HAPPY BIRTHDAY! 45th Anniversary Issue
TalkBack Quarterly magazine of BackCare, the UK’s National Back Pain Association
■ NEWS
■ EVENTS ■ COMMUNITY summer 2013
£2.95 • FREE TO MEMBERS
Caring for carers Celebrating 45 years Rethinking chronic pain Antibiotics for back pain
The Charity for Back and Neck Pain www.backcare.org.uk
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BackCare Events Calendar 2013 AOHP – National Conference 11-14 september 2013 – Hilton Orlando, Florida
Annual conference for the Association of Occupational Health Professionals in Healthcare. More information: www.aohp.org
British Scoliosis Society – Annual Meeting 12-13 September 2013 – Ashley Conference Centre, Staffordshire University
Workshops, keynotes and invited lecturers from international leaders in the field. More information: www.staffs.ac.uk/BSS2013/
British Chiropractic Association – Conference and AGM 21-22 September 2013 – Thistle Grand Hotel, Bristol
Updates from a range of speakers at the leading edge of chiropractic. More information: www.chiropractic-uk.co.uk
Body Control Pilates Development Weekend 28-29 September 2013 – The Royal College of Physicians, London
RCP hosts a weekend of lectures and workshops from leading UK and international presenters. More information: www.bodycontrol.co.uk
National Back Exchange – Annual Conference 30 September – 2 October 2013 – Hinckley Island Hotel, Leicestershire
The latest on the multidisciplinary prevention of work-related musculoskeletal problems. More information: www.nationalbackexchange.org/
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.
International Alexander Awareness Week : ‘Get a Back for Life’ 7-15 October 2013
An international campaign to raise awareness of the Alexander Technique in the treatment and prevention of symptoms caused by stress, tension and posture. More information: www.stat.org.uk
Society for Back Pain Research – Annual General Meeting 14-15 November 2013 – St Thomas’ Hospital, London
Lectures and debate featuring a range of speakers. More information: www.sbpr.info
Virgin London Marathon 2014 – Application Deadline 24th January 2014 (Race day: 13th April 2014)
Join the BackCare team at the world’s largest marathon. We have 40 guaranteed places but they won’t last long! Minimum pledge: £1,300. Registration fee: £50. Contact events@backcare.org.uk or telephone 020 8977 5474..
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Talkback news 3
Welcome
Contents 4-6
News
Welcome to a special 45th birthday edition of TalkBack. With another great British summer now largely behind us, I hope you’ve made the best of it and perhaps enjoyed a week or two away. The world was a very different place when BackCare was founded in 1968, but back pain remains a pressing global issue and BackCare continues its work to turn the tide. This year, we mark BackCare’s 45th anniversary and bring you a montage of contributions and perspectives from long-standing supporters. BackCare Awareness Week is, of course, imminent (7-11 October 2013), and we’ll be taking a look at the issues surrounding this year’s campaign theme – “Caring for Carers” – as well as reviewing event plans for the week. In the news pages, we report on an exciting new fundraising collaboration between BackCare and the health insurer, Simplyhealth. The project will see much needed upgrades to the BackCare Helpline and the smartphone app. Congratulations again to Team BackCare for achievements at this year’s Virgin London Marathon; find out how much they raised in the full report. We’re now booking places on the team for 2014 – sign up now to avoid missing out. I hope you enjoyed reading the high-concept piece, “What is health?” in the last issue. I presented the developmental model at three events this year where it certainly sparked interest among patients and healthcare professionals alike. As news breaks of Prime Minister David Cameron’s “phenomenally bad back”, the educational series continues with a much needed, evidence based update on chronic and non-specific pain. As always, we welcome contributions from our members – whether you have back pain or treat people with back pain, if you can inform and inspire others, we’d like to hear from you. Just drop me an email at yourstory@backcare.org.uk or send us a letter to the usual address. Enjoy the magazine and I’ll see you in the Autumn issue.
