The magazine of BackCare, the UK’s National Back Pain Association
AUTUMN n 2021
A long haul on the path to long Covid
FREE TO MEMBERS
also in this issue: Spines get thirsty, too Water doesn’t just quench our thirst Backing the future Childhood posture
Apps and toolkits Self help ways to reduce the pain
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TALKBACK LEADER 3
Lockdown and beyond… IT HAS been a tough time for everyone, regardless of our age, regardless of our health or whether we are studying, working or living in retirement. Slowly, we are coming out of different lockdowns (depending on which area of the UK we live in) and the restrictions placed on us during a global pandemic none of us will have ever witnessed or predicted in our lifetime. Who knows whether we face more enforced lockdowns as we approach another winter with the prospect of new variants that scientists the world over are trying to understand and protect us against. If the pandemic has taught us anything, it is that we have to be agile enough to accept new ways of living, adopt our own coping mechanisms and adapt to the need for spending more time at home, whether we are working, studying or simply occupying ourselves. This brings to attention how our spines cope with this. Are we sitting for too long, are we hunched over desks to work on laptops or are we simply ignoring the fact that for bone health we need to exercise because we cannot do things that we would normally do? Our 2021 National BackCare Awareness Week, which runs from 4-8 October, will be the largest awareness week we have organised – and all during a pandemic when our committed
staff and volunteers are operating remotely. For 2021, we have chosen to focus on the need to protect our spines during these uncertain times when many of us are still spending more time in our own homes. You can access our BackCare Awareness Week information at www.backcare. org.uk. Other important news is the imminent publication of our long-awaited, 7th edition of The Guide to the Handling of People (HOP7). We are especially proud that work on producing this edition has continued despite difficulties posed by the pandemic. Furthermore, we have also been able to include important information about the additional requirements related to moving people during such a pandemic. BackCare has always prided itself in working together with other organisations to improve awareness and education about neck and spine related issues. As part of that, TalkBack likes to invite other charities to talk about their work and in this edition we welcome Dr Dale Webb, PhD who lifts the lid on living with axial SpA.
Membership enquiries contact Email firstname.lastname@example.org Tel 0208 977 5474
‘Higher mortality risk’ for women 4
Long Covid: does it make back pain worse? 6/7
The BackCare team
CONTACTS Advertising enquiries contact Margaret Floate Advertising Manager Email email@example.com Tel 01483 824094
Media enquiries contact Email firstname.lastname@example.org Tel 07751 667645
Awareness Week: lots of help 10/11
Other enquiries Denice Logan Rose Email email@example.com Tel 07751 667645
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: firstname.lastname@example.org 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.
Keeping active: putting your mind to it 22/23
Sciatica: the painful truth 26/27 TALKBACK l AUTUMN 2021
4 TALKBACK NEWS
IF you have a few hours a week to spare to help BackCare we would love to hear from you. We have recently been offered some pro bono office space in Bradford and Aberdeen which means we could welcome on-site volunteer assistance at these locations for the first time. Plus, we welcome support remotely. There are many tasks we need assistance with and so, whatever your skills and however many hours you have to offer us, we are sure there will be something meaningful you can contribute to BackCare and help support us in helping people who are living with back pain, regardless of cause. For further information contact denice. email@example.com or phone her on 07751 667645.
Your unwanted items could help us IF you have unwanted items they could be of use to BackCare. These include games consoles, mobile phones, video cameras, digital cameras, iPods, laptops, tablets, gold, silver, foreign banknotes and coins and more. We have freepost labels/ envelopes for your smaller items and free sacks for larger items. For more information about our partnership with Recycling for Good Causes, contact info@ backcare.org.uk or phone us on 0208 977 5474.
Legacies live on… IN 2020, BackCare received two substantial legacies. The two donors understood our work in trying to help those living with pain and our work in research and education. If you would like to remember us in your will, contact firstname.lastname@example.org or phone us on 0208 977 5474.
TALKBACK l AUTUMN 2021
Back pain might be linked to higher mortality among women
‘Higher mortality risk’ for women who have back pain NEW American research has identified a higher risk of mortality for women with back pain compared to women who don’t suffer from the condition. The overall results of the Boston Medical Center study also found the mortality risk was increased for adults with more severe back pain, while mild discomfort was unlikely to affect lifespan. The potential links between back pain and mortality included reduced daily living activities
and movement that may result in weight gain and the development – or worsening – of serious health problems. Back pain has also been linked to balance issues and falls, which could cause fractures that, in turn, may contribute to higher mortality. The investigation, which was published in the Journal of General Internal Medicine in April, involved researchers reviewing 11 studies covering 81,337 middle-aged and older adults.
Move to expand occupational health A WIDE-RANGING programme to expand occupational health (OH) for NHS staff has been launched. The move follows the vital role the OH service has played throughout the Covid-19 crisis supporting employees’ health and wellbeing. The Growing OH programme’s aims include boosting workforce capacity and capability, increasing proactive and preventative care, and ensuring equality of access to “services that
meet the needs of all our diverse NHS people”. Its discovery and co-design phase includes collaborating with users, physiotherapy workers and other stakeholders through a 10-minute online survey to evaluate and build on best practice. If you use the service or are involved in delivering it, you can take the survey. A spokesperson for NHS England and Improvement said the initial consultations
TALKBACK NEWS 5
Research finds arthritis and Covid link Council and the Italian Ministry of Health. “This is a step forward in understanding why inflammation continues in both RA and Covid-19 and may provide a potential target for the future treatments for both conditions,” said Dr Aylott. The work was led by Dr Mariola KurowskaStolarska of the Research into Inflammatory Arthritis Centre Versus Arthritis in collaboration with Professor Elisa Gremese at Fondazione Policlinico Universitario Agostino Gemelli. Their results were published in the Journal of Clinical Investigation (JCI) Insight in June. © iStock.com
RESEARCH into immune cells in Covid-19 patients and people with rheumatoid arthritis (RA) could help the development of new treatment strategies for both conditions, including long Covid. A study found similarities between the cells, called macrophages, in the lungs of people with a severe case of the virus and in the joints of RA patients. Both involve the gene SPP1, which triggers the production of a protein that may contribute to inflammation. Dr Caroline Aylott is head of research delivery at Versus Arthritis, the charity that funded the investigation along with the Medical Research
Cell similarities have been found between Covid-19 and rheumatoid arthritis
for NHS staff “will inform future ‘blueprints’ for potential service delivery models, and subsequently the development of a longer-term programme of work and investment plan”. The vision behind Growing OH, which launched in July, has been drawn up with key strategic partners, among them the NHS Health at Work Network, the Faculty of Occupational Medicine and Social Partnership Forum members.
Back pain drugs ‘may give little relief’ MUSCLE relaxing drugs widely prescribed for low back pain may give little effective relief, an Australian study suggests. While the non-benzodiazepine antispasmodics may help acute pain in the first two weeks, the benefit is seen as not clinically meaningful, and their use might increase the risk of an adverse side effect. Muscle relaxants, a class that includes non-benzodiazepine antispasmodics, were prescribed more than 1.3 million times in England in 2020. The study analysed their efficacy, acceptability and safety through a systematic review of randomised controlled trials involving more than 6,500 people. The researchers, however, emphasise their findings are drawn from “very low and low certainty evidence” and that there were no trials available that assessed long-term outcomes. Their work, which was published in July in The British Medical Journal, also calls for large, high-quality, placebocontrolled trials to be conducted to resolve uncertainties about the efficacy and safety of muscle relaxants for low back pain.
World Spine Day 16 October THE THEME for 2021 is Back2Back, focusing on highlighting ways people can help their spines by staying mobile, avoiding physical inactvity, not overloading their spines and adopting healthy habits such as weight loss and stopping smoking. Visit www.backcare.org.uk
for more information about World Spine Day.
TALKBACK l AUTUMN 2021
6 TALKBACK INVESTIGATING THE INFLUENCE OF LONG COVID
Long Covid: is it making The pandemic has With Covid-19 increased back pain likely to linger incidence We have all experienced significant and abrupt for some time to routines both at work and home yet, PROFESSOR disruption because of Covid lockdown and restrictions FRANCES on freedoms. Those with low back pain have reduced seeking medical attention, management WILLIAMS from and support – but back pain cases have begun King’s College to escalate, perhaps because many are working from home in sub-optimal conditions and lack the London and her exercise of travelling to and around the workplace. team, ROGER Up to half of people responding to questionnaires COMPTE throughout the UK, Europe and the US have experienced new back pain episodes since the BOIXADER pandemic began. and ISABELLE The SARS-CoV-2 virus induces the illness Covid-19, which is associated with symptoms in GRANVILLE many different organ systems. At the beginning of SMITH, explain the pandemic, Covid-19 was thought to be mainly a respiratory disorder. However, nearly two years how the down the track it is recognised that it may affect pandemic has multiple body systems. affected rates of Myalgia or widespread muscle pain and unusual joint pain are commonly reported symptoms of low back pain and Covid-19. Such pain likely reflects the immune discuss whether response to viral infection, including production patients with long of cytokines and other inflammatory mediators. These have been well documented in Covid-19 Covid may be patients as well as multiple other infections more susceptible including flu. The production of autoantibodies has been detailed in some patients and is the to chronic low subject of current research efforts. back pain. How the body produces these antibodies is influenced by our genetic make-up, and our genes may be responsible for the type of response we have to a virus. Genetic diversity in Covid-19 patients has been associated with illness severity and outcome. But that is to be expected. In fact, it has long been recognised that our response to viral or bacterial infection is regulated through our host genetics. Individual differences and genetic predisposition are currently the core hypotheses of many studies aiming to decipher the response to SARS-CoV-2 and the development of long Covid.
