymakers should consult with a wide range of professionals such as healthcare, social workers and third sector workers to plan local strategies which meet individual as well as collective needs within the population.

PROLONGED periods of lockdown have prompted many of us to reorganise our lifestyles. One encouraging trend is to reduce, re-use and recycle more, with the aim of a greener, more sustainable future for all of us. BackCare is partnering Recycling for Good Causes and we are encouraging our supporters to recycle what they can to help protect our precious planet for future generations, whilst raising valuable funds to help us to help even more people who are living with back pain today. A win, win all round! So what sort of things are we looking for? There are many items you may not have considered recycling, including unwanted gold & silver, watches, costume jewellery, banknotes & coins, foreign currency – even unchangeable UK & foreign currency, mobile phones, video cameras, digital cameras, games consoles, iPods, laptops, tablets, games & accessories, MP3 players and much more. We have free-post labels/envelopes for your smaller items and free sacks for larger items. The more you can collect, the more cash BackCare will receive. For further information about how you can recycle more for BackCare contact: Info@backcare.org.uk or phone 0208 977 5474

l Zoë Zambelli is a doctoral student funded by the Economic and Social Research Council (ESRC), part of UK Research and Innovation.

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images: jmaster1305/freepik; jcomp/freepik; racool_studio/freepik

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Recycling can raise precious funds for BackCare


12 TALKBACK PAIN MANAGEMENT

Scientists weighing up the results of “retrospective” medical scientific papers in to the safety of cannabis medicine. Right: cannabis oil

Do cannabis medicines have a role in treating back and spinal pain? Now legalised and increasingly available, cannabis medicines may offer pain management alternatives for those who are struggling with long-term back and spinal pain. Senior consultant in pain medicine, DR ANTHONY ORDMAN, discusses recent developments and the changing regulatory environment. TALKBACK l SPRING 2021

PERHAPS back pain is so common because our spines were designed by evolution for walking on all four limbs and supported at both ends! But we, as humans, insist on walking only on our hind limbs and sitting upright, putting much more mechanical strain on every structure in our backs than they were “designed” for. Many of us mobilise our backs through stretching and exercise rather less than we perhaps should. We also tend to be much more sedentary, and so the postural “core stability” muscles surrounding our spines can become rather less effective as “guy ropes” than they should be. Then, as intervertebral discs become worn, and facet joints at the back of the spine become enlarged and stiff, nerve roots leaving the spine to go down the arm or leg become pinched, and spinal muscles can become painfully tight, and spines can become stiff and painful. Often, with the right balance of rest and exercise, and simple pain medicines such as

paracetamol and ibuprofen, an episode of back pain can settle down relatively quickly. But some people are not so fortunate, and pain in the spine and limbs can go on to become long-term or chronic. And there are many other people, who suffer spinal pain brought on by their long-term medical conditions, such as multiple sclerosis, inflammatory arthritis, fibromyalgia, or hypermobility and Ehlers-Danlos syndrome, who really have a very difficult time, despite the best medical treatment of the underlying medical condition itself.

Centralised pain Modern physiotherapy and medicine can often be of great help in such circumstances. But sometimes, even in the best of pain clinics, with x-ray guided spinal injections, the best pain medicines, expert physiotherapists and clinical psychologists, acupuncture and homoeopathy, these are not enough, and we struggle to help people


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rid themselves of back pain, enough to be able to enjoy life again. Often, this is because the pain has been “centralised” by changes in the nerve cells of the central nervous system. Thinking in particular of the specialist pain medicines we have to offer, choices can be surprisingly limited, and we have to be careful not to do more harm than good. Opioids such as codeine, tramadol and morphine don’t often help after a few weeks, but continue to cause sedation, brain fog and constipation, with a high risk of dependency. Medicines such as amitriptyline used for nerve pain, low mood and poor sleep, can take away more from patients in terms of memory and alertness than they give through pain reduction. The same is so often true for gabapentin and pregabalin, and other medicines licensed for treating pain. And while we are hopeful that the new classes of pain medicines will come along soon, we can’t expect any miracles just yet.

The endo-cannabinoid system Throughout my years of attending national and international scientific medical meetings, almost every conference seems to have had at least one lecture on the mysterious “endo-cannabinoid system”. This is a system of natural biological pathways present in all of our bodies, where nerve cells, and immune and other cells use natural “cannabinoid” substances to signal to each other, regulating bodily processes such as pain transmission, inflammation, and so on. The function of the endo-cannabinoid system seems to have to do with normalising body activity

after illness or injury. The hope had always been that, very soon, the big mainstream pharmaceutical companies would find us the medicines we needed to modulate the endo-cannabinoid system to reduce pain and improve lives. Unfortunately, this hasn’t happened, partly because the legal and regulatory frameworks of many countries have made the development of cannabinoid drugs difficult or impossible. While one or two cannabinoid medicines did become available in this country, their applications and benefits were limited. By contrast, when desperation had driven some people to try illicitly sourced cannabis for their pain, we heard reports that these were sometimes more effective than new and expensive licensed medicines. Meanwhile, in other countries, such as Canada and Israel, the legal situation was eased, as it was seen that the pharmaceutical extracts of cannabis could be helpful for those suffering long-term pain and other conditions. Then, in November 2018, regulations were slightly eased here in the UK, to allow specialist doctors to prescribe cannabis based medicines legally, for long-term conditions where conventional medical approaches had been tried or seriously considered, without benefit to the patient. I was keen to find out for myself what cannabis medicines might have to offer patients who I could not help in other ways. I was approached by Integro Medical Clinics to see if I would take up the medical leadership role in a service that would specialise in using the new cannabis based medicines. With the partnership and support of IPS, a pharmacy expert in dispensing

The regulatory environment Why does NICE, the National Institute for Health and Care Excellence, not recommend cannabis medicines for treating chronic pain in the NHS? It relies on evidence from large “double-blinded random allocation clinical trials”, which are usually so expensive and time-consuming they have to be sponsored by the large, international pharmaceutical companies.

