SPECIAL ISSUE Rethinking Medicine in 2013 ■ NEWS
■ EVENTS ■ COMMUNITY Quarterly magazine of BackCare, the UK’s National Back Pain Association
£2.95 • FREE TO MEMBERS
What is health?
Prevention is better than cure Ageing is Not a Disease Personal health planning Swimming matters
The Charity for Back and Neck Pain www.backcare.org.uk
2 Talkback news
BackCare Events Calendar 2013 Primary Care 2013 22-23 may 2013 – NEC, Birmingham
Now in its 23rd successful year, Primary Care continues to be at the forefront of healthcare events as the UK’s leading conference and exhibition for GPs, commissioning groups and all healthcare professionals working in primary and community care. Find out more at www.primarycare2013.co.uk
London 2 Brighton Challenge 25-26 May 2013
This challenge is like no other: walk, jog or run 100km city to coast. An epic cross-country ultra marathon or the longest walk of your life, you choose! £85 to register + £400 fundraising pledge required. Full support checkpoints, hot meals provided en-route. Info: www.london2brightonchallenge.com
BUPA London 10,000 27 May 2013 – Starts 10am at St James’ Park, London
Join Team BackCare at one of the most popular mass-participation 10k races in the UK. Fundraising pledge is £250 due in a month after the event. Info: www.london10000.co.uk
COPA Practice Growth 2013 6-7 June 2013 – ExCeL London
The interactive exhibition and conference specifically for chiropractic, osteopathy, physiotherapy and acupuncture practice owners. Order your FREE tickets at www.copashow.co.uk
Open Day at the Anglo-European College of Chiropractic 15 June 2013 – Bournemouth
Speak to teachers and students at this college open day for prospective entrants. Find out more at www.aecc.ac.uk
Prudential Ride London 100 3 August 2013
As many as 70,000 people are expected to participate in the debut of London’s newest mass-participation challenge event, riding 100 miles from the Queen Elizabeth Olympic Park into central London through the scenic Surrey Hills before finishing on The Mall. Info: www.ridelondon.co.uk
British Chiropractic Association Autumn Conference and AGM 21-22 September 2013 – Thistle grand hotel, bristol
Updates from a range of speakers on the cutting edge or chiropractic. Programme available soon at www.chiropractic-uk.co.uk
Body Control Pilates Development Weekend 28-29 September 2013 – The Royal College of Physicians, London
A weekend of lectures and workshops from leading UK and international presenters. Full programme available in June. Info: www.bodycontrol.co.uk
BackCare Awareness Week: ‘Caring for Carers’ 7-11 October 2013
The UK’s 6 million carers save the NHS and social services a staggering £87 BILLION every year, but they’re at risk and 70% of them already suffer back pain. Help us to support society’s backbone through the launch of our ‘Caring for Carers’ campaign.
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Talkback news 3
Hello and welcome to TalkBack. After what seemed an almost unendurably long winter, I am pleased to announce that spring is finally and most certainly in the air. First, I’d like to thank the courageous runners of the BackCare Marathon team who took to the streets of London in support of the charity. I’m told that only 1% of people ever complete a marathon in their lifetime, and, as I can now personally attest, it can be quite a challenge. Many thanks also to the supporters, both financial and emotional, without whom such accomplishments would be insurmountable. Fundraising is still ongoing so do consider donating if you haven’t already. We’ll be presenting you with a full report in the summer issue. In the meantime, you can read our interview with BackCare Team runner, Emma Richardson, on page 8. Now, it occurred to me that being a 24-page quarterly we do have limited space, so it’s important to ensure that the educational content we bring you is top notch. I’m pleased to be bringing you this special issue with a challenging piece that questions our very concept of health and presents a ground-breaking developmental model of healthcare (pages 16-19). I’d be interested in hearing your views on the inclusion of more in-depth, think-pieces such as this. Starting in this issue, we’ll also be exploring the theme of ageing with a series of educational reports entitled, “Ageing is Not a Disease”. The aim is to address the elderly as a growing sub-population with a look at how new evidence of the last few decades serves to remedy many of our ill-founded common sense assumptions. I might add that this was inspired by the correspondence of BackCare member, Miss Elizabeth H. Dickinson. Finally, we’ve assembled some excellent contributions from our Professional Members and Corporate Partners, on a diverse range of topics. I’d particularly like to draw attention to two of our newest professionals, swimming teacher and world-record holder Lucy Lloyd-Roach who has contributed a two-part article on swimming for back pain, and physiotherapist Nick Sinfield who begins a new mini-series exploring the ‘Personal Health Plan’ approach to self-management. Please remember, we do value your contributions. In fact, it is your feedback that makes BackCare a community. So if you have an inspirational story to tell or would like to help produce educational content around a topic in your field of work, please don’t hesitate to email me (yourstory@backcare. org.uk), pick up the phone or write a letter. Until next time, enjoy the magazine and take care.
Increase in membership fee
Dr Adam Al-Kashi Head of Research & Editor of TalkBack
After a five year membership rate freeze, we took the decision this year to increase our rates by 10% across the board as a necessary step to counter inflation. This change will be reflected in your next direct debit or renewal form. We appreciate your understanding and continue support. 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
News and letters
Self help plan
A skill for life
SUMMARY TABLE OF THE 5 PARADIGMS BY THE 3 VALUE SPHERES Individual “Health is…”
Relational “Therapy is…”
Institutional “Medicine is…”
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: email@example.com 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 Severnprint, Gloucester.
IntegRal What is health?
Age old myths
Each successive stage includes and goes beyond the depth and power of the previous. Palliation represents the fundamental inception of medicine, addressing the symptom of ill-health. Management recognises the organismic syndrome beyond the symptom. Cure recognises the personality beyond the syndrome. Prevention recognises individual life beyond personality. Integral addresses life beyond the individual. (Note: colours are coded to suggest correlation with the ‘Spiral Dynamics’ model 8 ).
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4 talkback news and letters
Asiatic Pennywort article sparks home-grown interest Our report on the health benefits of this adaptogenic vegetable sparked significant interest. Several people contacted us about growing the plant at home, including our very own Beryl Kelsey from the Hull and East Riding Branch, who came over to say hello at The Back Pain Show in February [Beryl – we look forward to a photo of your crop!]. We also received this email from Mary Scheu who has been eating the Asiatic pennywort for several weeks now and is experiencing great results:
Your article on the Asiatic Pennywort was one of the most interesting and helpful articles I have read. As well as suffering in the past from back pain, I have been living with depression, anxiety and poor quality of sleep. Since reading your article I have been eating pennywort for three weeks now and have never felt better (touch wood). It is easy to find in local shops and we shall shortly be growing our own. I am also a member of Depression Alliance, a small charity. Could I pass on your article and contact details as they would like to spread the word? Thank you. Mary Scheu For those inspired to try this nutritious and medicinal vegetable for themselves, it is available fresh from Thai and Sri Lankan grocers or you can purchase seeds from several companies. We can recommend B & T World Seeds based in France. Their contact details are: B & T World Seeds, Paguignan, 34210 Aigues-Vives, France. Email: firstname.lastname@example.org Telephone: 00 33 (0)4 68 91 29 63.