Persistent symptoms Long Covid, or post-acute Covid syndrome, describes symptoms that persist past the usual infective period of two or three weeks. “Long” when referring to Covid-19 symptoms has differed between research groups, but now the National
TALKBACK l AUTUMN 2021
Our unfamiliarity with long Covid can heighten fears over how long symptoms might last Institute for Health and Care Excellence (NICE) has reasonably proposed symptoms lasting beyond 12 weeks from the first day of symptoms. This is because many viral infections have effects that last for several months as a normal part of the illness. The Covid Symptom Tracker app from King’s reports that around 5% of people logging symptoms on the app have gone on to become “long-haulers”. Other estimates are higher – a study from Imperial College London including half a million participants found as many as 37.7% of Covid-19 patients still experience one or more symptoms at 12 weeks. Different methods of data collection and interpretation of symptoms may explain the dissimilarity of these estimates. Nevertheless, with infection so common in the general population and new infections continuing, the number having long Covid in the UK is likely to increase. People experience long Covid in different ways, and there are currently no tests or biological markers for the condition. People tend to experience long Covid symptoms in waves or intermittently – some days patients seem to be recovering, and the next they are so sick they can barely get out of bed. An additional problem is that only around half of those who have been sick with Covid-19 display any immunity, meaning re-infection is possible, which may be confused with long Covid. Like the symptoms of Covid-19, long-haul symptoms are extremely varied. Below are the more commonly reported symptoms: l fatigue l myalgia
TALKBACK INVESTIGATING THE INFLUENCE OF LONG COVID 7
chronic back pain worse? l breathlessness or shortness of breath l poor sleep l mood disorders: anxiety/depression l heart palpitations/chest restriction or pain l unusual muscle pains l poor concentration or “brain fog” l loss of, or altered sense of, smell or taste l persistent cough. Two of the most common symptoms of long Covid are fatigue and myalgia. Fatigue is far more debilitating than feeling tired or run down, it can be so extreme that people may be unable to get out of bed. Myalgia can range from a dull, persistent ache to a very sharp, nerve-type pain. Post-acute Covid syndrome, like SARS-CoV-2, can affect several biological systems at once. Two post-Covid symptom clusters have been identified; the first dominated by respiratory symptoms and the second by fatigue complaints. Such findings may go some way toward helping researchers untangle whether post-acute Covid syndrome is really one disorder – or in fact, several different post-viral illnesses.
Who gets long Covid? The short answer is anyone can get long Covid, but there is a slightly increased risk in certain groups. The UK government and the National Institute for Health Research (NIHR) have supported the Longitudinal Health and Wellbeing National Core Study aimed at understanding how and why long Covid comes about. Diagnosing and treating physical and psychological long Covid triggers is an important goal of the work. Trials of current medications used for other conditions and collaborative work with many clinic centres is included within the project. Twin research at King’s College London is contributing to one of these longitudinal cohort studies; it will use electronic health records and other patient data about Covid-19 and long Covid for more than one million participants. An important new finding of the study noted that as age increases, up to 70, so does the occurrence of long Covid. There were also slightly higher rates of long Covid seen in the following: l women l those with a high BMI (overweight or obese) l people with asthma l people with poor mental health (pre-pandemic) l people with poor physical health (prepandemic).
Other research has found patients who had more serious Covid-19 illness and people who smoke or vape are more likely to develop long Covid. Poor pre-pandemic mental health and general health are new conditions to be associated with long Covid. In the future, we may gain a better understanding of how the contributions from genetic variability, general health and socio-economic characteristics lead patients to experience Covid-19 and if they develop long Covid.
Are back pain and long Covid linked? Back pain is common, but the good news is that there is no current evidence linking long Covid with an increased risk of developing or experiencing back pain. For example, the Covid symptom tracker app data, which early in the pandemic showed loss of smell and taste as a significant predictor of infection, has shown the proportion of people reporting unusual muscle aches and pains are similar for those with both Covid-19 and long Covid. As early as April 2020, research from China reported those with rheumatic diseases, which are mostly autoimmune, were more likely to experience higher levels of inflammatory markers – akin to that experienced during a rheumatological flare as well as worse respiratory distress or failure than their counterparts without rheumatic disease. However, autoantibodies can be produced during Covid-19 by people without autoimmune disorders and may be found to be a pre-cursor to long Covid muscle and joint pain. The good news is that despite great initial concern autoimmune patients would be at increased risk from SARS-CoV-2, that has not been the case. Covid-19 inflammation can, in rare cases, produce myositis or painful swelling of the tissue around the spine. This could be a potential cause of back pain during long Covid. However, we are still in the early days of understanding the long-term effects of Covid on the body and the prognosis for long-haulers. Research is currently focused on understanding individual responses to the virus and long Covid. Trials using existing medications, such as blood thinners and statins, are also being explored to treat long Covid. We must continue collecting data to better understand the risks of long Covid – and reasons why it develops.
Vaccination holds out the best hope against Covid illness
We must continue collecting data to better understand the risks of long Covid
No evidence yet to suggest long Covid sufferers experience more back pain
TALKBACK l AUTUMN 2021
8 TALKBACK SPINES NEED WATER
Water doesn’t just quench our FOR DECADES, doctors and fitness experts have been telling us that drinking plenty of water is good for our general health and wellbeing. But how many of us ever consider that a lack of proper
hydration could be part of the cause of our back pain? Water affects every organ and cell in our body, but it has particular importance for the spine. That’s because the discs that
sit between the vertebrae in our spinal column are filled with a substance which is comprised mainly of water. These discs act as shock absorbers and stop our bones rubbing against each
By Anthony Padgett, Director of Back in Shape Clinic Ltd
ABOUT IDD THERAPY
IDD Therapy is the fastest growing non-surgical spinal treatment for intervertebral discs with more than 1,000 clinics worldwide and a network of clinics across the UK. http://iddtherapy.co.uk/ Facebook: IDD Therapy Europe Twitter: https://twitter.com/ IDDTherapyDisc
TALKBACK l AUTUMN 2021
l Anthony Padgett is an MSK physiotherapist, IDD therapist and director of Back In Shape Clinic Ltd in Croydon. He has treated some of the world’s greatest athletes at the Crystal Palace National Sports Centre and has lectured for the MSc sports medicine course at the London Hospital.
TALKBACK SPINES NEED WATER 9
thirst… our spines need it too other, especially when moving or bending. You’ve probably noticed we are all a little taller when we wake up in the morning. This is because when we are lying in bed the spine relaxes, there is no downward pressure on the discs and they absorb water, increasing their height fractionally. However, once we stand and start moving, gravity acts downward and the constitution of the discs in our spine begins to change. Whether we’re walking, sitting or standing, it all puts pressure on the spine, causing the vertebrae to continually squeeze our discs, which can then lose water. If we’re not constantly replenishing this lost water, the disc walls can start to dry and crack, which makes them weaker. Simultaneously, the loss of water reduces pressure in the disc, rather like a deflated bicycle tyre, and there is less support, especially as we age. If the space between the vertebrae narrows, or if the disc bulges outwards through the weakened wall, this can pinch or put pressure on sensitive nerves around the spine and can result in back pain or nerve pain in the legs (from lower back) or arms (if coming from the neck). When we’re young, fit and healthy, it’s easier to replenish and rehydrate but, as we age, we tend to drink less water and are less able to retain water as efficiently as we used to. That’s one of the reasons that falls among the elderly happen and why older people have more restricted movement. Even a relatively low level of dehydration can cause dizziness or stiffness. This, added to the overall aging process, can lead to falls. Our spine relies on movement to stay healthy. Having a degree of flexibility and strength is important and movement allows the body to replenish water in the discs. But if
we don’t move our spine, which is common as activity levels decrease, then we can start to lose that flexibility. It comes down to the simple saying “use it or lose it”, which is important in spine health and avoiding back pain.