These studies have not yet taken place. On the other hand, there are plenty of “retrospective” medical scientific papers discussing safety and effect. In this and other ways, the NHS is not ready for cannabis medicines, except in a few limited cases. Fortunately, specialist cannabis medicine clinics have been quick to respond to the new opportunities to use cannabis carefully and safely.

pharmaceutical cannabis medicines, and further study on cannabis medicine, I found myself prescribing cannabis medicines for people whose lives were on hold because of pain. Many had already tried CBD oil and found this just wasn’t enough to help, something we are seeing more and more now. But in the clinic we find that, by blending just the right amount of THC and terpenes in each individual patient’s cannabis oil or flower, we are improving patients’ nerve and inflammatory joint pain and the painful muscle spasm of spinal pain, as well as improving sleep at night, without the daytime sedation or dependency of conventional pain medicines. People can begin to get back to their work, childcare and leisure activities with a clear head and sharper memory. Then, within two or three months it becomes possible to relieve some of the burden of conventional pain medicines. The same cannabis medicines can also restore healthy sleep to patients, and lift mood which had been depressed by pain for so long. People also felt brighter and less anxious than before. n Anthony Ordman spent 20 years working in the Pain Management Clinic of London’s Royal Free Hospital and is Past President of the Pain Medicine Section of the Royal Society of Medicine. Awarded the Fellowship of the Royal College of Physicians in 2005 in recognition of his work in Pain Medicine, Anthony is now Senior Clinical Adviser and Hon. Dr Anthony Medical Director of Integro Ordman Medical Cannabis Clinics.

Use of cannabis oils CANNABIS oils are taken by mouth, perhaps 0.5ml, placed under the tongue or swallowed. The oil’s effect comes on gradually and, taken two or three times a day, gives benefit over many hours. Cannabis flower, also pharmaceutical grade, and with known levels of CBD, THC and terpene content, is inhaled using

a specialist medical vaporiser, which heats the flower to exactly the right temperature to activate the cannabinoids. Vaping is safer than smoking cannabis, with or without tobacco, which we never recommend, and vaping preserves the medicinal cannabinoids which are damaged by the excess heat of smoking.

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14 TALKBACK PAIN MANAGEMENT

Using medical cannabis for neck Jessica is a 51-year-old mum with a large family and a physically active lifestyle who became affected by chronic pain in her neck, resulting from a skiing accident in 2017.

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ON THIS occasion, I was going much faster than I was comfortable with, and while taking a corner, I hit some ice and had a wipe-out fall. I remember at the time my neck flicking backwards and really smacking my head on the ice. I lay there for a minute terrified that I had broken something. I was literally seeing stars and my ears were ringing. In the ridiculous way that you do when you trip up, I pulled myself up as soon as I could, desperate to find out if I was still in one piece and I could move everything. I was helped to the side of the slope and spent 10 minutes collecting myself before

Jessica: Getting your treatment right is a balancing act

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At the time I didn’t know it, but this was nerve pain that would eventually wake me every night, bang on 2am! attempting to limp down the mountain. That was the end of my skiing for the week and my neck was stiff and painful, but by the time I returned to the UK I felt pretty much normal and carried on with life


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pain after a skiing accident as usual for the next six months or so. I then started to become aware of a deep aching pain in my neck that would not go away. The pain crept down my neck and into my left shoulder and arm. At the time I didn’t know it, but this was nerve pain that would eventually wake me every night, bang on 2am! Initially, the pain would come and go and I would dose up on over-the-counter painkillers, but over time I found that it was really limiting the amount of exercise I was able to do. It also made me extremely grumpy and generally out of sorts. My sleep at night was very disturbed as I had pain down my left side and could not get comfortable. It led to me feeling low and miserable and hugely affected me enjoying time with my family, as all I really wanted to do was go and lie on my bed. When you are suffering chronic pain, it affects the whole family unit as you just aren’t yourself and its hard to feel excited or show interest and get involved with your children when you feel constant pain. It’s like your attention is somewhere else the whole time.

Brain scan It was when my husband pointed out the dangerously high number of empty painkiller boxes that were appearing in the bathroom bin that I had to address the situation. I made an appointment with a spine surgeon and had a brain scan and MRI of different cross-sections of my neck and back. What the images showed was that my C4, C5 and partially my C6 cervical disks had massive degeneration, were bulging, and pretty much touching the spinal cord. Typically, this type of injury can take some time to start hurting, after the initial impact, so it came as no surprise to the consultant that my fall had taken place six months before. My doctor presented me with a range of options. I was a candidate for an operation called an ACDF (anterior cervical discectomy and fusion) which involves slicing open the front of your neck to access the spine, removing the damaged disks and replacing them with artificial ones that are held in place by a titanium cage. While generally successful and relatively commonly conducted on professional sportsmen

(especially rugby players), there is risk to your vocal cords – and every operation involving the spinal cord is a big deal.