Bone marrow injections for lower back pain Back pain sufferers may benefit from injections of their own bone marrow cells into their lumbar discs, according to researchers from the Columbia Interventional Pain Centre, USA. Mixed results were presented at the annual meeting of the American Academy of Pain Medicine in early April, ranging from complete pain relief to no improvement. The retrospective study involved 22 patients, with lower back pain lasting an average of four years, who were assessed up to 24 months after receiving the bone marrow procedure. “The results of our case review are encouraging,” said Donald J. Meyer, MD, PhD, the study’s primary author. However, while we do celebrate the recovery of back pain sufferers via any means, it is important to critically appraise even good news. It’s important to note that these were chronic lower back pain patients and we understand that chronic pain does not relate to dysfunction at the local site of pain despite
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objective diagnoses by scan. In fact, Dr Meyer’s own presentation entitled “Know pain, no pain” (at www.knowpainnopain.com) goes on to explain that 60% of pain-free people have spinal abnormalities, and that herniated or collapsed discs, arthritic joints, a pinched nerve, bone spurs, or a twisted or curved spine don’t necessitate chronic pain. We would add that the recent study was retrospective and did not involve control interventions such as sham injections administered by a double-blinded clinician. This means we cannot rule out whether recovery was a consequence of the patient’s own expectation and beliefs. Placebo is, of course, a most powerful therapeutic and curative agent, but we must exercise caution when it is attached to interventions that are unnecessarily invasive, elaborate and expensive. Unfortunately, with a sci-fi upbringing, our society does tend to idolise high-tech approaches to medicine.
textbooks in tablets Long-time BackCare member David Lang contacted us about the issue of heavy schoolbags. David’s 14-year-old grandson Matthew has experienced the problem and come up with a digital solution: I have had an idea that would make my school bag, and those of school children up and down the UK, much lighter to carry around all day. This idea is for all textbooks to be put on to a tablet. I appreciate this will take some time to do and will not be in all schools, but I am suggesting it is done in this way; you could give parents forms asking them to donate some money if they wanted their child going ahead with this and could afford it. Alternatively, or in addition, the school could use the money it gets from the council for textbooks to buy the tablets instead. I can see this working out for most parts of the UK as it would have beneficial effects now and when the students are older. It would not be such a drain on the NHS, with pupils having to attend appointments and receive treatment for back pain. Matthew Lang (aged 14) London N12 Thanks Matthew and David. While the paper aesthetic and physical reading experience would be lost with a tablet textbook, it’s perhaps a worthwhile trade-off in return for helping to safeguard our children’s spinal health. Back pain is such an expensive ailment that investing in prevention would unarguably pay for itself!
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Exhibitions and events new and ongoing campaigns – thanks John!
Since the last issue, the BackCare team has exhibited at three major events. The Moving & Handling People 2013 Conference at the Business Design Centre in London ties in with BackCare’s flagship and field-leading educational series, A Guide to the Handling of People. This year we also presented showgoers with our Carer’s Guide that now comes with a free DVD. The response was overwhelmingly positive and we met with many students and trainers who use the BackCare educational materials as part of their daily lives.
Professional members Alison Trewhela and Nick Sinfield on the BackCare stand at the Olympia Exhibition Centre
The Back Pain Show is a regular February fixture at the Olympia Exhibition Centre in London. This year our stand space was larger than ever and sported our new exhibition banner thanks to the generous donation from Christie’s Care. Head of Research Dr Adam Al-Kashi presented a well-received seminar on the ‘Evolution of Healthcare’ which has been
further developed into the think-piece that appears in this issue on pages 16-19. He was also interviewed for UK Health Radio by station director, John Hicks. The relatively new station, which already boasts 69,000 monthly listeners (40% UK, 40% US/Canada, 20% rest of Europe), was very enthusiastic about the BackCare mission and has offered further coverage around
driving away YOUR back pain pROUDLY EnDORSED bY:
BackCare made a debut appearance at the Health & Wellbeing at Work 2013 conference and exhibition at the NEC in Birmingham. We presented a seminar and had a stand hosting several BackCare Professional members who are collaborating with us on current research and education projects. Overall, the event was very positive, many new contacts were made and we plan to attend next year. An 18-strong team of marathon runners participated in the London Marathon in the name of BackCare. We made quite an impression at mile 16 with our new threemetre-high teardrop banners – thanks to the kind donations from Colebrook Bosson Saunders and Mike Dilke at Relaxback UK. Our new-design runners’ shirts were sponsored by Vitabiotics. Pictures and full report in the summer issue.
The Posture Genie helps you correct your posture naturally as you drive, thus avoiding the twisting that occurs in the lower back and hips from repetitive use of the right leg during driving. It is easy to use and allows you to arrive at your destination in comfort, feeling relaxed and refreshed.
£10 off USE vOUchER cODE:
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Talkback l spring 2013 12/04/2013 09:16
6 meet the professional
World record breaker Lucy, left
Swimming has the best strokes for back pain I
am fortunate enough to have a career that allows me to follow my passion: swimming. I have swum competitively for more than 20 years and one of my personal highlights is that I currently hold several FINA Masters World Relay Records. Growing up with swimming, I took all its benefits for granted. Only after completing my psychology degree and setting up my own Adult Swim School did I fully begin to appreciate the physical and psychological benefits of swimming correctly and regularly. Soon after setting up my business, clients began approaching me following a recommendation from their doctor or physiotherapist that swimming would help with their back pain. Initially, I was wary as I’d seen how debilitating it can be and I didn’t want to make it worse. However, following some research, my confidence and understanding of how swimming could help increased, which was reflected in the results my clients were reporting to me.
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World record breaker and professional swimming teacher Lucy Lloyd-Roach talks to us about the benefits water-based exercise can bring to those living with back pain.
My clients, with back pain, have various levels of swimming ability. Some have never swum before while others have been swimming incorrectly (keeping their head out of the water) and have found that swimming aggravates their back. You only have to go down to your local pool to see the number of people swimming with their head up. This means that your back takes the weight of your body rather than the water and puts pressure either on your
neck or lower back causing pain in these areas. Swimming correctly means swimming with a neutral spine – the water providing a support for your back taking the pressure/ strain off it. To help imagine what this is like, the buoyancy of the water has been reported to make us feel like a tenth of what we do on land. This is a particularly amazing feeling when we’re used to our back supporting the majority of our body weight. Often my clients report that they don’t feel any pain in the water. One client memorably described the feeling as “outside of the water I can’t do anything, but inside the water I’m free”. To swim with a neutral spine you can
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swim on your front or back. Scientifically, due to the positioning of your lungs, it is easier to swim on your back, allowing you to feel the water supporting your head, neck and spine. However, we’re all different and some people may prefer to start on their front. To maintain a neutral spine while swimming on your front means swimming with your head in the water. Maintaining this comfortably requires breathing with the correct technique and is the key to relaxed swimming. When breathing inefficiently people can become tense/panicky, affecting their enjoyment of swimming, their co-ordination, and thus limiting the benefits of swimming. This is where the guidance of a good swimming teacher comes in (not all teachers understand the importance of breathing properly). Whether it’s a beginner or a more advanced swimmer I always start with breathing. Everyone is different and it takes different amounts of time to relax and to understand how to breathe in the water. For new and more experienced swimmers this may take a couple of sessions or it might take six months or more. Patience is key as once you have it right, the benefits are priceless. In addition to stretching and relaxing the back, swimming can help strengthen the core muscles, which in turn may bring benefits such as improving functional mobility and decreasing pain experienced while doing everyday tasks. The crucial property of water that helps to strengthen
The positive impact swimming can have on people with back problems continues to amaze me muscles is its resistance, which is estimated to be 4-12 times more than performing the same action on land. To help illustrate why water resistance varies take the example of walking: in shallow water there’s more resistance than walking on land and walking in deep water (with the aid of a flotation device) there’s more resistance than walking in shallow water. Due to the strengthening and stretching/ relaxation that swimming brings, a nice benefit of this is that my clients report a reduction in medication. There seem to be a number of commonly reported outcomes around this. Some clients find that, after swimming, the pain relieving effects can last until the end of the day or for a few days, thus reducing dependency on medication. Others have stopped taking medication altogether. So far, I have outlined a few benefits of swimming, but don’t just take it from me. I’d like to share with you on these pages some of my clients’ experiences. In the next issue of TalkBack, I’ll go into more detail about water aerobics. Lucy Lloyd-Roach
CASE #1: Shabana Azim (age 36) swims 2-3 times a week
I’ve had a protruding/floating disc for 12 years. Five years ago I was very fit, often going to the gym twice a day. I went through a demotivated stage and while I managed to go the gym some days I found I was in a lot of pain afterwards. Before starting to swim, my fitness levels were very low for me. I needed to do some exercise and started to look for something that would help with my back. I had always loved swimming, so two-and-a-half years ago I decided to make some time to swim. Initially, I could swim a splashy length of head up front crawl and would be exhausted at the end. Last year I swam the Great Manchester Swim (one mile outdoors) and a further 6km (outdoors). This year I’m training for the Great Manchester Swim and a 10km swim. Swimming helps with my pain management and is a necessary part of my rehabilitation. During swimming I feel very little or no pain, so I am able to swim longer and build up my fitness level. Swimming has noticeably strengthened my back and core, meaning I can support my back better. During swimming I feel very little or no pain…
CASE #2: Sarah Jones (age 44) swims once a week
I was diagnosed with Facet Joint Syndrome back in June/July 2012. I suffer from inflamed facet joints that cause nearby muscles that parallel the spine to go into spasm, causing poor posture of the back. To correct the spinal curvature ‘manually’, requires me to relax the spasmodic muscles. The problem will never go away but can be maintained. Initially, my motivation to swim was personal. I was depressed with going on holiday and seeing people swimming. I wanted to learn as I was aware of the health benefits and it’s something I had always wanted to do. My fitness levels before I started were not good. I was extremely overweight and in a slightly depressed state. As a result, I struggled to exercise. Six months later, I no longer take anti-inflammatory tablets, I’ve lost 20lbs and I’m the fittest I’ve ever been. I would recommend swimming to anyone with a back problem. I was amazed how such a low impact exercise could take away constant pain; which in turn emotionally eases stress. It’s a fantastic all round exercise and the best medicine for my back pain that I’ve ever had.