Key factors in keeping your back healthy l Exercise. Pilates is particularly good for the back. It increases flexibility and improves your core strength. l Follow a healthy diet. l Drink plenty of water – about two litres a day is ideal. If you don’t like the taste, flavour it with some fresh lime or lemon but don’t substitute with sugary drinks. l Check the colour of your urine. If you are drinking enough water it should resemble a very pale white wine. If you do find that, despite all your hard work, you still suffer with back pain, the most important thing is to keep moving. It might be painful, but it won’t be harmful, so there’s no need to think you have to lie or sit in one position.
What you can do l Increase your intake of water. l Keep moving, even though it is the last thing you will want to do. l Visit a physiotherapist or other practitioner. l Intervertebral Differential Dynamics (IDD) Therapy for disc problems.
Three years ago, I added an IDD Therapy spinal decompression machine at our practice, having turned down approaches from the manufacturers on three occasions, dismissing it as “only traction”. While it’s not the busiest part of the practice, it is the part I am most passionate about and I wish I had discovered it 20 years ago. IDD Therapy helps patients primarily with
unresolved disc problems, although back pain has many factors and the disc is just one part of the picture. IDD Therapy is expanding because more and more clinicians are seeing such positive outcomes for a category of patient they previously hadn’t been able to treat. I hope at some point IDD Therapy will become the first point of call for people in pain, although it does take time for NICE (National Institute for Health and Care Excellence) to change its guidelines. IDD is a computer-controlled treatment that helps decompress the specific spinal segment that causes the pain. The machine applies a gentle pulling force at a precise angle to take pressure off the targeted disc and to gently mobilise the joint and surrounding muscles. Around three quarters of patients having IDD Therapy enjoy success. This is especially significant when we consider that most of the patients we see for IDD Therapy have failed to respond to other treatments. Whatever treatment patients opt for, I think the most important thing is to remember there is no real quick fix for back pain and patients need to take their own steps as well to make sure they are doing everything possible for a healthy back. While I can do a lot to help and give them relief from the pain, the overall message at my practice is to get people to take responsibility for themselves. It is important people work at strengthening and lengthening their backs through movement and exercise and realise the importance of drinking enough water to make sure those hard-working discs in the spine are replenished and rehydrated. Patients might only see me once a week, the rest of the time the responsibility for their wellbeing is on them. So, as well as offering treatment, I think it is just as important to enable and empower patients to take charge of themselves and do everything they can to be as healthy as they can be.
TALKBACK l AUTUMN 2021
10 TALKBACK BACKCARE AWARENESS WEEK
Awareness week has something for National BackCare Awareness Week 4 to 8 October 2021 THERE are an estimated 540 million people in the world suffering with low back pain at any one time. It remains the leading cause of years lived with disability and the biggest single cause of disability on the planet today and presents a major challenge to international health. Since the global pandemic started, it is reported that the number of people suffering from back pain has risen. While back pain is not necessarily a Covid symptom, it could well be a consequence of lifestyle changes that have been forced upon us. Lack of movement gradually takes its toll on muscles, weakening them slowly before leading often to back pain and Covid has resulted in people engaging less in physical activities. People who would ordinarily participate in sport, or travel to and from work, school or social activities have had their daily lives disrupted. There are enforced changes too, with offices, schools and other educational institutions closing, in favour of working from desks at home and conference calls. Many people are hunched over screens and working at desks and tables not entirely suited for the purpose. Before we look at how best to care for our spines, we need to first appreciate why we need to protect our backs. The spine is one of the most important structures in the body. It helps to keep us upright, supporting our entire body and allows us a huge range of movements. The spinal bones (vertebrae) along with various joints, muscles, ligaments and tendons make up the back and any one of these structures, if damaged, can result in back pain.
TALKBACK l AUTUMN 2021
The vertebrae are arranged in a column which extends from the base of your skull all the way down to the top of your buttocks. These vertebrae function to take most of the weight placed on the spine and protect the very important spinal cord. The 33 vertebrae making up the spinal column are grouped according to the various regions in which they are found: cervical, thoracic, lumbar, sacral and coccygeal. The different vertebrae vary slightly in structure in order to carry out the different functions required at the different regions of the spine. From this small piece of information, we can understand how important our backs are and BackCare Awareness Week 2021 (BCAW 21) brings together materials to prevent strain, prevent pain and protect our backs from avoidable harm. With lockdowns in mind, BCAW 2021 is themed around: l Working from Home l Studying at Home l Spending More Time at Home. But we have not forgotten those who are still working from offices, factories, schools, colleges, universities and hospitals too. BCAW 2021 has something for everyone, including booklets, information sheets, videos and posters to inform and remind us how to support the structure that supports us, day in, day out. For more information, please visit backcare.org.uk/i-have-back-orneck-pain/back-care-awarenessweek/
TALKBACK HOP7 11
The Relaxback UK podcast will be promoting BackCare Awareness Week with interviews from the prime contributors to the theme of “Spending More Time at Home”. For details and links to the shows go to the BackCare Awareness Week page. BackCare Awareness Week info backcare.org.uk/i-have-back-or-neck-pain/ back-care-awareness-week Relaxback UK page relaxbackuk.com Relaxback UK podcast ukhealthradio.com/blog/program /the-relaxback-uk-show/
December release for essential publication The Handling of People (HOP) series has pioneered lifting techniques since it was first published by BackCare 40 years ago. Now, BackCare is pleased to announce the upcoming publication of the 7th edition of The Guide to the Handling of People (HOP7), which will be on general release at the beginning of December 2021. BackCare is proud to be the publisher of what is widely seen as the “gold standard” for the safe handling of people in a health and social care setting. Fulfilling one of our charity’s stated aims of preventing spinal injury through education on a national scale, this book also generates significant income so we can support research programmes and help people already living with neck and back pain through guidance and information. This latest publication in the landmark HOP series comes as the health and social care sector is continuing to experience the most challenging of times as a result of the Covid-19 pandemic. No industry felt the effects of the coronavirus more than health and social care and the efforts and dedication shown by all during this time has been outstanding. HOP7 remains an essential document for all those involved with delivering safe care, mobilisation, positioning or rehabilitation for people receiving assistance. It is intended for all staff working across the health and social care services, and others who may be involved directly or indirectly with the moving and handling of people. This includes senior managers at executive and operational level, policy makers, budget holders and those appointed in each organisation to be responsible for strategic decisions essential for the implementation of prevention-focused, safer systems of work, staff health and wellbeing and improved care in relation to manual handling practice. Person handling and person handling decision making continue to be core skills for health and social care professionals. This updated publication extends the balanced approach defined in previous editions. The philosophy of supporting those receiving care and those delivering care remains key in all sections of the publication – supporting staff with safety and efficiency and allowing those receiving care to be empowered by knowledge, and supporting independence, enablement and personal choice, while also being assured of the best quality of care. HOP7 will be shipping at the beginning of December this year, but BackCare is offering special pricing for prepaid orders. e d practic -centre Person To find out more please contact email@example.com for more information.
7 HOP IDE TO
7th editio rs
Edito Pam Smith, Jacqui
TALKBACK l AUTUMN 2021
12 TALKBACK CHILDHOOD POSTURE
Backing the future: childhood posture WHEN I saw my seven-year-old son doing his homework stooped over his iPad, then getting up, putting his droopy backpack on, and walking to school with rounded shoulders, my heart sank. Had he really developed bad posture already? This got me thinking. We used to care about our backs. The Victorians were regimented about having straight backs, with daughters walking up the stairs with books on their heads. In the 80s, parents sent their kids off for the Alexander Technique. But, in recent years, this really important health issue seems to have been largely overlooked. Not because the problem has gone away. In fact, it’s getting worse. Poor posture in childhood is on the rise, and back problems are being diagnosed in younger age groups1. A study in 2007 found that around 38.3% of primary schoolchildren have poor posture2. A more recent study found that 10% of 10-year-olds have bad backs1.