Steroids The recuperation time from the op was also a consideration. Before I took this route, he recommended that I try transforaminal epidurals of steroids. I did this for about six months until the specialist that I was seeing said there was no point as further injections would not help and advised that I went ahead with the operation. These injections were a pain as I was sedated first and had to spend a day in hospital every few months and I had horrible brain fog from the anaesthetic for a day or two afterwards. I saw a specialist consultant physiotherapist but any manipulation or pressure upon the area made the pain worse. It was at this point I tried medical cannabis medicine, really as a last attempt to find a solution before undergoing the operation. Getting your treatment right takes a while and for me it was a balancing act of getting the correct percentage of THC and CBD in an oil, specially mixed for me and then vaping an indica flower at night and, if additional pain relief was needed in the day, a sativa blend. Though this became unnecessary once I was taking the oil three times a day. I have now reached a “sweet point” in terms of my dosage, which I feel is just right and I am living pain-free at the moment. I am able to run, weight train and do yoga again and feel in peak fitness. But I do listen to my body and never overdo things and check in with the practice nurse at the clinic every couple of weeks.”

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Cannabis plant

Register for our FREE webinar If you would like to hear Dr Ordman in the forthcoming BackCare webinar and ask him any questions, please register for this free event on Tuesday 25 May 19:00 - 20:30. This webinar will be of interest to healthcare providers and anyone suffering from back pain whether it is

a primary condition or a secondary symptom of a more complex pain condition such as MS, fibromyalgia or osteoarthritis. To register: https://www. eventbrite.co.uk/e/discussingback-pain-and-cannabismedicinestickets-146736608145.

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16 TALKBACK SPECIAL FOCUS: MULTIPLE SCLEROSIS

Chronic back pain: a frequently overlooked symptom of MS

Multiple sclerosis (MS) is a complex and personal condition. Rarely are two patients’ experiences identical which makes treating the condition all the more difficult. SOPHIE HAYES reports.

MS is a lifelong condition which primarily affects the brain and the spinal cord. It is characterised by unpredictable inflammation and scarring of the central nervous system. The most common symptoms include fatigue, muscle stiffness and spasm, spasticity (increased muscle tone), problems with cognition, neuropathic pain (experienced as burning, pins and needles, squeezing, hugging or pressure), problems with balance and co-ordination and back and joint pain. Back pain experienced by individuals living with MS is often an indirect symptom resulting from the condition. The disrupted messaging causes mobility difficulties which, in combination with muscle spasms and muscle tone changes, puts pressure on the lower back causing stiffness and pain. Back pain can also be a result of the disrupted or misdirected pain signalling. Pain in MS comes from different reasons. Everyone has different symptoms, lifestyles and coping strategies. There are a number of different technique combinations that can be curated in order to obtain optimum symptom management. Symptoms such as chronic back pain in MS can have a significant impact on daily living, relationships, social roles and patients’ working lives. It is understandable that many people who live with chronic conditions find there is an impact on their psychological wellbeing. This can result in depression and anxiety. There are also many psychosocial factors that influence a patient’s adjustment to chronic pain. These include painrelated beliefs, coping behaviours and family members’ responses to pain behaviours. Managing such a complex range of symptoms often requires a multidisciplinary approach encompassing practices that can be used alongside prescribed medications. Introducing these methods can give those living with MS a greater sense of control over managing and treating their pain for both short and long-term. Pain management strategies are by no means a “one size fits all” and should be discussed with a patient’s clinical team.

Short-term pain management Short-term pain management techniques are those intended to provide relief in the moment

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rather than for any extended period of time. Research into a number of these practices is still ongoing. Transcutaneous electrical nerve stimulation: When the TENS machine is switched on, small electrical impulses are delivered to the area, such as the lower back. These electrical impulses can reduce the pain signals going to the spinal cord and brain, distracting the nociceptors, helping to relieve pain and relax the muscles. Cooling and/or heat therapy: 60-80% of the multiple sclerosis patients present adverse clinical symptoms when their body temperature is increased. This can be the result of over-exertion or factors as simple as hot weather, or a bath that is too hot. Raised temperatures stop nerve fibres from working properly. When the body overheats, the electrical impulses, or messages, find it harder to pass along the nerve. For individuals living with MS, these nerve fibres are already damaged, so these messages may not get through at all. This can result in increased pain levels. Simple actions such as drinking cool liquids, sucking on ice cubes/lollies, taking a cool bath or sitting in front of an open window or fan can help provide some relief. Conversely, some patients experience mobility issues, spasms or muscle tightness if temperatures are too low. In these cases, hot drinks, hot food and warmer but loose items of clothing can be helpful. Complementary therapies: These are used alongside regular healthcare practice. It is not advised that these are used in replacement of the advice provided by an individual’s clinical team. Many living with MS have taken this approach, and find benefit from visiting chiropractors, osteopaths, going for massages or acupuncture, and attending yoga or meditation classes. The National Institute of Clinical Excellence states that complementary therapies such as these can be helpful for individuals living with MS in terms of improving a general sense of wellbeing. However, it does highlight that there is not enough research evidence.


Image: freepik

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Long-term pain management Long-term pain management aims to stabilise and manage pain levels over a longer period of time and are often focused on how we manage our physical and mental health alongside pain and other symptoms. Physiotherapy exercises: The key to longterm back pain management is found to be movement. The less movement, the less synovial fluid is produced. This fluid cushions the ends of bones and acts as a shock absorber. Therefore, it reduces friction when joints move. If these joints stop being used, synovial fluid stops beings produced. This leads to significantly reduced ranges of movement and subsequently, decreases mobility, hence increased back pain. Another cause of back pain in MS is determined by spasticity or increased muscle tone. Physiotherapy is considered to be fundamental in managing prevention of spasticity associated secondary complications, including back pain. Results from randomised controlled clinical trials of physiotherapy exercise programmes in MS have demonstrated benefits in muscle strength, cardiovascular fitness, aerobic thresholds, activity levels and functional improvements, such as walking ability. A comprehensive programme that includes strengthening and stretching exercises will help to ensure the core muscles are strong enough to support the individual’s weight and allow for greater range of movement for a longer period of time.