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Self-help plan Swimming benefits
45 years of BackCare 10-13
14/15
Access to Work
Dr Adam Al-Kashi Head of Research & Editor of TalkBack
We welcome articles from readers, but reserve the right to edit submissions. Paid advertisements do not necessarily reflect the views of BackCare. Products and services advertised in TalkBack may not be recommended by BackCare. Please make your own judgement about whether a product or service can help you. Where appropriate, consult your doctor. Any complaints about advertisements should be sent to the Head of Information and Research. All information in the magazine was believed to be correct at the time of going to press. BackCare cannot be responsible for errors or omissions. No part of this printed publication may be reproduced, stored in a retrieval system or transmitted in any form or by any means without permission of the copyright holder, BackCare. ©BackCare
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Caring for carers
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London Marathon
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Chronic pain
BackCare 16 Elmtree Road, Teddington, Middlesex TW11 8ST Tel: +44 (0)20 8977 5474 Fax: +44 (0)20 8943 53318 the wn look back TalkBackA do Helpline: +44 (0)845 130 2704 1988 1974 Email: info@backcare.org.uk Website: www.BackCare.org.uk Twitter: @TherealBackCare Registered as the National Back Pain Association charity number 256751. Talkback is designed by Pages Creative 2004 www.pagescreative.co.uk and printed by 2000 Severnprint, Gloucester. 24 Talkback news
years 1995
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4 talkback news
Antibiotics: a cure for chronic back pain? Earlier this year, news broke of a research study appearing to show that antibiotics can cure chronic back pain. The story received wide coverage and was reported by national and international media channels. Unfortunately, the claims, with headlines such as “The stuff of Nobel prizes: half a million sufferers of back pain ‘could be cured with antibiotics’” (The Independent, 7 May 2013, UK) overplayed the research findings and may have given false hope to many millions worldwide. Since then, reports have come to light through the BackCare Professional Members of patients gobbling up left-over and unfinished courses of antibiotics in a desperate bid for pain relief.
Placebo pills
So what did the research really show? Researcher Hanne Albert and colleagues at the University of Southern Denmark treated 162 patients with an antibiotic (Bioclavid) or placebo pills for 100 days. The patients all had chronic lower back pain (lasting more than six months) and ‘Modic type-I changes’ (a type of vertebral bone oedema). Modic type-I changes are seen in 6% of the general population but in up to 40% of people with lower back pain. This means that you can have this type of bone oedema without any pain, but it’s far more common in people with lower back pain and is thereby ‘correlated’ or ‘associated’ with pain. Modic type-I changes are
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also associated with infection by low virulent bacteria (mainly Propionibacterium acnes). These bacteria may be found in the lumbar discs of up to half of discectomy patients with lumbar disc herniations, but not with other spinal disorders (such as scoliosis, fracture or tumours).
Improvements
The researcher’s hypothesis was that these bacteria might cause Modic type-I changes which might cause chronic lower back pain. Sure enough, disability scores (RMDQ), as well as days of sick leave and other measures, were greatly improved after 100 days of Bioclavid treatment, but not in the placebo group. Furthermore, these improvements not only lasted but continued to develop up to the one-year follow up appointment, while the placebo group deteriorated further. This sounds fantastic and we’re very happy for those patients who experienced substantial and lasting improvements. So what could be wrong? Well, it’s important to be critical and sometimes play devil’s advocate, and the devil is in the details. The bacteria identified, such as P acnes, are largely commensal. In ecology, commensalism is a class of relationship between two organisms where one organism benefits without affecting the other. In short, the presence of these bacteria may represent a colonisation rather than an
infection. These bacteria as well as Modic type-I changes may indeed be more common in back pain patients, but we must be very careful not to confuse coincidences and correlations with causes. Looking more closely at the study design, the test drug, Bioclavid, has a number of side effects including nausea, vomiting, diarrhoea and rash. In fact, nearly one in 10 of the patients taking Bioclavid dropped out of the study due to the side effects. While these reactions do not usually require medical attention, they would certainly be very obvious to both the patient and the clinician.
Double blind
While the placebo and active tablets may have appeared identical, the calcium carbonate
placebo lacked Bioclavid’s side effects. The strength of the study hinges on its design being ‘double blind’, meaning that neither the patient nor doctor knows who is receiving the real drug, but the side effects of Bioclavid would have made it quite obvious, effectively ‘unblinding’ the whole study. This means that the researchers did not rule out the influence of the placebo effect after all. Moreover, the deterioration in the so-called ‘placebo’ group may have, in part, been an inadvertent ‘nocebo’ effect in patients who realised they were not receiving the ‘active tablets’. If anything, this study may be testament to the power of the placebo effect. ■ Turn to page 20 for “Rethinking chronic pain”.