Lucy’s credentials Lucy Lloyd-Roach is a BackCare Professional, holding the ASA Level 2 Swimming Teacher’s Award, STA Aquacise certificate and is a member of the Register of Aquatic Professionals. She offers adult swimming lessons in Manchester and can be contacted online (www.swimmingmatters.co.uk) or by phone 0777 278 2884.
Lucy will return in the summer issue to tell us about water aerobics Talkback l spring 2013
8 talkback SUPPORT
BackCare marathon runner EMMA RICHARDSON offers valuable motivational insights in this interview we recorded in the build up to the 2013 London Marathon Emma at the Windsor
Half Marathon 2012
Emma sets her sights on a full marathon Why did you decide to support BackCare? I’ve suffered from back pain since university and it’s been a constant dull ache in my life. Doing simple tasks like washing dishes or vacuum cleaning are made so much harder because, after 10 minutes, my back hurts and I have to lie on the floor (which I’m sure my fiancé thinks is an excuse to avoid housework!). People often suffer from back pain in silence because it’s not a visible pain, but it can have such an impact on your life. This is the reason I chose to support BackCare, so that people who are suffering can be given help. It’s the one charity I can really relate to because of the back pain I suffer.
things I’d love to achieve. Last year, I decided it was time to challenge myself because I’m turning 30 this year and I’d like to finish my 20s on a massive high by completing a marathon, which will be my proudest accomplishment. It’s a big decision because it’s not just the distance but the commitment you have to make to training, but it felt like the right time to try… and you never know whether you can do it until you try.
amazing it feels to tick off a run, especially a long one! It also helps you plan your week when you can see what runs you have to do – sometimes it can be tricky finding time for the long runs. I ended up having to run 18 miles before work on a Friday because I realised I was busy all weekend. Of course, everyone at work thought I was crazy, but that made me feel even prouder of myself. I’ve invested in a new pair
I’ve secretly been jealous of people who do a full marathon and I’ve had it on my list of things I’d love to achieve
How did you get into marathon running?
What sort of personal benefits do you get from running?
I ran my third half marathon last year and after I finished I got the usual questions about when I would tackle a full marathon. My answer has always been the same, which is that there’s no way I could complete a full marathon, my body just isn’t capable of running that distance. But I’ve secretly been jealous of people who do a full marathon and I’ve had it on my list of
The benefits are amazing – obviously it’s good for the waistline, but it’s the world’s best natural mood-booster. Whenever I’m feeling down or unhappy, I always find I’m feeling happier after a run. I think it’s the combination of fresh air, exercise and having time on your own to switch off. Some people use running as a way to collect their
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thoughts, but for me it’s time to switch off from everything, all I concentrate on is listening to my breathing and taking in the scenery. I’m lucky to live by Windsor Great Park and when you’re running through the park with Windsor Castle in the background, it’s hard to stay in a bad mood! There are days when going out running is the last thing I want to do, especially when it’s really cold, but those are the days when you feel most proud
of yourself if you can get out of the front door. Running gives me such a sense of personal accomplishment and that makes it all worthwhile. Can you tell us how you’ve been preparing for the London Marathon? I found a four-month training plan on the internet which I’ve been following. To motivate myself, I printed a huge copy of it and stuck it on my kitchen wall; every time I complete a run I tick it off on the chart. You can’t overestimate how
of trainers with heat moulded inserts – they are moulded to the shape of my foot and they’ve made such a difference (no more blisters!) so I definitely recommend them. The final thing I’ve done is to read lots of articles about people who have completed the marathon, it’s a great motivator when you hear about others who have run their first marathon and how great they felt afterwards. It certainly makes it easier to get out of bed on a Sunday morning for a three hour run!
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Self help plan is your own personal trainer Following the release of his ground-breaking self-management programme, physiotherapist and BackCare Professional, Nick Sinfield will be presenting some of the key concepts as a mini-series over the next few issues of TalkBack. He starts today with an overview of the ‘Personal Health Plan’. The Back Pain Personal Health Plan (PHP) is a way of empowering people with longterm back pain to be able to take greater ownership and responsibility for the condition. Over time, we have all become too reliant on the medical profession to treat back pain when, in most cases, the best and most powerful solutions can be provided by the sufferer. The PHP was developed in the context of increasing adoption of the biopsychosocial, patient-centred model of treatment. Blending these management approaches offers a more comprehensive management of back pain. It offers a standardized systematic model of care for
the treatment of this condition, but remains an individualised plan for each patient where they select the relevant self management skills to plan their recovery. A Personal Health Plan can best be described as a focused self-help journey that, over time, manages and controls the condition and builds a stronger body and mind, thereby reducing, or even eradicating, the pain. Because you and your commitment to achieve a solution are the primary motivators, a PHP is often the most beneficial course of treatment to the back pain sufferer and surprisingly the most cost-effective. Once you have the
knowledge and skills contained in the PHP, you could just implement it on your own. Alternatively, you may benefit from the additional support of working in conjunction with both professionals and nonprofessionals, particularly family and friends. Having additional people involved provides you with a mentoring facility much the same as a personal trainer in a gymnasium. The goal of the PHP is to get you started in the right direction. The philosophy behind it is based on the premise that both your mind and your body can affect the level of your pain. It will give you a solid foundation of knowledge and back pain relieving exercises.
By committing to this simple exercise programme, you’ll establish healthy new habits that you can build on, throughout your life. The PHP has been designed to be flexible so you can work through it at your own pace in order to allow it to fit in with your busy schedule. You can choose which sections provide the most benefit to support the management of your condition. It can also be used in conjunction with treatment from a healthcare professional. Based on current medical research, the PHP offers practical advice and information to help you control your back pain better and make the most of life.