Supportive braces: These are likely to be introduced following an orthotic review and can include a wide range of braces, splints and supports. One example of these supportive braces is a thoracic lumbar sacral orthotic brace. When worn correctly they will offload weight from the spinal vertebrae, which can relieve some of the pain experienced by the individual. These are typically introduced in the later stages of progressive MS, when an individual wishes to exercise other parts of their body but have difficulty controlling their core muscles. 24hr postural management: In the latest stage of progressive MS, significantly reduced mobility will be a key factor in the management of back pain. Ensuring regular position changes throughout the day will help manage this. This may require the help of carers and equipment such as hoists and supportive pillows to reposition an individual every 3-4 hours. This will ensure that muscles do not become too stiff and joints do not become “locked”. Psychotherapy: How an individual living with MS relates to their pain can be a key factor in not only the management of it, but the experience of it. Having psychological support as part of an individual’s care regime can have a significant impact on their experience of pain. Cognitive behavioural therapy: CBT is a type of talking therapy based on the idea that continued on p18 >

Above: carefully planning an effective and varied care regime, can help the patient regain a sense of control over their symptoms

Support BackCare Our BackCare members help support our work and in return receive benefits including discounts and priority booking for our free webinars. For more information about becoming an ordinary, professional or corporate member contact: membership@ backcare.org.uk TALKBACK l SPRING 2021


Image: kjpargeter/freepik

18 TALKBACK SPECIAL FOCUS: MULTIPLE SCLEROSIS

Disrupted messaging causes mobility difficulties which, in combination with muscle spasms and muscle tone changes, puts pressure on the lower back causing stiffness and pain < from p17

thoughts, feelings, what we do and how are bodies feel are all connected. CBT proposes that if we change just one of these aspects, we can change the rest over time. CBT practice encourages individuals to practise noticing and eventually changing problematic behaviour or thinking patterns. Studies have shown improvements in pain severity, pain interference and emotional wellbeing, suggesting that including CBT can be beneficial for persons living with MS.

Newly available medicines Through advocacy campaigns lead by patients, such as those living with MS,

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cannabis medicines became legal to prescribe in November 2018. These medicines are currently available primarily via private clinics, although Sativex is available on prescription via the NHS for spasticity in MS. Cannabis medicines can be an effective symptom management tool when added to a care regime. Cannabis flowers grow tiny hairs called trichomes, which themselves contain hundreds of different chemical compounds. The most common are two of a family of compounds called cannabinoids, THC and CBD. These two compounds are the most researched and are each known to have a multitude of medical actions and play a role in treating pain.

These cannabinoids interact with our body’s own endo-cannabinoid system (ECS). The ECS is a system of receptors, situated on certain cells throughout the body. To date, we have identified two key ECS receptors; CB1 and CB2. Humans naturally produce their own endocannabinoids. Two examples of this are anandamide and 2-AG. These receptors and endo-cannabinoids make up the ECS. The ECS is involved in regulating numerous physiological functions including (but not limited to) motor co-ordination, neuroprotection, pain control, appetite stimulation and regulating our immune systems. Endo-cannabinoids such as anandamide are produced through activities such as


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exercise, but for those living with chronic conditions, this is more difficult to produce naturally. It is more difficult to regulate all body systems, and cannabis medicines can be useful supplements to these essential naturally produced compounds. THC has been proven to alleviate neuropathic and inflammatory pain caused by multiple sclerosis by reducing pain signalling and acting as an anti-inflammatory. CBD is an effective muscle relaxant making movement more comfortable and therefore enabling individuals to be able to engage with physiotherapy exercises or complementary therapies such as yoga, all of which contribute to maintaining muscle strength and tone. Better pain management, with fewer side effects than opioid medications, can result in higher quality sleep. This, coupled with the mood stabilisation effect of some cannabis medicines, can help build emotional resilience and empower individuals to manage symptoms such as anxiety and even enable them to engage with mindfulness or meditation techniques as part of a holistic approach to back pain management. The goal of carefully planning and sticking to an effective and varied care regime is to help the patient regain a sense of control over their symptoms. In order for this regime to be sustainable, it has to be right for their lifestyle. When considering how best to manage back pain, or other symptoms associated with multiple sclerosis, it is always important to do this in collaboration with your clinical care team.

A patient’s experience of cannabinoids JASMIN was diagnosed with multiple sclerosis in 2015. During a holiday to Morocco, where the temperatures reached up to 44 degrees centigrade, she noticed she was experiencing symptoms she had never had before. “I lost hearing in my right ear and would get a painful, vibrating sensation in my spinal cord when I moved my neck. I was exhausted all the time. It would get to four o’clock in the afternoon and I would need to take a nap, I knew something wasn’t right.” Jasmin was referred by her GP to the ear, nose and throat clinic to investigate her new hearing loss. When there was no evidence of a burst eardrum, she was sent for a brain scan to check if there was an internal cause. “They identified lesions straight away.”

Jasmin is in the early stages of MS. While she does live with symptoms such as fatigue, muscle tightness, back pain and brain fog, she is still self-employed, working full time but flexible hours as founder of CBD company OhanaCBD. She is also expecting a baby very soon. “My hips are now very painful at this late stage of my pregnancy, but cannabinoids really help me manage.” Jasmine is one of many MS patients who has found benefit from compounds found in the cannabis plant called cannabinoids and is a vocal advocate of the benefits of cannabinoids in combination with non-pharmacological methods such as yoga, meditation, regular exercise, a plant based, gluten free diet and ayurvedic supplements in the management of her MS symptoms.