Tablets and smartphones Why the increase? Well, obesity is more common, and watching TV and lugging heavy bags around are ongoing issues. All three cause rounded backs and lumbar lordosis. And now there is a new problem – tablets and smartphones. Such devices tend to be held at chest level, so the child looks down, protruding their head forward, causing “text neck”. Children and adolescents spend more than five hours a day on their screens3. Schools now use tablets for work in school and at home. Covid has only accelerated this trend. Unfortunately, the counter solution, exercise, is on the down. Most children in the UK do less than one hour’s physical activity a week4. Bad posture causes a number of immediate health issues in children: l Headaches. Maintaining an abnormal head position causes a build-up of tension in the neck muscles. l Pain. In the neck, lower back and joints,
TALKBACK l AUTUMN 2021
By Dr Hannah Scott especially in the hips and knees. l Fatigue. Slouching reduces lung capacity, meaning the body doesn’t get as much oxygen. l Concentration. Sitting up straight increases blood flow and oxygen to the brain by up to 40%. l Mental health. A study in 2015 found children who slumped released more stress hormones and were more tearful, hostile, nervous, quiet and passive. By converse, standing up straight was directly related to elevated mood5. l Confidence. Posture has been shown to have a powerful effect on how others perceive you. The psychologist Jordan Peterson dedicates a whole chapter of his book The 12 Rules of Life to standing up straight with shoulders back for success6. Most importantly, poor posture when young leads to structural back problems later in life. Over time, habits form and the growing child defaults to the position they have become used to, until eventually it becomes the norm. The bones in a young person adapt to the load it is placed under (Wolff’s law). Tissues and ligaments recondition, altering normal development, and these unhealthy positions become fixed. The list of complaints related to structural back problems in adults is endless, including arthritis, gastric reflux, poor
balance, fractures, decreased mobility, even heart problems and a shortened life span7. Correcting structural back problems is far more challenging than correcting posture. As an anaesthetic doctor, I’m only too aware of this. We see patients in chronic pain clinics, with a lifetime of suffering and failed treatments behind them. Or, presenting for an operation, a last resort, which is so woefully fraught with difficulty, back surgeons in the UK are struggling to get indemnity insurance8. The medical communities all agree; it is best to avoid letting backs get this bad in the first place. Prevention really is better than cure. So, it’s time to start getting serious about childhood posture. We are fastidious about kids’ teeth, cleaning and flossing daily, and visiting the dentist regularly (even when bad teeth can so easily be taken out). So, now we need to dedicate just as much effort to our children’s precious, irreplaceable, backs.
AGR awards Our friends on the continent are ahead of the game. In Italy and Germany, when a child starts school, by rite of passage, parents go out and spend some 300 euros on an ergonomic backpack, the item being given as much importance in protecting their children as we give the pram. The Germans have the AGR, an association made up of professionals dedicated to back care. The AGR awards products a seal of approval on complying with back protecting standards. Tables, chairs, car seats, straps and bags are examined and reviewed yearly. Consumers
Watch your back! The Active backpack, with its many ergonomically designed features, is the only bag to be officially endorsed by BackCare. It features a patented, curved underside to help spread the load as well as ergonomic carrying straps and a lightweight profiled back panel for improved ventilation. For more information about price, colours and sizes visit https://backcaretrading.org.uk and search Active backpack.
TALKBACK CHILDHOOD POSTURE 13
The Victorians were regimented about having straight backs, but in recent years, this really important health issue seems to have been largely overlooked look out for the AGR approval logo when buying such items in the same way we look out for the organic logo when buying food9. The good news is, there is a lot we can do right now. l Eye level. Teach your children good posture while using tablets and computers. Bring their device up to eye level. Make sure their desk chair and device are set at the correct height. l Exercise. Get them moving. As little as half an hour extra a week will pull their tissues and ligaments into a healthier position. Sign up to a sports class or walk more – try walking to school instead of driving or taking the bus. l Ergonomic equipment. Buy a backpack with wide straps that places heavy items nearest the back and use both shoulder straps. Consider a standing desk. And check the height of their chairs and desk, looking out for feet being flat on the floor, and straight backs. l Encourage stretch breaks. Every 20 minutes when doing homework or playing computer games or watching TV, get your kids into the habit of having a quick stretch.
l Postural training. When you see bad posture remind your child to stand or sit up straight. This can be done verbally, or by gentle pressing on their back. Physios use a red dot technique – placing red stickers around the house as a visual reminder. When the child sees the sticker, they remember to stand tall. All such reminders are incredibly powerful tools for neuromotor training. And start early. Research shows that to create a habit takes about
300-500 repetitions, but to correct a faulty habit takes about 3,000-5,000 repetitions or about four to six weeks of training10. It is never too late to start. It takes time, repetition and effort, but correcting your child’s posture will profoundly change their lives for ever. l Dr Hannah Scott is a consultant anaesthetist. She did her registrar training at UCLH and affiliated north London hospitals.
Calvo-Muñoz I, Gómez-Conesa A, Sánchez-Meca J. Prevalence of low back pain in children and adolescents: a metaanalysis. BMC Pediatrics. 2013;13(14). Available from: doi.org/10.1186/1471-2431-13-14. 2 Kratenová J, Zejglicová K, Malý M, Filipová V. Prevalence and risk factors of poor posture in school children in the Czech Republic. J Sch Health. 2007;77(3):131-7. 3 David D, Giannini C, Chiarelli F, Mohn A. Text Neck Syndrome in Children and Adolescents. Int J Environ Res Public Health. 2021;18(4):1565. 4 Scholes S. Health Survey for England 2015: Physical activity in children, NHS Digital. Available from: http://healthsurvey. hscic.gov.uk/media/37752/hse2015-child-phy-act.pdf. 5 Nair S, Sagar M, Sollers J 3rd, Consedine N, Broadbent E. Do slumped and upright postures affect stress responses? A randomized trial. Health Psychol. 2015;34(6):632-4. 6 Peterson JB, Doidge N, Van SE. 12 rules for life: An antidote to chaos. Random House Canada; 2018. 7 Katzman WB, Wanek L, Shepherd JA, PhD, Sellmeyer DE. Age-Related Hyperkyphosis: Its Causes, Consequences, and Management. J Orthop Sports Phys Ther. 2010;40(6):352–360. 8 Foy MA. Loss of malpractice insurance for spinal surgeons: why you need to know about the discount rate. Journal of Trauma and Orthopaedics. 2017;5(4). 9 AGR. Available from: https://www.agr-ev.de/en/about-us/agr [Accessed 2021] 10 Paul Chek. Pattern Movements. A Neurodevelopmental Approach to Conditioning. [Correspondence Course]. Surg Technol Int. 2003.
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14 TALKBACK EDUCATION CAMPAIGN
Lifting the lid on axial spondyloarthritis YOU have probably never heard of it – but you can be forgiven, because 91% of the UK population are not aware of axial spondyloarthritis (axial SpA), although it is a condition that affects around 220,000 people in the UK. It affects almost double the number of people who currently live with multiple sclerosis in the UK – and it affects younger people, with the average age of onset just 24 years old.
So, what is axial SpA? Axial SpA is a progressive, painful and incurable form of inflammatory arthritis that mainly affects the joints of the spine. Early symptoms include a back pain that can be a slow or gradual onset over a number of weeks or months. While it mainly affects the spine, it can affect other joints, tendons and ligaments too. Apart from lower back pain, other symptoms can include an inflammatory eye condition known as uveitis, inflammatory bowel disease and psoriasis.
Diagnosing It can be difficult to diagnose axial SpA as it cannot always be easily identified on every X-ray or MRI scan. Those undertaking the assessment need to know what they are looking for to decide upon the correct imaging. Around 40% of axial SpA patients are referred to ophthalmology, gastroenterology or rheumatology because of secondary symptoms and have not had their primary condition of axial SpA first diagnosed. Worryingly, the diagnosis of this serious condition can take more than eight years from the onset of symptoms and, in the meantime, irreversible damage can be done. Dr Dale Webb PhD, CEO at the National Axial Spondyloarthritis Society (NASS), and his team are trying to change this.
Symptoms starting shortly Pain in the lower back Improvement with movement Nightime waking Early age onset
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By Dr Dale Webb, PhD, CEO of the National Axial Spondyloarthritis Society “There needs to be an improved education programme and an integrated approach to diagnosis,” said Dr Webb. “A faster diagnosis will enable people to get the right care earlier and start living well with axial SpA sooner. While many young people wait for a diagnosis, some withdraw from socialising and find it harder to establish careers, form relationships and start families. For some people, a late diagnosis can even cause their spine to start to fuse, with irreversible damage caused. “Our findings tell us that there are four main reasons for the delay in the diagnosis of axial SpA and we are using these as our basis to be the first organisation in the world to initiate a ‘Gold Standard Time to Diagnosis Programme’ of one year from onset of symptoms to diagnosis.”
Causes of delay in diagnosis
SpA symptoms are picked up, people are encouraged to see their GP. “We know how difficult it can be for people to approach healthcare professionals about a condition they have no prior knowledge of, and so we have put together guidance for patients undertaking their first appointment with the GP and the consultant rheumatologist. “From a healthcare professional’s perspective, we provide advice for the GP for onward referral in the form of individual patient printed information from the symptom checker for a clear care pathway. “To reach our target of Gold Standard Time to Diagnosis for all patients by 2024, we know education and awareness are key and we are doing everything we can to improve knowledge for all in being better informed about the symptoms of axial SpA, which will lead to more informed decision making from early diagnosis onwards.”
At NASS, we believe that delays in diagnosis are caused by: l long-term back pain that people tolerate, without seeking medical assistance l primary care, where symptoms are often mis-diagnosed as a mechanical problem l patients not being directed to the right services in their care pathway l waiting many months for rheumatology appointments.
Reducing the time to diagnosis
“Awareness is key to addressing this serious problem. NASS’ national implementation plan to reduce the time to diagnosis includes improving public and healthcare professionals’ awareness so its existence is known and its key symptoms understood,” said Dr Webb. “We have recently introduced an online symptom checker. If five or more axial
Treatment for axial SpA aims to: l reduce pain l reduce inflammation l reduce disease progression l help patients to continue normal activities. Symptom control includes medication, physical therapy and living a lifestyle to support wellbeing.