Overview of The Back Pain Personal Health Plan learning stage
action planning/goal setting
Identify from the Back Pain Personal Health Plan (PHP) which skills will most benefit your recovery n cognitive behavioural therapy n prevention and treatment n exercise programmes n action plan
n The PHP structure allows you to plan how and when you will put these new skills into action n Identify your lifestyle goals: short, medium and long term
n Work consistently towards your goals by following your action plan n Work independently, with a friend or with the guidance of a healthcare professional, to achieve your goals n Over time adapt, evolve and progress your action plan as you control the management of your condition
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10 corporate partners
Work related back injuries: what are your legal rights? HSE statistics revealed that in 2012 almost half of all work related injuries and illnesses were musculoskeletal disorders, which includes back injuries. This is a growing concern, especially for employers. Work related back injuries
The causes of back injuries and back pain can occur through many work situations. The common roles and actions can include: Heavy and/or repetitive manual handling Manual handling is a term relating to the moving of items by lifting, lowering, pushing, pulling and carrying. When carrying out manual handling, it is important for an employer to consider the weight of the item as well as the distance the item is being carried/pushed/pulled, the height the item is being lifted from and is being put to, the frequency of the manual handling as well as any awkward posture whilst carrying out the task such as twisting, bending or stretching. Back injuries arising out of manual handling can be an isolated incident which consists of a single/one off action, or a cumulative injury which consists of manual handling over a period of time. It is possible that an employee can carry out manual handling over a period of time which then leads to one or a series of back related incidents during their employment. Poor posture Back injuries arising as a result of poor posture often involve employees performing a task that requires them to work in an unnatural position for long periods of time. It is important that an employer considers the height and size of the employee for the job they are doing as well as the set up of their workstation. Poor posture can consist of stooping, bending over, crouching, stretching,
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twisting and reaching. Manual handling and poor posture can occur in most workplaces and particularly susceptible jobs/industries include: l ground workers (manual handling and posture) l construction workers (manual handling and posture) l road workers (manual handling and posture) l general labourers (manual handling and posture) l nurses and care assistants (manual handling and posture) l warehouse workers (manual handling and posture) l manufacturing (manual handling and posture) l delivery workers of heavy goods (manual handling and posture) l office workers (posture)
The legal framework
Management of Health and Safety at Work Regulations 1999 These regulations require employers to assess the risks of the tasks to be performed by the employee so that they can identify the measures they need to
have in place to reduce the risk to the employee. Manual Handling Operations Regulations (1992) These regulations impose a duty on the employer to take appropriate measures to avoid the need for manual handling of loads which involve a risk of an employee being injured. The key duties from the above include carrying out a risk assessment for the specific task identifying hazards involved in the task, assessing the risk of harm posed by the hazards, evaluating the consequences of the risk and using risk reduction control measures. Where a risk assessment identifies potential injuries from manual handling loads and an employer cannot reasonably avoid the need to undertake manual handling, the employer should make a suitable and sufficient assessment of the manual handling operation. The employer should then take reasonable steps to control the risks found and reduce the risk
A musculoskeletal disorder is a term for any injury, damage or disorder of the joints or other tissues in the upper and lower limbs or the back. Once an individual has developed damage to their back, it can have an impact on other parts of the body such as their shoulders, neck and legs.
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to the lowest level reasonably practicable. The employer should implement and monitor the controls put in place and ensure adequate ongoing training is given to the employees.
Some employees will already have a pre-existing back condition. This could be through work or outside of work and may have even happened many years ago. These symptoms may have appeared to have resolved but may actually have made the spine vulnerable to develop further damage more easily than if the pre-existing condition had not developed. Alternatively, the symptoms may be ongoing but do not appear to be significant or hindering an employee’s ability to carry out their work normally. Employers and employees have mutual obligations in the workplace towards each other. While employers have a non-delegable duty of care regarding the health and safety of their employees, employees also have duties such as the duty to prevent risks to their own health and others, as well as the duty to inform their employers about any health problems or concerns they may have at work. Once an employee has developed a back injury or back pain, whether it is through work or not, an employee is under a duty to inform their employer as soon as possible. This puts the employer on notice and the employer is then under a duty to carry out an individual risk assessment and if any potential risk is identified, the employer should then reduce that risk to the lowest level reasonably possible and continue to monitor the employee. Positive steps should be taken by the employer to make sure they do not engage in manual handling or work with poor posture that could potentially cause further harm. Often, employees who have developed back injuries require time off work due to the severity of their symptoms. Measures the employer could look at taking in these situations may include a phased return back to work, putting the employee on lighter duties, providing mechanical assistance, providing assistance from other employees, and redeploying the employee in a different area of the company. Continuing to carry out manual
handling or working with bad posture without amended duties or an amended workstation may result in an employee’s condition worsening.
Tips for employees
If you are carrying out manual handling at work or working with poor posture and are concerned, speak to your employer and visit your occupational health department. It is best if you can put it in writing so that it can be put on your personnel file. If your employer is reluctant to assist you and you are a member of a Trade Union, you should speak to your safety representative. You should also see your GP for specialist medical advice and your GP may be able to provide you with a note which details the problems you are experiencing and what aspect of your work might be causing or aggravating your symptoms. If you have developed a back condition, or you have had a pre-existing back condition which has been aggravated or made worse by work, you should seek legal advice. If your employer is not able to accommodate the recommendations by your GP or occupational health department and your employer is seeking to dismiss you on capability grounds, you may wish to seek legal advice regarding your employment rights. In English law you take your victim as you find them and discrimination in the workplace is forbidden. An employee who has had pre-existing back problems or developed a back problem since working for their employer has just as much right not to carry out manual handling or work with poor posture that could give rise to an injury as anyone else.
CASE #1: Mr ‘H’ manual worker
Mr H worked in the construction industry for many years carrying out very heavy manual handling. He had a pre-existing back condition before he started working for his employer. However, at the time his symptoms did not appear to be too significant to him and his symptoms were under control. A few years into his employment, his work changed and became full time and permanent. Shortly after, he began to notice his back pain symptoms come on and worsening. He reported his symptoms to his GP and his employer. However, his employer failed to take any action and continued to expose him to heavy manual handling and poor posture which could give rise to an injury. As a result, his symptoms worsened and he had to take time off work now and again and eventually had to leave his employment with the employer due to his symptoms and take up alternative employment. It also affected how he went about his daily life. Mr H brought a claim against his previous employer and recovered compensation for the injuries he sustained as a result of his employer’s breaches as well as compensation for his loss of earnings.
If you are having difficulties with your back or symptoms generally and believe that work is to blame, you may require some advice on how to improve your health and safety generally at work and to minimise your risk of injury. Alternatively, you may wish to consider seeking compensation from your employer or previous employers for your back problems. Hundreds of thousands of people each year suffer from bad backs caused by work and a large percentage of these are entitled to compensation which can run into tens of thousands of pounds. Please do not hesitate to call Roberts Jackson on freephone 0808 252 5097 or email email@example.com for free legal advice quoting Back 123 and ask to speak to Leila or one of her team. Roberts Jackson Solicitors www.robertsjackson.co.uk Roberts Jackson is a law firm which is regulated by the Solicitors Regulation Authority (SRA number 512695)
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12 Your stories
I’m not just an
Alexander fan, I’m a disciple
have always been a hard-working, practical and rational person, with a positive outlook. So when I suffered a riding injury at the age of 27 it simply wasn’t in my nature to let it take over my life. I am a keen and experienced rider, but one day I hurt myself when trying to remount an 18-hand horse. As I put my foot into the stirrup, the horse started to walk and I quickly had to pull myself up into the saddle. But my body twisted as I struggled back into position and I was badly winded. Shortly afterwards I started to suffer from neck pain and, what felt like, at the time, a series of random complaints including numb and tingling fingers, headaches and indigestion. I visited my GP to discuss this list of seemingly unrelated ailments and was diagnosed with a possible problem in my back, even though I wasn’t experiencing any pain there. Keen to get to the bottom of it, I made an appointment with my GP’s own chiropractor, where I discovered that I had knocked my spine out of alignment in two places. The mystery of the unusual symptoms had, on the face of it, been solved.
The chiropractor administered a spinal adjustment treatment designed to ‘straighten’ my body out and alleviate nerve interference and bodily discomfort. The first session did lessen the intensity of my symptoms, but the relief was short-lived. I quickly became dependent upon monthly re-alignment sessions to reduce the pain and stiffness to a more manageable level. Even then, the benefits lasted for only a matter of days and my mobility would deteriorate as the weeks passed until my next visit to the clinic. Unfortunately, I had become resigned to the fact that this was what I needed to do to manage my condition. My need to alleviate the unrelenting discomfort
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in one position for any length of time, but again the relief was minimal. I even missed my oldest friend’s wedding as a result. It was upsetting and frustrating not to have been able to see her get married and, to a certain extent, for that decision to have been beyond my control. Despite being a level-headed person, the feeling of not knowing where to turn next in search of a more permanent pain management solution was becoming overwhelming and infuriating. I was not even looking for complete pain relief; just something to make life that little bit easier.