“Under the guidance of your healthcare professional, it is vital that patients empower themselves with the knowledge about their condition and how well traditional medicine and complementary medicines can work together. There is no ‘one size fits all’, you have to find what works best for you.” n Sophie Hayes is a registered nurse who has specialised in Emergency and Acute Medicine. She has worked in A&E in the Royal Sussex County Hospital, St Thomas’s Hospital and in Critical Care at Kings College Hospital. In 2019, she cofounded and launched the Nurses’ Arm of CPASS (Cannabis Patient Advocacy and Support Services) at the Royal College of Nursing.

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20 TALKBACK SPECIAL FOCUS: MULTIPLE SCLEROSIS

Using oxygen therapy to reduce pain swelling and inflammation At BackCare, we understand that people often live with back pain as a consequence of their lifestyle or other underlying conditions. PAUL BISHOP from Herts MS Therapy Centre, discusses his experience of back pain and how people with multiple sclerosis (MS) and back problems can benefit from oxygen therapy provided by an MS Therapy Centre.

Way back when… my father, a keen tennis player when he was a young man in the late 1940s and early 50s, thought Lew Hoad was the best player ever. Australian Hoad was world number 1 in 1953 and 1956 and had a game based on strength and power. However, he was plagued by serious back problems throughout his career. Ironically, the problem was self-inflicted. In 1954, Hoad had devised a weightlifting exercise which involved doing push-ups with 50lb weights on his back. By the time I was aware of Hoad, watching him on TV at Wimbledon in 1968, he was a spent force and was drinking

heavily to ease the pain. My father learnt that this former giant of the game was human and I learnt about back pain. Some years later I tweaked my lower back playing tennis but it was only a minor injury. However, one-third of the adult population in the UK suffer from back pain. Some live with back pain caused through injury and wear and tear while others live with back pain because of other underlying and serious health conditions. One such condition is MS – a lifelong disease of the central nervous system, which has, as yet, no known cure. It is the most common neurological condition among young adults today.

Some 100,000 people are living with MS in the UK today. One of those is Barbara Cowan, from Stotfold, near Hitchin. Barbara has been receiving oxygen treatment at Herts MS Therapy Centre in Letchworth since it opened 32 years ago. “I have foot drop that causes my left foot to drag and this causes considerable pain in my back and affects my balance as well. As a consequence, I have needed to walk with a stick for the past two years. “The regular oxygen therapy I receive has helped relieve the pain and negative sensations in my back and legs,” Barbara said. In oxygen therapy, pure oxygen is breathed through a mask under pressure in a specially constructed chamber. Many people using oxygen therapy find it can help reduce their pain, decrease swelling and inflammation, boost energy and improve vision, for example. Our chamber in Letchworth, Herts, is like a room inside a large steel tube that can be sealed and pressurised. It is large enough to seat up to seven people. People living with pain and symptoms related to MS, Parkinson’s disease, chronic fatigue syndrome, ME, fibromyalgia, leg ulcers, sleep apnoea, long Covid, and cancer, can often benefit from oxygen therapy. There are a large number of MS therapy centres in the UK all operating as charities. www.hertsmstherapy.org.uk www.msntc.org.uk/find-a-centre

Let us know If you have a story for ‘Talking Barbara Cowan preparing for more oxygen therapy

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Backs’, please contact: media@backcare.org.uk


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Image: katemangostar/freepik

Where there is a will there is a way

A gift in your will can make a huge difference to someone living with back pain

BACK pain is often seen as the Cinderella condition, too often ignored and neglected and far too easy to brush under the carpet. Like Cinderella, back pain is invisible, but it does affect eight out of 10 people at some stage of their lives, often wreaking havoc in the process. A gift in your will can make a huge difference and help to transform the lives of people who are tormented by back pain. Denice Logan Rose, executive director of BackCare, said: “We have people’s backs, quite literally. At BackCare, we work tirelessly to help prevent back injury through education and provide practical and emotional support to those living with back pain. While BackCare is

a small charity, we are a national one, with a wide remit, and legacies are crucial to the funding of our work.” There are two main ways you can leave a legacy to BackCare – a pecuniary bequest (a gift of a specified amount of money) and a residuary bequest (a gift of the balance of your estate, or part of it, once all other gifts have been distributed). Many people choose to leave a residuary bequest to their favourite charity or charities because this is a gift which is least affected by inflation. l If you would like further information about leaving a lasting legacy to BackCare, please contact: Legacies@backcare.org. uk or phone 0208 977 5474.

FROM 1 July the Chartered Society of Physiotherapy (CSP) will be explicitly excluding a number of spinal injection interventions from cover within the CSP professional liability insurance (PLI) scheme. Members who undertake these activities and rely on CSP PLI for their indemnity will need to adjust their practice in order to remain insured. Therapeutic injection therapy has been within the scope of physiotherapy practice since 1997. CSP adviser Pip White says: “It typically includes injection to the structures of the peripheral skeleton and increasingly, with advances in professional capability, may now include injection to the structures

Image: kjpargeter

CSP to exclude spinal injections from liability insurance cover of the spinal skeleton. All injection therapy carries risk, but the risks for spinal injection interventions are greater. Pip White adds: “The CSP has taken a pragmatic risk-management decision to be very clear to members that some spinal and other interventions will be explicitly excluded from PLI cover from 1 July this year.” The explicitly excluded activities will be: regional and general anaesthesia, including peripheral nerve blocks; epidural injections with or without the use of local anaesthetic; spinal and caudal injections; spinal and caudal nerve blocks. www.csp.org.uk

Take part in a research study into chronic pain COULD you help with this doctoral research? María de los Angeles Zapata Rodríguez at Heriot-Watt University is undertaking a research project in the intersection of gender and disability in the employment

experiences of people in Scotland living with chronic pain (including back pain). She is interested in hearing from people who are working or looking for employment in STEM careers and living

in chronic pain (including arthritis, fibromyalgia,

neuropathies etc) or is working as a team leader (in charge of organisational practices) in HR, diversity or occupational health. María can be contacted by email: mz56@hw.ac.uk or by phone on 07395 390245.