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New mobile phone app offers users greater interaction
BackCare has collaborated with healthcare provider Simplyhealth to launch an updated back care app. The app is being promoted in a national Simplyhealth television advertising campaign, helping to raise awareness of the problem of back pain and the charity. Simplyhealth is pledging to donate £1 to BackCare for every download of the app, up to £120,000. The Simplyhealth Back Care app uses some of the content from the original BackCare app, but users can now get an exercise plan and search for a practitioner from a much wider database of professionals. The look and feel of the app is in the Simplyhealth brand with all information and exercises supplied and endorsed by BackCare. By collaborating with
Simplyhealth, BackCare has the opportunity to reach many more people and promote the importance of a healthy back. With the new app you’ll be able to: ■ record where and how severe your own back pain is in the ‘Me and My Back’ diary ■ watch videos and animated illustrations of common back pain relief and prevention exercises ■ get an exercise plan to follow ■ search for qualified practitioners near you from a wider database of professionals ■ follow the latest news and discussions about back care on social media. It will also help you find information on preventing back pain: ■ at home ■ in the office ■ when driving ■ when cycling.
WHO IS SIMPLYHEALTH? Simplyhealth has been helping people access affordable healthcare for over 140 years. It provides health cash plans, dental plans, private medical insurance and self-funded health plans to more than three million people. Simplyhealth Independent Living provides mobility
products and daily living aids. You can find out more at www.simplyhealth.co.uk. Simplyhealth is using its advertising and the Simplyhealth Back Care app to support the millions of people who suffer back pain every day in the UK.
For every download of the app, Simplyhealth will donate £1 to our charity (up to £120,000). You can help reach that total by downloading the app on your smartphone or tablet device. The app is available from the App Store and on Google Play.
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6 Talkback news
“Look, feel and grow younger” with the Alexander Technique People across the UK are being given the chance to “look and feel younger” by trying the Alexander Technique – acclaimed by celebrities across the globe. Discounted lessons in the Alexander Technique are being offered by participating members of The Society of Teachers of the Alexander Technique (STAT) as part of the annual International Alexander Awareness Week, which runs 14-20 October. Celebrity actors, dancers and athletes have all praised the Alexander Technique for its ability to improve professional performance. But this year’s awareness week is also highlighting how
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the Alexander Technique can make you “Look, feel and grow younger”. STAT member and Alexander Technique teacher Angela East said: “The Alexander Technique restores the natural poise that people enjoyed as young children by improving body alignment and teaching a more effective and effortless way to move.” “People with rounded shoulders and poor posture tend to look older than they are. With graceful poise comes much more fluid movement and increased confidence and that can take years off you, making you look and feel younger.” The Alexander Technique
helps improve your general health and prevent a range of ailments including backache, stress and tiredness by releasing tension and by restoring balance. It has also been recommended by the National Institute for Health and Clinical Evidence (NICE) as the only therapy to help in the treatment
The Alexander Technique restores the natural poise that people enjoyed as young children
of people with Parkinson’s disease, by helping to ease day-to-day movements and decrease the speed at which symptoms worsen. The technique was developed in the 1890s by Frederick Alexander, an Australian actor who was worried his hoarse voice would end his career. He realised that he was stressing his vocal organs through tension, not only in his head and neck, but in his entire body. You can find your nearest Alexander Technique teacher by contacting The Society of Teachers of the Alexander Technique (STAT) online at www.stat.org.uk and by phone on 020 7482 5135.
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Pain: it’s not just a physical thing Following the release of his ground-breaking self-management programme, physiotherapist and BackCare Professional Nick Sinfield presents some of the key concepts as a mini-series over the next few issues of TalkBack. In the second instalment, he looks at the mind and body‌ Changing your mind
Recent medical research demonstrates the positive effects of psychological interventions, such as Cognitive Behavioural Therapy for the treatment of chronic low back pain.
Treating the mind and body
The idea that a physical condition can also have a psychological component is difficult for some people to believe. But, as our pain becomes ingrained in our minds and bodies, our perception of the pain changes along with our behaviour towards it. These changes in our minds and bodies can create a chronic pain cycle. Emotional tension also has a proven ability to induce physiological change, including soft tissue changes, that expresses itself as muscular tension, tightness or pain. In the same way that emotional stress can suppress our immune systems and affect our resilience to disease, it can have a detrimental impact on our soft tissue structures.
Knowledge is the key to recovery
Successful and permanent treatment for back pain must be based on educating back pain sufferers. This is accomplished by teaching them to recognise and change ingrained perceptions and beliefs in their pain and the resulting emotional stress this produces. This holistic approach, which treats back pain as a physical, mental, and emotional issue, offers a more effective and lasting treatment option. By training the pain sufferer to recognise and change their perceptions and beliefs, we are able to add a powerful psychological dimension to existing, physically based treatment options.
Understanding pain
Injury and structural issues, such as simple strained muscle or inflammatory responses to structural problems in the spine, can cause acute back pain. This should settle in time as the healing process takes place. Therefore, why can pain persist after tissues have had plenty of time to heal? Pain is a multidimensional and complicated experience for the sufferer, with many contributing and interacting mechanisms. These mechanisms can be a mixture of contributory elements comprising emotional and physical causes, and with a better understanding of pain you will be better equipped to find your route to recovery.