NASS works with policymakers, funders, service commissioners and professional bodies to raise awareness and funds and make sure that every patient, every time, has early diagnosis and access to effective treatment and rehabilitation. Further information about early diagnosis of axial SpA can be found at www. actonaxialspa.com. You can also visit the main NASS website https://nass.co.uk/
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16 TALKBACK IMPROVEMENT TO FIND EQUILIBRIUM
The Alexander Technique… USUALLY, people take lessons in the Alexander Technique as a way to help their back pain or as a method for improving artistic performance. This wasn’t my reason as I didn’t know that I needed it, I was just curious. However, I walked away from my first lesson feeling as if I’d been introduced to my body for the first time and it was thrilling. I felt lightness, ease, internal energy and a sense that I was working correctly. I floated away from my teacher’s house and knew I wanted to train to teach it. The technique was developed by an Australian actor, FM Alexander (1869-1955). He had experienced vocal problems (in the days before microphones) which left him unable to work and had been treated by various doctors but showed no signs of improvement. After much self-observation, he identified a pattern of movement that constricted his throat and interfered with the natural workings of his body. When he was able to prevent the movement in response to the stimulus of projecting his voice, he was able to find a permanent solution to his problem. He recognised that change needs to be brought about by the individual to be effective and that we (our mind and body) work together as an integrated whole. When
By Andrea Hughes, a member of the Society of Teachers of Alexander Technique (STAT) you disrupt one part of it (in particular, the relationship between the head, neck and back), then you alter the natural balance and harmony throughout. Therapeutic benefits such as reduced back pain, neck and shoulder pain, headaches, joint problems and stress disorders are experienced by addressing how a person interferes with the natural workings of their body. Balance can also be improved and this is also applied to the distribution of weight on the joints.
Muscle spindles There is proof from an Oxford study that if we harbour tension in the muscles beyond a certain point, the muscle spindles (the transmitters) that send the message up to your brain cease to work. When the muscle spindles are doing their job, and we have the ability to listen to our body, then we have more feedback and can make better choices. This heightened awareness allows us
Alexander Technique active rest is a practice that can easily be done at home using a talk-through guide (there are many free ones on the internet and on my website). A short daily practice can show you how to release excess tension from your body. Position yourself on a firm surface with a few books to support your head, have your feet hip width apart and use a blanket to stay warm
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to notice unnecessary fixing, pushing or contracting at the idea of performing a task or as a reaction to a thought. If we are worried, our body can contract with a fear response, pulling our head back and down, the shoulders in or fixing our ribs which then alters our breathing. Sometimes, this response may be necessary, but often it can occur habitually due to work pressures or social pressures and only serves to do harm by distorting our form, altering our breathing and creating internal stress. By learning the technique, we can still have the thoughts but not disturb our internal workings in response. I have found that by noticing when I tense myself (for instance, clenching my jaw) in response to a negative thought and then releasing it, I am able to let go of the thought also and respond appropriately in the moment. Since I have reduced my physical tension, my mind has also calmed, bringing me a sense of peace. I used to work in a pressured job in television production. I was aware I had back pain, but didn’t know then that my response to stress is to pull my tailbone back and up and hold it there. The solution when applying the Alexander Technique is to recognise habits that interfere with the ease and mobility within our body and notice the tightness, rather than actively try to pull the body into a different position. Initially, thoughts of maintaining length, depth and width in your body and mobility in the top joint of your neck (this is higher than you think and is in line with the upper part of your ear lobes) need to be applied consciously, but eventually they become integrated into how you move and think. My lower spine is now able to move freely, which, in turn, allows other parts of my body to move freely too (I discovered that I held my breath, in addition to my lower back).
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an explanation I recently taught someone with similar back problems as myself. She had exhausted every avenue of treatment, but still had persistent back pain and reduced mobility which affected her enjoyment of life. With no medical explanation for her problem, she is now looking to herself and, with the help of the technique, becoming aware of her habits of tension and habitual contraction – just as Alexander did. The change and understanding required to learn and apply the technique isn’t an instant solution to a long-standing problem but, like learning any skill, takes practice. When applied, the student becomes aware of many things that happen within the mind and body and have more choice over their current state. Long-term effectiveness for musculoskeletal pain conditions has been demonstrated in two large randomised controlled trials1 and, in addition, learning the technique is often associated with good posture. Improved posture and body mechanics are associated with better balance, coordination and greater ease in all activity.
Physical response However, a common misconception of good posture is to be up and straight but, as the body is meant to move in multiple directions, how can there be a correct position? Learning the technique brings about an expansion and a quality of how you use your body, while freeing your mind of the notion that you need to fix parts of your body (such as pushing your chest out as a sign of strength or forced confidence). It is this expansion or desire not to reduce your internal space that can lead to improved aesthetics of uprightness, wide shoulders, free limbs and true confidence. This may sound esoteric, but the concept is actually very simple (and the technique is completely practical). If we can stop doing the wrong thing (like creating unnecessary tension or contracting our body inwards) then our head will balance on top of our spine, our whole spine will work with the whole body and we will function optimally. Length, width and depth in a person is encouraged and when a person has more
We need to pay attention to how we position ourselves when focused on screens. When the monitor is lower than eye level we naturally drop our head forwards and down towards it which can add up to 30lb of pressure on the spine, causing back and neck pain awareness of this, they notice when they take it away. They can relate the physical response to the situation or movement that caused it, thus learning not to do the same thing with the same stimulus. During a lesson, the teacher uses verbal guidance and a light touch to raise awareness of the amount of tension, ease or effort that the student is bringing to a simple task such as sitting down. This process, the abandonment of your own set of unhelpful habitual tendencies, can then be applied to all activities and responses to thoughts. With practice, you begin to notice how you respond and by applying the technique you develop and retain natural poise and co-ordination despite the demands made of you from the external world. I’ve found that realigning my body with various treatments does little to quell the contractions and internal pressures that I inflict upon myself as my response to life. It is only by addressing the environment in which the pain arose that we can change the outcome. The skeletal alignment, the gait patterns, the thought processes and beliefs about the use of our body are a
Children can easily spend hours hunched in front of a computer screen sitting on a sofa, which is harmful. By sitting them on a ball, they will effortlessly bring small movements into their spine, distribute their weight through their feet and find natural poise up from their sitting bones. Take care to check their environment for sharp edges as children become engrossed in games and loss of concentration could lead to a fall system as a whole and are influenced by the way we live our life. Having an awareness of our internal body while we are operating in the world around us is why the technique can bring about long-term benefits. It helps us to understand how to operate our body either by moving from the correct joints, or by using appropriate tension and balance throughout. It can solve much more than ergonomic problems and poor posture. It is a tool for life that can help you to remain calm and centred and not lose yourself to panic and fear. Having a method to apply in response to your reactions helps you to look after yourself in that moment and I’ve found this to be an invaluable asset. 1
Little P, Lewith G, Webley F, Evans M, Beattie A, Middleton K et al. Randomised controlled trial of Alexander technique lessons, exercise, and massage (ATEAM) for chronic and recurrent back pain. BMJ. 2008;337:a884. Available from: doi:10.1136/bmj.a884
l Andrea Hughes is a qualified member of the Society of Teachers of the Alexander Technique and registered with the Complementary and Natural Healthcare Council. Visit her website https://www. alexandertechniquealtrincham.co.uk/
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18 TALKBACK LONDON MARATHON
Our runners are ready for the off… AFTER the disappointing cancellation of the 2020 event, there is hope that the Virgin Money London Marathon will go ahead this year. We are only days away from this great event and have a number of runners taking part this year, all sharing a common goal to help BackCare to support even more people who are living with back pain, regardless of cause. However, our runners are all individuals and they each have their own unique reasons for wanting to take part in this iconic race. Some have overcome injury or live with musculoskeletal problems. Others will be running in someone’s cherished memory or to support a charity that has helped improve their life or that of a loved one, or a friend. From the team at BackCare, a big thank-you to all our runners who are taking part. If you would like to know more about why some of them are supporting BackCare or help them raise even more money, you can visit their individual Virgin Money Giving pages by following the links at the bottom of this page.