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22 TALKBACK PUBLICATIONS

BackCare’s role in evolving best BackCare was formed in 1968 as the National Back Pain Association, when Stanley Grundy (the founder) suffered a back injury and felt that he had nowhere to turn for support. His mission was to set about creating a charity dedicated to educating the public in ways of preventing or alleviating back pain. While back pain might reasonably be considered a side effect of being human, it is generally understood that there is an association between certain tasks, activities and exposures at work, in sport or at home, and the development of musculoskeletal (MSK) symptoms, including back pain. The Health and Safety Executive (HSE) offers a list of workplace risk factors that can contribute to the development of MSK symptoms including: l lifting heavy or bulky loads l carrying loads awkwardly,

asymmetrically or possibly one-handed l pushing, pulling or dragging heavy

loads l manual handling in awkward places,

such as during delivery work l repetitive tasks, such as packing

products l bending, crouching or stooping l stretching, twisting and reaching l being in one position for a long time l working beyond your capability or

when physically overtired. Other external factors such as work organisation, for example, high workloads, tight deadlines, lack of control over the work and working methods may also be relevant. The exposures listed above are typically associated with construction, heavy manufacturing and production work, but for many workers in the health and social care sectors, the “load” is a human being; and humans can also be heavy, bulky and awkward to move loads if they have limited or no ability to move themselves. Consequently, the delivery of care, in hospitals, by the emergency services and in the community, can also involve almost all of the

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practice in moving and handling Further editions followed in 1987, 1992, 1997, 2005 and 2011 as best practice manual moving and handling methods evolved and the range of moving and handling aids and equipment extended and became more readily available, accessible and user friendly. These developments, alongside the enactment of updated legislation and emerging case law, the latter influenced by the guidance set out in the HOP series, have ensured that each edition in its turn has become the gold standard of its time, each providing a historical record of “where we were then”. By 2005, the 5th and later the 6th (2011) editions moved significantly towards a more evidence-based and peer reviewed approach and have been endorsed by leading relevant organisations including the HSE, National Back Exchange, RCN, NHS Employers, Chartered Society of Physiotherapy and the College of Occupational Therapists. Since that first edition, there has been a paradigm shift in care delivery from the NHS to community care, so that now there are arguably more workers delivering care that may involve moving and handling in the community (in care facilities, supported living and people’s own homes) than in the NHS, and not everyone who needs help is a “patient”. To reflect that shift, the fifth and sixth editions of the publication were retitled The Guide to the Handling of People to Image: iStock/ alvarez

risk factors listed above. The prevalence of low back pain in nursing, and the consequent cost to the NHS, has long been recognised and in 1979 the Royal College of Nursing (RCN) published their first guide, Avoiding Low Back Injury Among Nurses, that made a number of recommendations aimed primarily at prevention strategies including the avoidance of lifting. Recognising a need, the (by then) Back Pain Association (BPA), working in conjunction with the RCN, set about gathering a multiprofessional group of relevant experts to produce best practice guidance on recommended methods of assisting or moving patients, emphasising the importance of skills development so that, once trained, nurses could “accurately assess each situation and make the correct decision about patient movement, even in an emergency, to protect not only the nurse but also the patient”. The dual aims of managing risks to the worker, whilst also meeting the assessed needs of the patient, remain as relevant today. The resultant guidance document was published by the BPA in collaboration with the RCN in 1981 as The Handling of Patients (HOP), a Guide for Nurse Managers. It was quickly established as the gold standard guidance for the moving and handling of patients at a time when almost all care was delivered within the NHS.

include and address all relevant sectors. It seems appropriate that the latest revision in this established series, the seventh edition of the HOP series will be published in the summer of 2021, 40 years since the first, and 10 years since the last, publication. The approach and content of this new edition will focus on two significant aspects. The first is the ever closer focus on person-centred care that takes full account of the needs, choices, dignity and comfort of the person, and that takes an enabling approach to promoting the function and independence of the person being cared for as a clearer inclusion in the decision making process. This applies as much to meeting a person’s moving and handling needs as to any other aspect of personal and/or clinical care, including rehabilitation. Second, this edition has taken the step to underpin all of the guidance included with as much supporting evidence as is currently available. This includes other sources of practical guidance, academic literature and, where appropriate, equipment manufacturers’ recommendations. Over the past 40 years, the hazardous lifting of patients/people has been all but eradicated (except in dire emergency where there may be no reasonable alternative) due to greater understanding of the risks to both the handler and the person being handled, the growing evidence base for the safer handling methods set out in the publication (some of which are illustrated in this article) and also due to an ongoing evolution in equipment/technology development. Nevertheless, real, and sometimes new, challenges remain. Some examples of equipment designed to substantially avoid or reduce the risk from moving and handling include: Electric profiling beds (EPBs) have bases that are sectioned so the mattress can be profiled to achieve various positions, the height can also be adjusted. Movement is powered and controlled via a bedside handset by care staff, or by the user to facilitate independence. These beds enhance comfort, facilitate repositioning, reduce the risk of pressure continued on p24 >

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24 TALKBACK PUBLICATIONS

< from P23

area breakdown and reduce the amount of moving and handling required of attending carers. Multipositional aid is designed to provide supportive seating, tilt in space, lateral rotation and passive standing as part of an early in-patient rehabilitation programme such as patients recovering from prolonged ventilation in ICUs and avoids potentially high-risk moving and handling by critical care/rehabilitation professionals.