Struggling to manage
regularly meant that I continued to visit the chiropractor every month for 10 years, spending about £4,000 in the process. Deep down, however, I yearned for a more impactful solution; something that would provide more permanent relief. So when I moved house and couldn’t find a chiropractor in the area, the discovery of an osteopath felt well-timed. I hoped she would be able to offer a new perspective on my approach to pain management. But time went on and, in the same vein, I had to attend monthly appointments to experience only minimal, short-term pain relief. In the two years that followed, my condition, at its worse, completely turned my life upside down. It got to the stage where, after only just leaving the osteopath’s clinic, I would be in unbearable pain and couldn’t face long car journeys. I used an ice pack in my thoracic spinal area to try to ease the discomfort when sitting
After a holiday to Egypt in 2006, where I enjoyed a Thai massage, I switched my monthly osteopathic appointments for equally helpful, but more cost-effective, sports massage treatments, complemented only by biannual visits to the osteopath. To a certain extent this worked, but I was all too aware that I was completely dependent on these physical treatments that only other people could administer. Knowing how much I was struggling to manage the pain and stiffness, my HR manager at work suggested I try the Alexander Technique. Her father had learned the principles of this ‘way of being’ after suffering a stroke and needing to walk with a stick. She said that he had experienced such a significant recovery that he had thrown his stick away. While I am not someone to get carried away with sensationalism, this story, from someone I trusted, gave me hope. I turned my attentions to finding out how I, too, could learn about this technique. I found a teacher on the Society of Teachers of the Alexander Technique website (www.stat.org.uk) and booked a couple of lessons. Surprisingly, after only the first lesson, I felt a dramatic difference. Perhaps it was because I wanted it so
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Horse-riding enthusiast Annette Shaw battled with excruciating neck discomfort and stiffness for 10 years before the Alexander Technique shed a completely new light on her approach to pain management...
much, or perhaps because I am open minded and eager to learn, but it all just clicked. I felt like a giraffe as I walked on to the street from my first lesson! It was as though my neck felt long and free because I reeducated my mind and body about the impact of poor posture and movement. By lesson three, my teacher believed I had learnt enough to incorporate the technique into everyday life and manage the situation myself. However, I knew I had progressed so much in such a short time that I wanted to deepen my understanding of the Alexander Technique principles. I continued my lessons and it is safe to say I didn’t just become a fan; I became a disciple. Four years on, my symptoms – neck pain and stiffness – are a thing of the past, and I accredit that to my application of the Alexander Technique in every part of my life. The Alexander Technique can sound too good to be true, and it certainly felt that way for me when I first learnt about it,
Four years on my symptoms, neck pain and stiffness, are a thing of the past but it does require commitment from the individual, too. It is a preventative way of being, not a treatment, and this is why it works. It does not offer an instant fix or the short-term pick-me-up that can be experienced following an appointment with a chiropractor, osteopath or masseur. After years of my body being placed under unnatural pressure, I have had to learn again how to move and use my body. But in taking on this responsibility for my physical and emotional health, I regained an element of control and dismissed the feeling of confusion and frustration that had dominated my thoughts for so long. Gone
are my fears of moving and doing. I even apply Alexander Technique principles to other elements of my lifestyle, everything from tackling my nerves and controlling my breathing before I go on stage with my amateur dramatics group, to helping me control stressful situations in ordinary life. The fact that this behaviour now comes to me naturally is a good thing, because there is less chance of me reverting to old habits and once again succumbing to my old symptoms. Not everyone will be lucky enough to experience such a profoundly positive effect after so few lessons. However, the more you learn and understand about the technique, the greater your chance of progressing towards being pain free. Life is not a rehearsal. We only get one chance at it. I think the Alexander Technique should be taught in schools as a skill for life, to act as an insurance policy to help us cope better with whatever problems lie ahead of us.
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Campaign trail update Schoolbag Campaign
Caring for Carers
specially designed for informal carers due to be launched soon. ‘Caring for Carers’ is of course the theme of this year’s BackCare Awareness Week (7-11 October) and we’re excited to be making such a positive impact on the millions of at-risk UK carers.
Builder’s Back Pain
by teaming up with Pristine Condition – world leaders in manual handling training. Their method is based on a combination of an Olympic weightlifting technique and a behavioural change intervention that impacts the whole organisation from top management to worksite. With a protocol proven to reduce injuries by 88-100%, we’d like to see it become a national standard. In March 2013, our campaign was recognised and adopted as a national initiative by the Societal Impact of Pain – an EU medical politics platform. We hope this will pave the way for further support as the campaign moves forward.
The UK is home to six million informal carers who look after a disabled or otherwise impaired loved-one. Our Carer’s Guide now comes with a free DVD that features real carers demonstrating safe moving and handling techniques in their own homes. The response has been overwhelmingly positive with several thousand copies already snapped up by county council back care advisors for distribution into their communities. In addition, BackCare has just formed a partnership with the training experts at ARC Learning. Together we’ll be creating a suite of gold-standard educational courses, including one
The construction industry is the worst offender when it comes to manual handling related injuries and 40% of workers over 50 now suffer from chronic back pain. In 2012, BackCare made ‘Builder’s Back Pain’ the theme of the 2012 Awareness Week
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The average UK schoolbag weighs double the medical safe limit. Earlier in the year, we announced that the long-standing campaign for new legislation to protect our children’s growing spines had gone global. Dr Winn Sams, a South Carolina based chiropractor and founder of the Backpack Awareness Council, has spent six years campaigning for change and is expecting to receive New York’s final draft bill any day now. The state of New Jersey will be using the same template for their own new legislation and there are several other states waiting in the wings. Joining forces with BackCare, Winn inspired the creation of BackCare’s Global Schoolbag Campaign action group on LinkedIn. She has recently been working with BackCare Professional Helen Brister to create UK and US petitions on the Change.org website. The next step will be to create a global platform online to integrate the local successes of campaigners into one unstoppable worldwide movement.
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Your back pain treatment probably won’t work... if you keep smoking A recent study involving more than 5,000 back pain patients has shown that back pain treatments tend to fail if you continue smoking. Dr Glenn Rechtine and colleagues at New York’s University of Rochester looked at both surgical and non-surgical treatment outcomes in both smokers and non-smokers. While non-smokers were able to improve with treatment, those who continued to smoke during treatment saw no clinically significant improvement in their pain. However, smokers who quit during treatment were able to achieve successful treatment outcomes. The researchers concluded: “This study supports the need for smoking cessation programmes for patients with a painful spinal disorder.” REFERENCE Title: Smoking Cessation Related to Improved Patient-Reported Pain Scores Following Spinal Care Authors: Behrend C, Prasarn M, Coyne E, Horodyski M, Wright J, Rechtine GR. Journal: Journal of Bone and Joint Surgery, 94(23):2161-6. Publication Date: 5th December 2012 Online record: www.pubmed.gov/23095839
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Prevention is better than cure Part 2
What is health? “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. In the latest instalment of this ongoing educational series, we’ll be taking the title of the series literally, looking at how we define health and presenting a developmental model of healthcare.
The Institute of Medicine (IOM) defines the patient-centred approach as “providing care that is respectful of and responsive to individual patient preferences, needs, and values Talkback l spring 2013
INCLUDING THE HUMAN IN HEALTHCARE
The highly complex and multi-factorial traits of health status are a dynamic interplay between genome and envirome – that is to say, our health is an ongoing dialogue between nature and nurture. Enviromics is the formal study of factors influencing organismic systems, but to a high degree within our increasingly post-modern societal consciousness we simply intuit the biopsychosocial model. The human organism inhabits several dimensions, at least including biochemical, biomechanical and psychosocial. The recognition and adoption of fuller sets and depths of these dimensions within the healthcare process renders access to more complete and sustainable outcomes for the patient, practitioner and policymaker.
THE PATIENT-CENTRED MOVEMENT
Recent decades have seen an evolution of the values animating the therapeutic alliance between patient and practitioner. We have witnessed a movement away from authoritarian modes of relation towards the increasing realisation of a patient-centred approach. The Institute of Medicine (IOM) defines the patientcentred approach as “providing care that is respectful of and responsive to individual patient preferences, needs, and values, and ensuring that patient values guide all clinical decisions”1. Don Berwick, formerly of the Institute of Healthcare Improvement (IHI), goes a step further to forward a more highly elaborated description: “the experience (to the extent the informed, individual patient desires it) of transparency, individualization, recognition, respect, dignity, and choice in all matters, without exception, related to one’s person, circumstances, and relationships in health care”2.