Joe Gra ves
And y Fortune
hort Sarah S
nes Amy Jo
tt Ian Garra
t Jenine Nugen
Hamedah S hkokani
Kate Lancefi eld
Martin Willia ms
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MATTHEW CHESSON from Sittingbourne uk.virginmoneygiving.com/matthewchesson
KENTON JONES from Sleaford uk.virginmoneygiving.com/kentonjones2
STUART EDGE from Portsmouth uk.virginmoneygiving.com/stuartedge3
KATE LANCEFIELD from Folkestone uk.virginmoneygiving.com/katelancefield
ANDY FORTUNE from St Helier uk.virginmoneygiving.com/andyfortune
JENINE NUGENT from Hampshire uk.virginmoneygiving.com/jeninenugent
IAN GARRATT from Sheffield uk.virginmoneygiving.com/iangarratt
RICHARD POTTER from Tiverton uk.virginmoneygiving.com/richard.potter1
JOE GRAVES from Middlesex uk.virginmoneygiving.com/joegraves2
HAMEDAH SHKOKANI from Borehamwood uk.virginmoneygiving.com/hamedahshkokani
ZOE HUGHES from Pocklington uk.virginmoneygiving.com/zoehughes11
SARAH SHORT from Billinghay uk.virginmoneygiving.com/sarahshort13
AMY JONES from Sleaford uk.virginmoneygiving.com/amyjones135
MARTIN WILLIAMS from Stockport uk.virginmoneygiving.com/martinwilliams67
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20 TALKBACK NEWS
Toolkit offers help and advice NEED help managing pain in the workplace? An online toolkit from the University of Nottingham is here to help with information, advice and guidance. The free, open access Pain at Work (PAW) resource is for anyone with chronic or persistent pain. Along with videos, patient stories and useful links, its content includes the nature of pain, physical and psychological selfmanagement strategies, workplace adjustments and employment rights. The developers – Dr Holly Blake, Sarah Greaves, Sarah Somerset and Victoria Abbott-Fleming – worked in consultation with people living with chronic or persistent pain as well as professionals in different sectors, and with Burning Nights, the charity for complex regional pain syndrome.
Morfit car seat back support OSTEOPATH designed, Morfit car seat back support begins soft to take your shape, then firms up to hold you in place. With the ability to optimise and remember your unique posture, driving can be good again. For more information, visit Morfit Car Seat Back Support (https://www. backcaretrading.org.uk)
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App users ‘reduce their pain disability’ A NEW app that gives tailored treatment advice can help with non-specific low back pain, a trial in Norway and Denmark has found. selfBACK draws on clinical best practice and knowledgedriven artificial intelligence to provide self-management guidance geared to a person’s
back pain and lifestyle. The app gives weekly advice on physical activity and strength and flexibility exercises along with daily educational messages. In a randomised trial with 461 people, one group used the app alongside their usual primary care from health providers, while a second only had access to
their usual primary care. After three months, 52 per cent of app users reported reduced pain-disability compared to 39 per cent in the usual-care group. The findings were reported in The Journal of the American Medical Association Internal Medicine in August.
Volunteers to swap notes on care consultations UNIVERSITY of the West of Scotland are looking for individuals with chronic pain aged 18 and older to take part in a 45-60 minute interview via Zoom. If you live in Scotland, suffer chronic pain and you have made a treatment/healthcare decision, you are invited to take part. The purpose is to obtain views on, and experiences of, the conversation that happens between you and your healthcare professional to reach a healthcare choice together. For more information or to take part please contact firstname.lastname@example.org
Olympics physio tells how he prepares athletes
FRESH from supporting Team GB’s Olympic diving success, which saw Tom Daley and Matty Lee taking gold in the synchronised 10-metre dive and Daley winning bronze in the men’s 10-metre platform, physio Gareth Ziyambi talks about gold-medal winning preparation and performance in a website interview. In the Q&A for the Chartered Society of Physiotherapy we gleaned things about his approach which has changed over the years, his priority now moving from preparing to compete, to preparing to train. He believes the ability to maintain the training as long as possible is the most important factor in a technical sport like diving where repetition is necessary to master the difficult manoeuvres under the pressure of Olympic competition. An essential part of the build up to this Olympics meant that he helped the team prepare through lockdown and he said the diving team were in great shape going into the competition ‘emerging fitter and stronger than may have been the case in a normal season,’ he felt. Their at-home training had focused on strength, flexibility and core stability and making good use of whatever equipment the divers had at home. From a physio perspective, he also felt that it was an ideal time to work on the long-term niggles and injuries, develop better strength for areas of particular injury, and a time to develop self-management strategies.
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Gareth also ran online sessions on managing different types of possible injuries. As a team, they also worked hard to mitigate the psychological impact of losing daily routines and the athletes’ anxiety around the effect it would have on their Olympic preparations. ‘Our sports psychologists were simply superb during this time,’ he says. When asked about what is going through his mind when watching the team dive, he offered, ‘far too many things! Firstly, I’m hoping I’ve done everything possible to get them to the start line in the best possible shape. Right up until the last moment I’m evaluating if there is anything I can do or making a note of things I can do better for the next time.’ And, asked what Tom Daley is really like, ‘well I can honestly say that he really is the way he comes across. He’s a very thoughtful, intelligent and the consummate professional athlete when it comes to his training, recovery and preparation. He sets very high standards and works very hard towards those. He has a great balance in his life that I think has really helped him this Games. He’s also very down to earth and quite happy to pull a prank or two!’ he concludes. The online interview also includes how he handles injuries, what is in his poolside bag and the Tokyo experience without supporters.
Implant uses electrical impulses to relieve back pain A PIONEERING implant that uses electrical pulses to key nerves and muscles to relieve chronic back pain has been used for the first time in the US after a successful trial. The ReActive8 Implantable Neurostimulation System – the size of a small pager – is placed in the lower back during an hour’s out-patient appointment. It’s connected to the muscle responsible for stabilising the lower back, the lumbar multifidus, and the patient uses a remote control wired to one of its leads to trigger 30 minutes of neurostimulation twice a day. Dr Krishnan Chakravarthy is director of clinical pain research at the Health Center for Pain Medicine of the University of California, San Diego, where the treatment was carried out this summer. “We’ve learned that, over time, patients with mechanical back pain experience degeneration of their multifidus muscle — a series of small, triangular muscle bundles on either side of the spinal column,” said Dr Chakravarthy, who’s also assistant clinical professor at the university’s school of medicine. “By targeting this muscle with neurostimulation, we can not only reduce pain but potentially restore function. “In a clinical trial, a significant improvement in pain and function was observed in a majority of patients after just three months, with durable effects lasting almost four years.”
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22 TALKBACK RECOVERY FROM A MAJOR SETBACK
A personal journey to find me A PARTICULAR accident has had a very long-term impact on my life… one that saw the life as I knew it disappear, and a new one having to be formed. In early 2008, a beautiful, sunny winter’s day was the setting for another day out horse-riding at local stables in the Aberdeenshire area. I had already spent the morning in the paddock and decided to join another group to go cantering up the back fields after lunch. All was good, everyone was happy, the day was bright and vibrant. But, within just a few minutes of entering the land for cantering, things changed instantly. I had broken my back. When we are in the midst of challenging times, it can be so hard, near impossible, to see possibilities or keep hope alive. Instead, we are focused on the here and now, how to process and move forward from whatever has happened. This is even more so when the situation is life-changing. Life is bumpy – I’m sure no-one expects otherwise. After all, it’s through experiences that we continue to grow, as we are forced to adapt and overcome. And it’s our life experiences that make us who we are today. I truly believe when we have the desire, we can move beyond life-changing situations. It takes time, but it is possible. Time is key here, as whatever you’re going through, you DO need to deal with the here and now. Without doubt, you have to give this focus, energy and direction. But, as we move from the raw moment, what are we left with? Do you still have the response of negativity, anger, frustration, a bleak side to all that’s around you? Are you left with a negative emotional entanglement that drags you down even further? What if, over time, you could move from the raw state of the moment to processing with clarity and acceptance, have a stronger mindset, be able to visualise the next best steps for yourself, be more connected with your true inner self and learn how to listen to what is good for you – rather than what’s expected? All sound a bit far-fetched? Too much of a stretch? Impossible, given where you are just now? I write this from a perspective of having
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By Gillian Fowler, Founder of BackStrong and Usana Mindset had to do just this. And, yes, there have been many hurdles and tests to my inner belief, but it is possible. Please read on as I share just a small part of my story so you can understand that life can be good again, despite having to say farewell to what was my “normal” life. I have zero memory of the accident, only of lying on the ground, crying out in extreme pain, unable to move, stuck in a fetal position. Although I was wearing a horse-riding hat, the impact affected my short-term memory. Unfortunately, back protectors weren’t common back then – or I would have worn one. The impact resulted in a horrendously painful ambulance journey to hospital where I was told I had broken my back, that it was an unstable break, and I had a suspected broken neck.