Your nervous system, which produces pain, is highly adaptable to change. Triggers such as injury or stress can result in an increased concentration of neural impulses from inflamed, scarred, weak, or acidic tissues around the spinal cord. This increases the sensitivity within the nervous system, meaning more pain signals transferred to the brain. If this continues over time these sensory distortions can cause things to hurt that didn’t hurt before and a loss of ability to activate muscles that help stabilise the spine. This means that simply touching the skin, or a cold breeze, might cause pain signals to be sent to the brain.
understand and overcome The latest medical research demonstrates a need for an integrated mind and body treatment programme for back pain. If you suffer from back pain, it is important to seek out and learn more about your pain. By doing this, it will become obvious what changes are required to improve your pain by recognising how your perception towards your pain has changed your thoughts and subsequent actions and behaviours. Talkback l summer 2013
8 meet the professional
World record breaker Lucy, left
Water-based exercise? You don’t need to swim A
s I mentioned in my article in the last issue, I’ve been involved in swimming for more than 20 years. In contrast, I’m fairly new to water aerobics, having been teaching it for only two years. So far, my clients have reported an improvement in their back pain quicker than with swimming. Before I completed my STA Aquacise certificate, I partly believed some common misconceptions that water aerobics is easy or that it is purely for older women. The training course quickly dispelled these myths! If you search on the internet, you will find examples of professional athletes using water-based exercise in their training, e.g. Paula Radcliffe and the Australian Rugby League team. How can one exercise class cover the range of fitness levels from those new to exercise or recovering from surgery right up to elite athletes? It is due to the unique properties of water. The supporting quality of the water means that it is a low impact exercise but not low intensity. For each
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In this follow-up article, world record breaker and professional swimming teacher Lucy Lloyd-Roach looks deeper into the benefits of water-based exercise.
exercise there are variations that alter the intensity, e.g. varying the speed. This allows me to have a variety of fitness levels within a class. Another common misconception about water aerobics is that you need to be able to swim. This isn’t true. During a shallow water aerobics session you’ll work within your comfort zone with your feet on the floor. Many non-swimmers who come to a water aerobics session will improve their
water confidence and find themselves enjoying being in the water. Some then go on to learn to swim, which increases someone’s water-based exercise options. Recently, within the aquatics industry there has been a push to challenge these misconceptions and there are now a range of classes available, e.g. shallow water sessions, deep water sessions (out of your depth with floatation devices), aqua jogging, circuit training, and dance inspired such as Aqua Zumba. Sessions are generally 45-60 minutes long. For example, the usual format of my sessions is 10-minute warm up, 20-minute cardiovascular work, 20 minutes of muscle strength endurance (using resistance equipment, e.g. mitts and dumb
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bells) followed by 10 minutes relaxation and stretching. As you will be starting to appreciate, water aerobics is a great all-over body workout that works on improving your strength and cardiovascular fitness. Naturally, as they’re both in water, swimming and water aerobics share benefits such as pain relief, reducing inflammation, increasing flexibility and mobility, increasing strength and improving posture. Water aerobics also removes a few barriers that may stop people using swimming to manage their back pain. In my previous article, I mentioned that to really get the benefits from swimming it is important to swim with the correct body position. In a water aerobics session it is easier to maintain good correct posture as your instructor will remind you to make sure that you’re optimising your workout. This helps to develop your core strength, which is beneficial in and out of the water. Another bonus of water aerobics is that, if you’re body conscious, it’s worth checking with the venue whether you need to wear swim shorts/shorts. Where I work you can wear leggings/shorts and a tight T-shirt. Water aerobics also brings a number of other physical benefits. The cooling effect of the water means that you can work hard, but you won’t overheat or get
Water aerobics is a great all-over body workout sweaty. A commonly reported effect from my clients is that in the water they can keep exercising for longer than they would on land. Being able to exercise for longer helps to strengthen muscles which improves functional movement on land and helps to maintain or lose weight. Losing weight has many health benefits, including reduced pressure on your back and other joints. There are social and psychological benefits. A number of studies have shown that, after a course of water aerobics, participants noticed a number of psychological improvements, e.g. a reduction in stress and depression and an improvement in sleep and quality of life. Furthermore, water aerobics is usually carried out in a class setting so the many social benefits include going with friends, meeting new people, and the external motivation from the music, other people in the group and your instructor. All these things make it easier to add it into your weekly exercise routine. Having described some of the benefits of water aerobics, I’ll leave it to my clients to tell you how it’s helped them.