BALANCING THE THERAPEUTIC ALLIANCE
This dawning confers an important shift in patient engagement and compliance. While the authoritarian must enforce their prescription, the truly patient-centred practitioner operates in collaboration with the patient. Since the patient is invested in co-authoring their prescription, the issues of engagement, compliance and motivation are transformed. However, while the patient’s own goals and values are an important inclusion
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in this upgrade from authoritarian healthcare, it is the practitioner’s responsibility to balance patient needs with their own, namely the practitioner’s need to foster patient development from reactive/ symptomatic towards proactive/preventative and beyond. Simply put, the patient’s own preferences and judgements may be largely incompatible with health. It is important to acknowledge that failing to engage the patient’s intrinsic developmental capacity deprives them of access to increasingly sustainable versions of health and becomes our most insidious and epidemic contravention of the essential Hippocratic edict.
THE RECONSTRUCTION OF HEALTH
Before we can begin to rethink healthcare, it’s important to ensure that we are clear on what we mean by the word ‘health’, and there are at least two routes we can take here. First, a brief lexicographical reconnaissance of contemporary definitions yields important insights. The Oxford English Dictionary defines health in a conventional sense as “being free from illness or injury”. Merriam Webster adds to this picture the notion of “flourishing” as well as the dimensions of “mind, body and spirit”. The Wikimedia Foundation’s Wiktionary speaks of “wellbeing, balance and overall level of function” and alludes to a spectrum of dimensions, “from the cellular level to the social level”. However, of the definitions briefly surveyed, only the World Health Organisation (WHO) makes the final emphasis, in contrast to still-prevailing convention, that “health is a state of complete physical, mental and social well-being, not merely the absence of disease or infirmity”. This definition has remained unchanged and served as a guiding principle since the organisation’s establishment in 1948. A second approach to the meaning of health is via the etymological route, delving into the origin of words. The word ‘medicine’ derives from the Latin verb ‘medeor’, meaning to ‘heal’ or bring to ‘health’, which in turn are found in the Old English ‘hælan’ (heal), to make whole, and ‘hælþ’ (health), to be whole. Unravelling this notion of becoming whole, we find the Greek ‘holos’, to become entire, complete and to bring to full development. It’s important to note that the etymological route does not lead us to an absence of disease (Old French ‘desaise’, lacking comfort or opportunity) or pathology (Greek ‘pathos’, suffering). It’s also important to be very clear that this ‘word play’ is not an exercise in pedantry. The very orientation of our medical and healthcare departments and institutions, as well as societal health consciousness, hinges upon what these words actually mean to us – the medicine that seeks an absence of symptoms looks very different to the medicine that seeks full human development. As philosopher, Ludwig Wittgenstein (1889-1951) declared, “The limits of my language are the limits of my world”.
A DEVELOPMENTAL MODEL OF HEALTHCARE AND ENGAGEMENT
Once we adopt health as a positive developmental process, it becomes essential to establish a coherent map that can guide the upbringing toward increasingly powerful models of medicine. Maps are merely abstract representations, so the emphasis here is not on dogmatic codifications but rather on a map that is conducive, operational and judged by its consequences. A suggested framework for the comparative assessment of healthcare paradigms would be to consider the following three faces3:
A INDIVIDUAL LEVEL: To what degree does this medicine permit and empower the individual to not only experience fulfilment but to recognise and engage their own development? B RELATIONAL LEVEL: To what degree does this relationship fulfil the shared need of both patient and practitioner for the ample provision of effective care, education and inspiration? C INSTITUTIONAL LEVEL: To what degree does this healthcare system facilitate effective and sufficient access to health within financial and human resource constraints? Natural systems and the models that describe their development, point us toward a universal toolkit of underlying processes (such as described by Systems and Complexity-type theories). Structural commonalities of developmental models include the unidirectional transition through a series of consecutive, self-consistent paradigms or stages4. A spectrum model of healthcare and patient engagement is hereby forwarded, ascending through five vertical stages, namely: 1-Palliative, 2-Management, 3-Curative, 4-Preventative and 5-Integral.
FEELING BETTER OR FEELING LESS?
Palliative care (Latin ‘palliare’, to cloak/mask) seeks symptomatic relief through the suppression of biological processes. While, palliative care may be a valuable response to acute emergency, the goal is not to feel better, rather to feel less. The underlying implication is that the organism is broken and disease is effectively incurable – rather disempowering in all but the shortest of terms. Relationally, the therapeutic alliance is authoritarian. The patient delegates their health to the objective professional expert. Engagement with the patient’s cognitive and emotional apparatus is economised and typically sufficient only for the overarching goal of compliance. Treating symptoms rather than the individual means that the patient can be processed rather speedily, especially with the dispensation of pharmacotherapy. However, since treatment provides only transient symptomatic relief, the patient remains an indefinitely dependent consumer, unless recovery is allowed or facilitated. Overall, palliative care is the most expensive and least effective option as a standalone medical model.
TAKING CONTROL OF DISEASE
Disease and pain management operates on the understanding that quality of life is subject to multiple influences. The management approach seeks to improve quality of life despite, and in the face of, on-going illness, most significantly by starting to involve patient psychology. Drug and manual therapies may be employed in conjunction with nutrition, exercise and psycho-technologies (cognitive, affective, and meditative) – harnessing a variety of domains that influence the expression of symptoms and quality of life. However, though this marks the beginnings of a patient-centred model, the inclusion of the mind in the management approach is fundamentally exploitative from the perspectives of higher-order healthcare models (i.e. curative and beyond). Moderating the symptoms/expressions of disease via the mind is essentially a more sophisticated version of biochemical suppression or biomechanical dissipation. In short, as long as disease is deemed incurable, the medical relationship with the human organism is suppressive (as in palliative) or manipulative (as in management) but not truly collaborative (as in curative) or beyond. continued on p18
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RE-ORIENTING SYMPTOMATIC BEHAVIOURS
In keeping with the underlying structure of development, each successive stage includes and goes beyond the power and depth of the previous. Successive models of medicine integrate more of the total human reality. New integrations marking stage transition unlock the emergent properties of new paradigms. While disease management integrates multiple palliative disciplines as well as patient psychology, curative medicine represents the first paradigm to relinquish the imposition or maintenance of limiting/ disempowering beliefs (e.g. “chronic pain is incurable”) and their supporting cognitive frameworks. Many of the psychological tools in the curative toolkit may also be found in a management approach, but their power is capped by the cognitive framework into which they are situated. Unlike palliative care where a drug can be administered in the virtual absence of psychological engagement, the curative process involves a complete reorientation of the patient’s understanding of their disease process from “I am broken” to “disease is a dynamic behaviour”. Again, in keeping with developmental dynamics, the drive toward completeness is balanced by the need for constancy. This latter need manifests in patients as well as practitioners and policymakers as an inability or unwillingness to engage with a higher-order paradigm to the degree that breaches their existing model. Higher-order paradigms can appear ‘soft’, untrue, uncomfortable, and bad or even offensive from preceding perspectives. Management approaches are now popular in modern national and private healthcare organisations, but curative medicine requires a depth of engagement that remains largely prohibitive for patients, practitioners and policymakers at this time.
THE EMBODIMENT OF HEALTHY LIFESTYLE
Despite the power of the curative paradigm and its incidental consequences, the therapeutic alliance is only formed once the individual becomes symptomatic. The curative focus remains a return to health rather than a growth towards increasing health. By contrast, preventative medicine begins to integrate medicine with lifestyle, transforming the temporal dimension with respect to patient engagement. It’s important to point out that by far the most commonplace and visible conception of ‘preventative medicine’ is merely the addition of preventative prescriptions to the palliative and management models. Fully fledged, preventative medicine is the embodiment of an entirely new orientation and outlook on living whose instillation resembles education rather than traditional healthcare. Unlike preventative prescriptions, where ‘exercise’ and ‘healthy eating’ are advised and subject to the compliance issues of an authoritarian relationship between patient and medicine, true preventative medicine is embodied by the individual for reasons that are their own, i.e. health becomes an identity rather than a coerced/ incentivised subscription. Nutritional and psychophysiological practices become subject to the same category of motivational mechanisms that drive and govern an individual’s pursuit and attainment of high-level proficiency in a serious hobby about which they are passionate. The role of the practitioner is transformed from remedial to educative, ensuring the individual’s health-promoting practices are effective and fully differentiated – for example: the lay “exercise” conception may be differentiated into cardiovascular,
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strength, calisthenic protocols; and the lay “think positive/don’t stress” conception may be differentiated into cognitive, affective and meditative protocols. While the focus remains the maintenance of health, effective psychophysiological practices catalyse the individual’s exposure to the experience of health as a growth process, thereby paving the way for further stage transition and emergence.