Adapt to a new life The doctors finally agreed my neck wasn’t broken, although an anomaly was noted, and so focused on how to stabilise my back. Emergency surgery was required – after which, it was discovered I was paralysed on my right side. For those reading this and having gone through a similar experience, you will know the fear and confusion that passes through the mind. I understood the words, but could not comprehend how this could be; it did not make sense to me. Yet, this is what I knew I had to face head on. Thankfully, over the next couple of months, and with lots of rehab, I regained some walking ability. And I was finally able to return home. I was adamant I needed to be back in my own space and be independent. And, so, I
Gillian on top of Mount Kilimanjaro in Tanzania stuck to my guns, and learned how to adapt to my new life. As with any recovery, it never goes quite to plan. The following years saw spinal collapses, four further major spinal surgeries to help stabilise and tackle the newer issues as a result of that first accident, on-going memory problems, and the resulting impact on how my body “operates”. However, I never gave up. It was so important to me that I could regain some of my outdoor activities. Having been very sporty from a very young age, I was determined to at least be able to enjoy some activities once again. There has been a lot of trial and error as I’ve tried to understand what my physical limitations are. I’ve learned to accept that most of my sports will be no more. However, finally managing to get back hill walking has given me a true sense of happiness, peace and clarity. It was seven years before I could have a rucksack on my back. This didn’t mean I was stuck, as I am very blessed with amazing friends who
Spinal research – participants wanted I am currently undertaking research into the walking spinal community, to gain greater understanding of the support mechanism and the impact on physical activity. If you are interested in finding out more, head over to BackStrong’s Facebook page, or email email@example.com
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once more would take my items so I could join them for time out and about. But the day I finally took a rucksack myself was sheer joy – and I’ve not looked back since. But how did I get back to the hills after such a bumpy journey in my recovery? Following my last major spinal surgery, I was again very focused on my rehab and this time became aware that the “elastic band” feeling that I had for six years had finally disappeared. This surgery had not only helped to stabilise my spine, but removed this “invisible” effect that meant most days I knew I had to stop what I was doing as I felt like something was about to snap. Wow, elation! And the day I came back from a walk, fully aware it was now completely gone, I announced I wanted to climb Ben Nevis to test it. Just four months after the surgery, I stood at the top and knew life and my recovery was moving forward in the way I wanted. I set up the charity, now community group, BackStrong, which mentors the walking spinal community and I founded Usana Mindset to offer key services to help all overcoming life-changing situations, old pain and limiting beliefs to flourish once more. I feel very blessed to have been able to have the following adventures: l Climbed Mount Kilimanjaro. l Climbed Toubkhal in the Atlas Mountains. l Abseiled in Scotland. l Abseiled Table Mountain in Cape Town, South Africa. l Hillwalked in the Accursed Mountains in Albania and over to Montenegro. l White water rafted in the Zambezi River, Victoria Falls, South Africa and Scotland.
l Kayaked to several islands in Croatia l Hillwalking in Julian Alps, Slovenia l Climbed Mount Kenya. Each adventure brings different experiences and emotions and I always come back a better version of myself. Just to be clear, I am not saying people should do what I’ve done – probably not! – but I only highlight it as it gives you an idea of the strength of mind and body, coupled with the rehab. I have had to build to live a life that my first surgical team said was not possible, where I was told to prepare my house for a wheelchair as there was nothing further they could do. (Note: I sought a second opinion and changed medical teams.)
A different path Over the years, many people have asked
me if I would have changed that day and not headed out to the horses. No! I never say “I wish I had never broken my back”, despite so many changes, so many unknowns, on-going pain and having to say farewell to my old life. I feel my accident has allowed a different path to be taken, one I would not have even seen had that fateful day not occurred. I founded BackStrong and Usana Mindset because I have a deep passion and commitment to help others. This is your life, choose how you wish to live it. Not for others, but for yourself. The bumps are just there to remind us how far we’ve come. Believe in yourself. Whatever has happened, you can still flourish. And should you want some support, please don’t hesitate to reach out.
Contact details: BackStrong: Website: www.backstrong.org.uk Facebook: www.facebook.com/ backstrongtrust Usana Mindset: Website: www.usanamindset.com Facebook: www.facebook.com/ usanamindset Instagram: www.instagram.com/usana_ mindset
Main picture: Gillian abseiling off Table Mountain in Cape Town, South Africa. Inset, it was seven years after Gillian’s accident before she could stroke a horse again
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Images: the Royal Osteoporosis Society
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How someone can lose height through curvature of the spine
Osteoporosis – the facts behind Back pain caused by spinal fractures Osteoporosis itself doesn’t cause back pain or any other symptoms unless you actually fracture a bone. While most fractures happen after a fall, spinal fractures can happen without an accident or fall. Bones in the back squash down and become flattened or wedge shaped – sadly, then staying in this changed shape even after healing has taken place. Osteoporotic spinal fractures are called “stable” fractures, which means they don’t affect the spinal cord and cause paralysis – a common concern of people when they are first diagnosed with a spinal fracture. Spinal fractures affect people in different ways. Some people get no pain and are not affected by the fracture, while other people get severe back pain when a fracture occurs. The pain normally improves gradually, but some people experience long-term, persistent pain as the shape of the spine changes. People experiencing a number of spinal fractures can also suffer height loss as a result of curvature of the spine and might also begin to experience long-term back pain as muscles and ligaments try to adapt to this changed spinal shape. Nerves can also become irritated by changes in the spine. Curvature of the spine can also have other physical effects such as causing difficulty breathing and mobility issues. There can
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By Sarah Leyland, Clinic Adviser, Royal Osteoporosis Society also be an emotional impact as people’s body image or self-esteem are affected.
Treatments for spinal fractures The good news is that many spinal fractures usually heal on their own in about six to 12 weeks. There is no need to keep still or wear a brace – in fact, regular movement and certain types of exercise are encouraged. However, where there is pain it can be helped by pain-relieving drugs, or practical measures such as using a TENS machine, gentle massage, relaxation and breathing exercises. Other approaches might be considered such as complementary therapies, psychological help, physiotherapy, hydrotherapy, pain clinics, pain management courses or self-management groups. There is also a surgical procedure which is sometimes used to help with pain that doesn’t resolve. The procedure is called percutaneous vertebroplasty or kyphoplasty, Visit the ROS website at https:// theros.org.uk for more information about osteoporosis, spinal fractures or bone health. You can also call the charity’s free Helpline on 0808 800 0035.
which is when a cement is injected into the spinal bones. However, this isn’t available at all hospitals and there is some dispute among experts as to whether it works or not. Specific exercises can also help with back pain after spinal fractures. Gentle stretching exercises are useful and, in the longer term, increasing muscle strength around the spine can support it and reduce the spasm caused as muscles adapt to the changed spinal shape. The ROS has videos and fact sheets to explain more about these exercises.
Diagnosing a spinal fracture An X-ray is the best way to find out if someone has a spinal fracture caused by osteoporosis. A GP will refer someone if they have specific symptoms such as getting shorter, back pain or curvature of the spine. If someone has broken other bones, for example a wrist or hip, then that too might be a sign that someone is at risk of spinal fractures. A spinal fracture that was not caused by any other medical condition or as the result of a traumatic accident could be symptomatic of osteoporosis. A bone density (DEXA) scan can be used to diagnose osteoporosis, highlighting that bones are less
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An illustration showing how the spine might compress
spinal fractures and back pain
Lifestyle for bone health
benefit from increasing your daily calcium intake to around 1,000 mg or you may be getting enough from your diet. Talk to your healthcare professional about what is right for you. l Make sure you get enough vitamin D. This can be through sensible exposure to the sun during the summer months when the sun’s rays stimulate the skin to produce vitamin D – about 10 minutes twice a day with bare face and arms, but not enough to get burnt. Alternatively, you can take a 10 microgram daily supplement if you cover up completely. Everyone should consider taking a supplement from the end of September to the end of March anyway because you can’t get enough vitamin D from the sun’s rays during that time. l Maintain a healthy body weight – not under or overweight. l Exercise needs to include weight-bearing exercise with impact (involves being on your feet and adding an additional force or jolt through your skeleton – anything from walking to star jumps), as well as muscle strengthening exercise. l Don’t smoke or consume excessive alcohol (above recommended limits).
A healthy lifestyle can help to build, maintain and promote bone strength – even if you already have osteoporosis, it’s still important. Top tips for a healthy lifestyle for bones: l Aim for a well-balanced, mixed diet with plenty of protein and calcium. Adults need 700 mg of calcium a day. If you’re taking an osteoporosis medication, you may
People living with osteoporosis often worry about exercise or everyday activities causing a spinal fracture. However, for most people, moving, lifting, bending and impact exercises like jogging are not going to cause a fracture. The Royal Osteoporosis Society (ROS) has lots of information about
dense than the average adult. Research has shown that the lower the bone density, the greater the risk of fracture.