An alternative forearm hold once the person is standing or walking. The handler’s right arm remains across the person’s back.

Using a ceiling track hoist can reduce the number of carers needed for specific tasks and reduce the overall moving and handling load for the carer(s) in that they do not require pushing across carpets and manoeuvring around other environmental obstacles such as cables, rugs, furniture etc. For individuals assessed as suitable, self-hoisting can facilitate independence. Emergency lifting chair is used for lifting a fallen person from the floor which is a hazardous physically demanding task. The emergency chair is lightweight and can be assembled by one care giver around the fallen person. It is battery operated and raises them to a seated or semi-standing position, significantly reducing the strain and risk to both the carer(s) and the person being retrieved from the floor.

A non-powered device to assist the person who is able to stand with assistance, but unable to take steps, to transfer between horizontal surfaces (bed, seating, toilet etc). Note the posture of the handler.

Starting position to assist a person who needs assistance to stand up. The handler’s right arm is across the persons back. The handler offers verbal prompts and encourages the normal pattern of movement.

A powered device can assist a person who is unable to stand even with handler assistance. It can have an important role in rehabilitation and also assists in care transfers between horizontal surfaces.

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In January 2020, the World Health Organisation (WHO) announced the outbreak of Covid-19 as a public health emergency. Of those critically ill Covid patients admitted to intensive care units (ICU), more than 50% developed Acute Respiratory Distress Syndrome (ARDS). ARDS in itself is nothing new and it had previously been established that oxygenation in these patients can be improved when ventilated in the prone (face down) position for periods of time. Manually manoeuvring a patient from lying on their back to lying prone is therefore an essential task aimed to increase the likelihood of survival in patients with ARDS. It is also a potentially hazardous task involving typically, six or seven appropriately trained ICU staff. It requires teamwork, timing, skill and the exercise of great care, to turn on to their front (or on to their back again) what is typically a heavy, unconscious and difficult load (patient) who may be intubated and be attached by lines and tubes to various pieces of medical equipment. From the ICU workers’ perspective, it involves force exertion, holding awkward postures, pushing and pulling, reaching and stretching, stooping and twisting on a repetitive basis with many patients over a long shift when the workload is high, the staff overtired and also wearing layers of restrictive and uncomfortable PPE. Many of you will have seen images of ICU staff involved in proning critically ill patients on your TV screens over the past many months. There is therefore a significant driver for identifying appropriate safer methods and equipment/materials for moving a patient between supine and prone and back to supine, and for disseminating that information to NHS Trusts and relevant workers, and the publication of HOP7 will be a significant contributor to that process. Ultimately it is the responsibility of the employer to implement safe systems of work aimed to protect workers from the risks of developing work related MSK symptoms/ back pain as far as reasonably practical. In relation to the moving and handling of people in health and social care, the best practice standards to which employers should aspire, and that balance worker safety and person-centred care, have been set out in the HOP series of gold standard publications published by BackCare over the past 40 years. The seventh (2021) edition will represent a further step in that evolutionary process. Jacqui Smith MCSP (ret), MSc (Human Factors), Editor 5th, 6th and 7th editions of The Handling of People. 5.4.2021. To preorder copies: media@backcare.org.uk


TALKBACK EDUCATION AND TRAINING 25

MSK technique helps decide where to treat and how to treat

HAVING qualified as a nurse (RGN) in 1989, AMANDA WHITE developed back problems from lifting patients. This set her on a journey of discovery. She became a qualified BAA acupuncturist and ran an NHS chronic pain clinic for 18 years. It was here that SKART was researched and developed. SKART uses the technique of kinesiology to test for issues. It is a way to communicate with the body, which allows practitioners to use the patient’s own body as the research tool to find out what it needs, where to treat, how to treat. It also gives feedback on whether the correction has held and corrected the problem area. Research has also shown that one of the most under-recognised causes of chronic back pain is due to misalignments. Misalignments of the vertebrae in the spinal column put pressure on nerves, causing shooting pain, weakness, numbness, tingling and different leg lengths if the pelvis is involved. Back and neck problems can be the cause of pain, headaches, dizziness, leg pains and restless legs. One patient reported experiencing such systems for around 18 months, responded to the first treatment, and within six weeks was

Image: jcomp/freepik

SKART (Structural Kinesiology Acupressure Release Technique) is a diagnostic and therapeutic technique designed for the management of back, neck, hip and leg pain. It is now available as an online training course.

Above: Amanda White, solving back issues using gentle correction techniques

Misalignments of the vertebrae put pressure on nerves functioning well with no relapse after nine months. Another area for treatment is the symphysis pubis, the joint at the front of the pelvis between the pubic bones. Unfortunately, this can become misaligned leading to pain in the groin, hip area, leg weakness and imbalance, and pain radiating down the outside of the leg. It can also contribute to the destabilisation of the back, causing general back pain as a secondary problem. A patient presenting severe groin pain and pain down the side of her leg, reported the pain had stopped after three treatments, removing her reliance on a walking stick and enabling her to resume outdoor activities. Other typical areas needing pain location and treatment include: l cranial issues which can cause headaches, pressure pain and excess crying in babies l lymphatic problems leading to feelings

of sluggishness, toxic build up and reduced energy l jaw issues leading to pain l shoulder problems causing pain, tingling and numbness down the arm and in the fingers l ileocecal valve problems causing pains in lower right abdominal area and gut spasms l hiatus hernia issues linked to pain and discomfort under the left ribs, indigestion and nausea. SKART allows the practitioner to solve back issues using practical, safe, nonforce, and gentle correction techniques. Amanda has written a full qualification specification which has been approved and accredited by the International Institute for Complementary Therapists (IICT). n Amanda White is founder and CEO of SKART International and is a BackCare professional member.