THE PRIMACY OF PURPOSE
Individuals who truly engage with the preventative paradigm often gravitate towards the field of ‘personal development’ as they naturally search for frameworks and communities that support their evolving outlook. However, even with healthcare and lifestyle firmly integrated, there remains at least one further integration and transition to be made. Once the individual feels that their basic needs (survival, comfort, socialisation and success) have been largely met5, a switch occurs from a sense of deficiency to abundance driving a newly predominant need for generative expression, particularly in the context of a perceived purpose or in fulfilment of a social/world need. This marks the integration of one’s life with one’s work as the primary focus shifts from material remuneration to serving a purpose beyond personal biography – the term ‘life mission’ is apt to convey the sense of primacy that accompanies this emergence6. The role of the ‘healthcare professional’ is again transformed in a move towards increasing decentralisation of the medicine, from the authoritarian doctor to preventative educator and now to the role of the mentor who inspires growth through an embodiment of growth. Intriguingly, this stage also marks a re-orientation from the ‘comfort zone’ to its boundaries and beyond where life conditions are more challenging but also more conducive to further growth. Disease itself is recognised as valuable feedback and part of a conscious internal dialogue on the ‘efficacy’ of one’s life path. With sickness, health, life and work all integrated into one deeply coherent stream of personal effort and experience, this stage is termed ‘Integral’. The fundamental premise of any developmental model is a ‘vertical’ dimension/axis along which growth through stages of increasing power is realised. It cannot be over-emphasized here that the ability to grasp and embody a given stage is a consequence of actual growth rather than of being convinced or persuaded. Just as one cannot be usefully persuaded into being a concert pianist or being fluent in a foreign language, so too can one not be persuaded into embodying a stage of development that has yet to grow within. This caveat serves two purposes: firstly to disarm the aforementioned notion that development is a matter of opinion; and, secondly, because there are profound consequences for how we apply a developmental approach to healthcare. Understanding that stage transition cannot be persuaded into patients, practitioners or policymakers alike, there is a three-fold duty to: meet them where they are, facilitate best practice at their existing stage, and foster stage transition through the design of ‘educational’ initiatives. To close on a thought-point, literature on the nature of such ‘educational’ initiatives suggests that development occurs in response to experiences that are “structurally disequilibrating, personally salient, emotionally engaging, and interpersonal”7.
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SUMMARY TABLE OF THE 5 PARADIGMS BY THE 3 VALUE SPHERES Individual “Health is…”
Relational “Therapy is…”
Institutional “Medicine is…”
Each successive stage includes and goes beyond the depth and power of the previous. Palliation represents the fundamental inception of medicine, addressing the symptom of ill-health. Management recognises the organismic syndrome beyond the symptom. Cure recognises the personality beyond the syndrome. Prevention recognises individual life beyond personality. Integral addresses life beyond the individual. (Note: colours are coded to suggest correlation with the ‘Spiral Dynamics’ model 8 ). REFERENCES/FOOTNOTES
1 Institute of Medicine. “Crossing the Quality Chasm: A New Health System for the 21st Century”. 2 Berwick, Don. “What Patient-Centered Should Mean: Confessions of an Extremist”. 3 The three irreducible value spheres – 1st person/subjective, 2nd person/intersubjective and 3rd person/objective – are found in numerous works throughout history, including those of Plato, Karl Popper, Jürgen Habermas, Immanuel Kant, Gautama Buddha, and Ken Wilber. 4 Examples of developmental models comprising discrete consecutive stages include: Jean Piaget’s theory of cognitive development; Michael Commons’ model of hierarchical complexity; Jane Loevinger’s stages of ego development; and Lawrence Kohlberg’s stages of moral development. 5 As in Abraham Maslow’s ‘Hierarchy of Needs’ with the appeasement of basic, ‘deficiency’ needs as being pre-requisite to the emergence of ‘being’ needs. 6 See the work of Søren Ventegodt. He has nine papers archived on PubMed with “life mission” in the title. Full text is available for most of these. 7 See “Promoting Advanced Ego Development Among Adults”, by John Manners, Kevin Durkin and Andrew Nesdale in the Journal of Adult Development (2004) – full text is freely available online. 8 See “Spiral Dynamics – A Model of Human Values Development”, by Don Beck and Christopher Cowan, based on the work of Clare W. Graves.
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Old age is the period of life after middle age, but the exact boundary between the two is subject to ever changing social interpretations. Nonetheless, many agree 65 years to be a reasonable definition. In this new educational series, we’ll be looking at back pain and health in the context of ageing and the elderly. The goal of this series is to make sure we are working with an up-to-date understanding of ageing by reviewing the modern research and theory.
Ageing is Not a Disease HOW OLD ARE WE?
One of the greatest impacts of the industrial revolution has been the extension of life through modern medicine, new technologies and the affordability/accessibility of better living standards. Life expectancy has risen since the dawn of the industrial revolution in the 18th century, to around 80 years today (77.7 years for men and 81.9 years for women; Office of National Statistics dataset 20072009). The UK is home to an ageing population in common with other western societies where standards of living and healthcare mean the old are getting older, while our busy professional orientation means there is less emphasis on having children. Between 1984 and 2009, the number of UK adults aged over 65 rose to nearly 10 million – that means one in six people in the UK are elderly. In the same period, the number of over-85s have doubled and the centenarians have tripled, while there has been a fall in under-16s. We are now living so old that popular culture has invented new language to describe it: approximately one in every 10,000 centenarians live to become ‘supercentenarians’, meaning they have lived to reach 110 years or 1,000,000 hours! Our increasing life expectancy is a testament to the successes of modernity, but while we’re living longer we’re not necessarily living happier, healthier or wealthier in our old age. For this reason it is becoming increasingly important for us to understand the true relationship between your chronological age and the symptoms associated with ageing.
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UK population change 1984-2009
Elderly people should not do intense exercise Many older people feel marginalised as victims of discrimination and prejudice at the hands of age-related stereotypes. But the bigger threat is actually the myths surrounding old age harboured by older people themselves. In this first instalment of ‘Ageing is Not a Disease’, we are tackling one of the biggest myths which continues to damage the health of older people. When we think of weightlifting1, a prevailing societal stereotype is that lifting heavy weights in the gym is for young men, not for women and certainly not for elderly people. Regardless of whether you personally accept this stereotype, we can certainly understand it and appreciate how dominant it is in our society.
Mainstream media has bombarded us with imagery of sedentary older people and any suggestion of exercise is accompanied by fear-driven messaging like, “take it easy”, “nice and slow”, and “relaxed pace”. Yet when we look at the actual scientific evidence surrounding the appropriateness, benefits and safety of weightlifting in elderly populations, we find that our common sense is anything but sensible. The National Institute of Health (www. ncbi.nlm.nih.gov/pubmed) has archived 243 research studies2 focused on weightlifting in elderly people, spanning 24 years (1989 to 2013) and research institutes in 21 countries. Decades of scientific breakthrough have been distilled for quick and easy digestion:
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TOP 7 MYTH-BUSTING RESEARCH INSIGHTS 1) Weightlifting is safe and effective Overwhelmingly, the research shows that elderly men and women can safely participate in highintensity weightlifting to build muscle effectively, build strength and increase functional mobility in elderly men and women with limited mobility. 2) Most studies looked at elderly women More than half the research involved female participants, and a quarter of all studies focused on elderly women only. This throws the stereotype on its head because we now know that weightlifting profoundly benefits elderly women. 3) Even 90-year-olds participated More than half the research involved participants aged 70 or over, many involved the over-80s and several studies looked at men and women in their 90s. This shows that age, even very old age, can no longer be considered a viable justification for inactivity. 4) Mind and memory Several studies showed that weightlifting benefited the brain, causing a sustained improvement in memory and cognitive function – this is exciting because cognitive decline and dementia are associated with ageing in our society. 5) Bone metabolism Osteoporosis is another age-associated
condition that is amenable to improvement through weightlifting. This discovery has profound implications for independent living because elderly people typically never recover full mobility and confidence after fragility fractures. 6) Insulin sensitivity Several studies measured an improvement in insulin sensitivity index after a programme of weightlifting. This signifies that their risk of developing type-II diabetes had been reduced (though this is unsurprising as insulin resistance3 is associated with sedentary lifestyle). 7) Systemic inflammation Weightlifting in the elderly was found to reduce blood levels of several inflammatory biochemicals4 that are associated with a number of chronic illnesses including Alzheimer’s disease, prostate cancer and rheumatoid arthritis.