Drug treatments for osteoporosis While receiving a diagnosis of osteoporosis can be a shock, the good news is that there are a number of drug treatments available to strengthen bones and reduce the chance of having a fracture. The drug that is usually prescribed first is a weekly tablet called alendronic acid which belongs to a family of drugs called bisphosphonates. It is generally given to older men and post-menopausal women who are deemed to have a high risk of fracture. This is calculated by assessing all the different risk factors someone may have, including bone density and whether other bones have been broken already. There are other medications available too and the decision about which treatment is right for the patient will depend on someone’s own individual circumstances.
caring for your back and sensible ways to approach activities by building up exercise gradually to make sure you don’t injure yourself. Muscles and bones need to be used and exercise is really important to improve the strength of both. The ROS also has information about specific exercises to reduce the risk of falling over as we get older by improving our balance and muscle strength. These exercises can be easily integrated into daily activities like standing on one leg with support if needed, sit to stand exercises and heel raises. See the ROS factsheet and video on “Exercise to improve balance and muscle strength” for more ideas, and to learn how to do these exercises safely.
Further support When people are diagnosed with spinal fractures, they typically have many questions about what this means for them. ROS has created a series of new videos to help answer some of the most common questions. Developed by people who are living with osteoporosis and spinal fractures, and bone health experts, the new videos can be found at https://theros.org.uk/ information-and-support/osteoporosis/ spinal-fractures/spinal-fracture-videos/. On World Osteoporosis Day – 20 October – ROS is encouraging everyone to consider their bone health at every stage of life.
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26 TALKBACK MOVEMENT IMPORTANT FOR THE CURE
Sciatica… the painful truth SCIATICA is a term used to describe a pain “experienced in the nerves” which leaves the lower back and passes through the buttocks and/or legs. It can be felt as a dull ache, shooting pain or numbness and can occasionally cause weakness in the legs. Unlike some pain which comes and goes, sciatica is often constant. There is no escape from it and this is why it causes misery. Fortunately, in most cases, the pain will subside with a bit of time because our body is able to heal itself. However, when the pain doesn’t pass, there are a variety of treatment options.
What is sciatica? Our bodies are controlled by electrical signals sent through the nerves to all areas of our body. Nerves exit the spinal column at every level, branching off from our spinal cord. The sciatic nerve is formed by nerves exiting the lower part of the spinal column, the “lumbar spine”. The sciatic nerve branches out into smaller nerves which control the bottom half of our body. They run like electrical wires through our buttocks and legs. When something interrupts or irritates these nerves, they deliver a pain signal to the brain and that can be felt as sciatica.
What causes sciatica? There are a variety of causes of sciatica, including sitting for long hours at an inappropriate desk while working from home, as many will have experienced over the numerous lockdowns recently. Usually, the origin is the lower back. Our spine is made of a stack of bones like cotton reels (vertebrae). Between the vertebrae, we have cushion-like discs or intervertebral discs which act as spongy shock absorbers as we move. The discs are also important because they create a gap between the solid vertebrae. The gaps create space for the nerves to pass through as they branch off from the spinal cord. There are two main issues which can affect the nerves: 1) a problem with a disc
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By Dan Plev, Consultant Spinal Neurosurgeon The London Clinic and 2) a narrowing of the space where the nerve travels. Disc problems: The discs have a strong outer wall made of tough fibrous collagen (annulus fibrosus). Inside the disc is a gellike substance (nucleus pulposus) which has a high water content and provides shockabsorbing properties. If the centre of the disc pushes out against, or even through, the disc wall it can touch or put pressure on the nerve. This “bulging” or “herniated” disc can press on the nerve and/or cause chemical irritation to the nerve, leading to pain. Narrowing between the vertebrae: If the gap between the vertebrae in the lower back narrows, this can reduce the space for the nerve. When there is pressure on the nerve, this can result in sciatic pain. The reduction in the space between the vertebrae can be caused by a loss of disc height. Over time, our discs lose water. Rather like a deflated bicycle tyre, if the disc loses water it can also lose height, narrowing the gap between the vertebrae. This can pinch a nerve. Alternatively, or as a result of the loss of disc height, the body can add more bone to a vertebra to strengthen it. The disc carries a certain proportion of our bodily load. If there is an issue with the disc and it takes less of the weight, then more load is placed on to our bones. To support the additional load, the body reinforces the vertebra by adding more bone
which can lead to a loss of space for the nerves. This additional bone is described as spinal stenosis. With less space for the nerve, they can again become “pinched” and the nerve pressure causes pain.
Sciatica treatment options A sudden onset of sciatica can be caused by a small disc bulge pressing on to a nerve. In this circumstance, as the body moves, pressure changes may help to retract the bulge and relieve the pain. Our discs are designed to support our weight and allow us to move freely. They rely on movement to stay healthy and function as a unit with the muscles and ligaments. Weakness and stiffness in the soft tissues can mean the disc and vertebrae are placed under increased load. When that is combined with exposure to load for long periods, most commonly from poor posture and lengthy periods of sitting, it can put more strain on the discs.
Manual therapy and exercise Manual therapists will use a range of stretching and mobilisation techniques to increase the flexibility of the soft tissues and alleviate the stiffness in the joint. Pain creates a vicious cycle where we can’t move, but it is the movement which is so important for the cure. The goal is to create some movement in the
IDD Therapy – gentle and non-invasive IDD Therapy is the fastest growing non-surgical spinal treatment for intervertebral discs with more than 1,000 clinics worldwide and 34 clinics across the UK. Safe, gentle and non-invasive, IDD Therapy helps patients who need something more for their pain when manual therapy alone is insufficient to achieve lasting pain relief. http://iddtherapy.co.uk/ Facebook: IDD Therapy Europe Twitter: https://twitter.com/IDDTherapyDisc
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Manual therapists will use a range of techniques to increase the flexibility of the soft tissues
spine and to unload the disc and the joints. Sometimes, the soft tissues even become stuck together (adhesions) which prevents movement. Part of the manual therapy and stretching will aim to address that. As movement is restored and pain subsides, certain exercises, which anyone can do at home, are important. These are designed to help to move the joints of the spine and hips, in particular. Exercise keeps them active, strong and engaged so they can support their share of load as we move. Combined with gentle walking, these simple exercises help to keep our spines healthy and prevent further episodes of pain.
IDD Therapy disc treatment Intervertebral Differential Dynamics (IDD) Therapy is a non-surgical spinal decompression treatment. When pain from a bulging or herniated disc persists and has not responded to manual therapy, therapists use IDD Therapy as a tool to help take pressure off targeted discs and gently mobilise the spine. IDD Therapy is a mechanical tool which uses computer controlled pulling forces to open the space between the vertebrae to decompress the disc and gently mobilise the soft tissues and joints with some soft oscillation. The goal is to relieve pain and help restore movement. Patients lie on the Accu SPINA machine which delivers IDD Therapy. They are connected to the machine using ergonomic harnesses and pulling forces are applied at specific angles to treat the affected spinal level. A series of treatments are given and the forces used are gradually built up as the body adapts to the changes.
A patient undergoing IDD Therapy
IDD Therapy is combined with some other modalities, such as heat, and is provided in combination with manual therapy and strengthening exercises as part of a care programme.
Injections There are different types of injection. The most common is aimed at reducing inflammation. Inflammation is a natural process of healing. However, after prolonged periods, the inflammation itself can become a problem and excessively irritate the nerves, causing pain. A steroid injection can be given which helps to neutralise the inflammation and relieve pain. Injections are usually given to create a pain-free window, whereas the other treatments described here address the causes of the problem.
Surgery Surgery is the preferred treatment for sciatica when either the pain is intolerable and has not responded to other noninvasive treatments or the pressure on the nerve is such it is causing weakness, usually in the legs or, in very extreme cases, a loss of bladder or bowel control (cauda equina). If a disc in the spine has herniated, this is where the centre or nucleus of the disc has pushed out through the walls of the disc. Sometimes, only a small amount of the nucleus has pressed through the wall, or it can be substantial. Usually, the body can reabsorb this disc material. However, if it remains, it can become hard and leave patients in constant pain. The most common surgery given is called a microdiscectomy, where a small incision is
made in the lower back and, using surgical instruments, the piece of disc material is removed. This can be very effective in relieving leg pain. If the space where the nerve lies is narrowed, other forms of “decompression” surgery can be used where small pieces of bone are removed to create space for the nerve or to remove bone pressing on it. It’s important to stress that long-term pain relief is best achieved if the causes of the weakness are addressed. Urgent surgery: Where a patient is experiencing weakness in their legs, this is a more serious proposition and usually surgery will be considered early. Weakness or a loss of leg power can mean the nerve is at risk of damage and relieving the pressure quickly is very important.
Summary While surgeons and therapists see a lot of patients with back pain, in some ways sciatica is the condition which causes the most stress and anxiety. Surgery and invasive treatments are only necessary in a small percentage of cases. The advances in conservative (non-invasive) care mean most sciatica can be addressed without the need for surgery. Clinicians work together to match the right option for the right condition. The final word on sciatica is that prevention is always better than cure. Staying mobile, keeping active and avoiding prolonged sitting are key to looking after your back and keeping sciatica at bay. l Dan Plev is a Consultant Spinal Neurosurgeon and IDD Therapy provider at The London Clinic in Harley Street, London.
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