Cut price on course BackCare is able to provide readers the SKART online course at the discounted rate of £199, reduced from £450.

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26 TALKBACK BONE HEALTH

Osteoporosis: can it We get the facts from the Royal YOU may not realise it, but our bones are alive and constantly changing. In childhood, our skeleton increases in density and renews itself in just two years. Bone mass then continues to increase slowly into your mid-twenties. After middle age (35-55), bone loss increases as part of the natural ageing process. This can lead to osteoporosis in men and women.

So, what is osteoporosis? Osteoporosis is a condition that causes bones to lose strength and break more easily. It occurs when the structure of bone gets thinner, making it fragile and more likely to break easily. There are 3.5 million people with the condition in the UK today.

Does it cause back pain? “It’s a common misunderstanding that osteoporosis causes aches and pains,” says Julia Thomson, specialist nurse at the Royal Osteoporosis Society (ROS). “Having low bone density or osteoporosis itself does not cause pain – but breaking a bone can be painful. In fact, an easily broken bone is often the first sign that our bones have lost strength. When we talk about the ‘symptoms’ of osteoporosis, we mean the broken bones it causes and the impact of these,” says Julia.

Comparison of normal (top) and osteoporotic (bottom) bone structure

Images courtesy of Prof Tim Arnett (UCL)

How do I know if I’ve had a spinal fracture?

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Although osteoporosis usually affects the whole skeleton, it most commonly causes broken bones or fractures in the spine, wrist and hip. “Spinal fractures caused by osteoporosis happen when the vertebrae squash down on themselves and can happen without a fall or injury. Although these fractures heal in the same way as others, they heal in their new shape,” says Julia. “This means that spinal fractures can lead to the height loss, back pain and postural changes that are sometimes associated with osteoporosis. So, if you have unexplained back pain and muscle spasms, height loss, a curved spine or notice a change in posture, this could be a sign of spinal fractures. These symptoms will become more noticeable the more broken bones you experience.”

What should I do? “If you think you have any of these symptoms, speak to your healthcare professional. They can investigate whether your symptoms are caused by spinal fractures or something else,” says Julia. “Spinal fractures aren’t always painful and there are many other causes of back pain, including conditions like arthritis.”


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Image: Freepik

cause back pain? Osteoporosis Society What will happen next? “If your healthcare professional believes you have spinal fractures, they may recommend an osteoporosis medication without doing further tests to reduce your risk of further broken bones,” Julia says. “In some cases, you may be referred for tests to find out about your bone strength – particularly if you are more at risk of osteoporosis because of other conditions or medications. Things like having had an early menopause, a close family history of osteoporosis, or malabsorption problems such as coeliac disease can all increase your risk. These tests might include a bone density scan, X-ray or MRI to establish whether you’ve broken any bones.”

What can I do to keep my bones strong? “It’s never too early or too late to take action on your bone health,” says Julia. “A healthy, balanced diet with adequate calcium, getting enough vitamin D and weight bearing and muscle strengthening exercise are all key. “Finding out more about your risk factors for osteoporosis can also help you to identify if you could be at risk before you break a bone. You might also identify something you can change to protect your bones,” she says. “If you’re concerned, discuss it with your healthcare professional who can tell you if a bone health assessment is needed.”

Did you know?

Our bones are made of a thick outer shell and a strong inner mesh that’s filled with collagen, calcium salts and other minerals. The inside looks like honeycomb, with blood vessels and bone marrow in the spaces between bone. The Royal Osteoporosis Society is the only national charity dedicated to bone health and osteoporosis. Visit theros.org.uk/questions-answered for videos with more information about osteoporosis and bone health, or call the charity’s free Helpline on 0808 800 0035.

Can you help? As a charity, BackCare relies on the goodwill of others to further our work and are looking for people to help. We are keen to expand advertising opportunities within TalkBack, so, if you have a background in sales and some spare time to volunteer, we would love to hear from you. For further information contact: denice.loganrose@backcare.org.uk

Strengthening offers crucial benefits for people with long-term conditions STRENGTHENING is sometimes referred to as “the forgotten guideline” in comparison to the far better-known national recommendation that adults should do 150 minutes of moderate activity each week. This is among the findings of a 15-month project, funded by Sport England and the Centre for Ageing Better. The study set out the beliefs, barriers and motivations of people living with long-term conditions when it comes to strengthening and contains key recommendations about effective messaging on the issue to that cohort. In its report on the findings, the Chartered Society of Physiotherapy says people living with long-term conditions have low awareness of the benefits of strengthening and fear it may make their symptoms worse, but they do recognise the role physiotherapy staff have in increasing participation. The need is for physiotherapy staff and other healthcare workers to discuss strengthening with patients in the same way they would talk with them about the broader benefits of being active. Sara Hazzard, the CSP’s assistant director for strategic communications, was encouraged to see how trusted physiotherapy staff were as a source of advice but stressed the importance for members to use the findings to inform their consultations. She said: “This is especially important after the events of the past year, which will have caused millions of people to decondition while in lockdown, shielding or simply less active than they would otherwise have been.” www.sportengland.org www.ageing-better.org.uk www.csp.org.uk

DIARY DATE

The 2021 Back Care Awareness Week will run from 4-8 October. The theme for this year’s campaign is Back Pain and Working From Home. BackCare will be releasing more information in the coming months. To be kept in touch, contact media@backcare.org.uk www.backcare.org.uk

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28 TALKBACK NEWS

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