An inevitable yet empowering caveat We are duty-bound to point out the obvious that – much like crossing a road, driving a car or even preparing a hot beverage – weightlifting and ignorance do not mix. It remains the responsibility of the individual to take the educative measures necessary to ensure they engage with weightlifting in a manner appropriate for their level of physical conditioning (as assessed by accepted methods; i.e. a confident and optimistic person may overpredict their ability, equally a fearful and negatively habituated person may feel they are entirely unable). Nonetheless, overwhelming evidence of the last 24
years makes it clear that our stereotypes of what women and elderly people can achieve are plainly incorrect, and that high-intensity weightlifting confers profound benefits to multiple organs and systems of the body in elderly people, both men and women, including those in their 80s and 90s. As we take on board new information and upgrade our obsolete common sense, we find there are fewer ‘hiding places’ for the outof-date reasoning that has previously justified our society’s widespread self-neglect. No longer can we think of intense exercise as being inappropriate for elderly people. If anything, the research shows it provides
benefits not accessible through aerobic or low-intensity exercise alone. And at a time of life when cumulative stresses collide with a slowing of restorative capacity, one might argue that this kind of physical activity is in fact essential for maintaining health into old age. But don’t take my word for it; here are parting words from the researchers themselves:
Pat – The Mighty Atom, aged 67 After 20 years as a staff nurse at Clacton Hospital, Pat Tombs took early retirement at 50. She joined a gym when she turned 60, working as a cleaner at the gym to pay for classes, and made national news headlines last year as the “powerlifting pensioner” in the best shape of her life. At 56kg and 5'1" high, Pat can lift 80kg above her head. She stunned judges when she set three British records for her age in squat, bench press and deadlift during a recent championship. “I have been shy my entire life, but powerlifting has given me so much confidence,” said Pat. “They nicknamed me ‘The Mighty Atom’ at my gym because I am small but strong!” She has since studied to become a gym instructor and hopes to qualify as a personal fitness trainer.
Dr Rachel Marom-Klibansky, Faculty of Medicine, Tel Aviv University, Israel “Resistance strength training in elderly of both sexes leads to similar or even higher values for muscle mass and strength compared to young people, reduces the body fat continued on p22
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from p21 mass, body weight and helps to preserve the active tissue mass. More beneficial effects are an improvement of posture and physical stability, improved flexibility and mobility capacity, a better cognitive function and a lower level of depression. The beneficial effects of physical activity in the very aged and frail elderly include physiological, metabolic, psychological and functional adaptations, which can substantially contribute to the quality of life and cannot be achieved by other treatments.” Professor Kevin Tipton School of Sport, University of Stirling, Scotland “Chronic resistance exercise training clearly is an effective means of increasing muscle mass and strength in elderly individuals.” Dr Darren Candow, Associate Professor, University of Regina, Canada “Muscle loss with age has a negative effect on strength and functional independence. Resistance training has a
positive effect on muscle mass and strength in the elderly.” Dr Charlotte Suetta, Senior researcher, University of Copenhagen “In recent years, strength training has emerged as an effective method to induce muscle hypertrophy and increase muscle strength and functional performance in frail, elderly individuals. Furthermore, there is increasing evidence that strength training is an effective method to restore muscle function in postoperative patients and in patients with chronic diseases.” Professor Frank Mayer, Dean of Human Sciences Faculty, Potsdam University, Germany “The elderly need strength training more and more as they grow older to stay mobile for their everyday activities.” Professor Burkhard Weisser, Director of Institute of Sports Science, University of Kiel, Germany “It is well established that the level of physical activity is lowest
in elderly people. Physical fitness continues to be the most important protective health factor and should be improved in the elderly population.” Professor Maria Singh, Research Supervisor, University of Sydney, Australia “Weightlifting improves insulin sensitivity and glycemic control, increases muscle mass, strength, and endurance, and has positive effects on bone density, osteoarthritic symptoms, mobility impairment, self-efficacy, hypertension, and lipid profiles. Weightlifting also alleviates symptoms of anxiety, depression, and insomnia in individuals with clinical depression and improves exercise tolerance in individuals with cardiac ischemic disease and congestive heart failure. All of these aspects are relevant to the care of diabetic elders. Moreover, weightlifting is safe and well accepted in many complex patient populations, including very frail elderly individuals and those with cardiovascular disease.”
Dr Boyd Foster-Burns Department of Exercise Science and Physical Education, Arizona State University, USA “Strength training is known to be an effective means of increasing muscular strength and size in many populations, and can significantly improve muscle strength, muscle mass and functional mobility in elderly women up to the age of 96. Such exercise can minimize the syndrome of physical frailty due to decreased muscle mass and strength. Any rehabilitation or exercise programme for the elderly woman would benefit from such a training regime.” Dr Robert Mazzeo Department of Integrative Physiology, University of Colorado “The major challenges facing healthcare professionals today concern the implementation of educational programmes designed to inform elderly individuals of the health and functional benefits associated with regular physical activity, as well as how safe and effective such programmes can be.”
References and footnotes 1) We now understand that the skeletal muscles not only enable us to move about, but also have an ‘endocrine’ function, secreting hormones into the bloodstream affecting every organ and tissue in the body. Running, swimming and cycling are great for the cardiovascular system and for emotional renewal, but are not sufficiently intense to stimulate muscle growth (‘hypertrophy’) and cannot access the benefits seen with muscle-building exercise (also know as ‘resistance exercise’ or ‘strength training’, such as weightlifting). ‘Intensity’ refers to how much weight or resistance the muscle moves against and it can be gauged by how many times you can lift a weight repeatedly until the muscle fails. If you lift a given weight 30 or 40 times then it is simply too light to stimulate growth, although this would be good for a warm up. Typically, the repetition range for growth needs to be less than 20, with 6-12 considered ‘moderate intensity’ and 1-6 considered ‘high intensity’. Research shows that high-intensity resistance exercise is both safe and more effective than lower intensity in elderly people. An actual weightlifting programme would consist of a few
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sessions per week doing a few different exercises with warm up sets followed by more challenging intense ‘work sets’. As the muscle and nervous system grows and adapts from session to session, the weights are slowly increased to maintain a ‘progressive overload’. 2) The specific search performed was for studies with “elderly” in their title and with either “resistance training”, “resistance exercise” or “strength training” in their title, summaries or keywords, including only new studies and excluding reviews of prior studies. Undoubtedly, there may have been some more obscurely worded studies that were missed, but this search will certainly have uncovered the majority of research in this area. 3) Insulin is a hormone secreted by the pancreas when your blood glucose level increases, e.g. after a meal. The key function of insulin is to communicate this elevation of blood glucose to the liver and skeletal muscle which then begin to store the surplus glucose in the form of glycogen (another hormone, glucagon then triggers the liberation of stored glucose when needed). Individuals with
insulin sensitivity cannot properly regulate their blood glucose leading to chronically elevated blood glucose and serious long-term health problems including heart disease, strokes, kidney failure and blindness. 4) Specifically, studies found reductions in blood levels of interleukin-6 (IL-6) and tumour necrosis factor-alpha (TNFα) which are associated with prostate cancer, Alzheimer’s disease and rheumatoid arthritis; leptin, which is associated with stress and obesity; and several other related biochemicals.
Acknowledgement I’d like to acknowledge BackCare member, Miss Elizabeth H. Dickinson who wrote me a letter to highlight the unmet needs of the elderly which served to inspire this new series – thank you, Elizabeth. Dr Adam Al-Kashi
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TalkBack is the quarterly magazine of BackCare, serving those with a personal or professional interest in back pain with news, views and edu...
Published on May 9, 2013
TalkBack is the quarterly magazine of BackCare, serving those with a personal or professional interest in back pain with news, views and edu...