CASE #1:
‘
Anne-Marie O’Toole, 35, attends once a week I suffered back and leg pain for around seven years. I was diagnosed with right sided L4/5 disc prolapse with bilateral L5/S1 prolapses. The pain was debilitating and I was on strong medication. I tried everything, from epilepsy drugs to block nerve pain to painkillers (codeine, tramadol) but I became allergic to these so stopped taking them and had to live in pain. My doctor suggested swimming and I discovered water aerobics and it has changed my life! In September 2012, I had microdiscectomy surgery. I went to water aerobics for about 6-8 weeks before surgery and my surgeon said that I had a fast recovery due to my strengthened core muscles and back! The surgeon was amazed how quickly I was back on my feet and back to work; it’s got to be down to the water aerobics. Water aerobics has improved the quality of my life in a number of ways. I’m healthier than I have been in years. I’m a single mum to a 10-year-old daughter and I am able to do more with her now. My mobility has significantly improved and it’s helped to maintain my weight. I don’t take any medication and my posture is much better. If I miss a session my back aches badly, but when I go to the next session it helps to ease it again. I like to think that surgery took away the pain but water aerobics keeps it away.
CASE #2:
Pat Davies swims once or twice a week and attends two water aerobic sessions a week
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Thirty years ago I broke my back in three places. Before starting water aerobics I would say that I only recovered to about 20% of my pre-accident state. I lived with severe back pain all the time. I could only walk for about 20 yards before I’d be in agony and I couldn’t straighten my back. In August 2012, a group of friends decided to try a swimming and water aerobics class. I went to be sociable: I couldn’t imagine it would change my life! From doing hardly any exercise I have built up to 3-4 hours a week and feel I have recovered about 90% from the accident. My posture (sitting and standing) has improved; I can now stand straight, move around more easily and walk for 30 minutes without being in pain. I recently had to take time out and I noticed the difference – I was in pain and looked forward to going again so I could be pain free. My outlook is now positive instead of negative (if like me, you’re living with pain, you’ll know just how much it takes over your life). I have more energy, am happier and feel better within myself.
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.
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10 Talkback looks back
Happy Birthday This year marks BackCare’s 45th birthday. Not quite a decadal event, but ample reason for a retrospective, nonetheless. To mark the occasion, we’ve gathered three different perspectives from long-standing supporters and take a look at the life of BackCare’s founder president, Stanley Grundy (1914-2006). But first let’s take a snapshot look at the turbulent world into which BackCare was born… Snapshot of the World in 1968 l l l l l l l l l l
Harold Wilson is the British Labour Prime Minister The Vietnam War enters its 13th and deadliest year Martin Luther King Jnr is assassinated, sparking riots across America The last passenger steam train service runs in Britain France enters the nuclear arms race, detonating its first atomic bomb First man in space, Yuri Gagarin dies in a jet fighter crash NASA’s Apollo 7 astronauts broadcast live from orbit around the Earth Saddam Hussein overthrows the Iraqi monarchy, securing his dictatorship Yale University announces it will start to admit female students The Soviet Union and Warsaw Pact allies invade the Czechoslovak Socialist Republic
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Talkback looks back 11
Nia Taylor Former CEO of BackCare (2003-2008)
A small charity with big ambitions I
joined BackCare as Finance Manager in 2001. Having spent the previous seven or eight years working at a large university finance department with more than 100 staff, it was quite a change. The first couple of years were a period of financial difficulties and we had to make some tough decisions to reduce the number of staff significantly while trying to maintain our vital services to people living with back pain. BackCare was very lucky to have Sir Frank Davies as Chair of the Trustees at that time and he was a source of unfailing support and wisdom. He worked as hard for BackCare with its tiny offices and eight members of staff as he did for the various multi-million pound businesses he had run over the years and was always positive and cheerful! Stanley Grundy, who had founded the charity, and was now in his 80s, was also still a formidable presence. He died, aged 91, in 2006, and his obituary in The Guardian is well worth a read. When I became Chief Executive in 2003, I had three key ambitions for BackCare: to publish a 5th edition of the greatly respected ‘Guide to the Handling of People’, the definitive manual handling textbook for nursing staff; to revive the telephone helpline, previously staffed by nurses, using volunteers who had experience of living with back pain; and to
update BackCare’s considerable library of information and make it accessible to more people. I had a brilliant team of people to help achieve those ambitions. Unless you have worked for a small charity, it is difficult to understand the constraints and difficulties of achieving big ambitious projects with minimal money, resources and IT equipment. Everything was done on a shoestring, but we succeeded because everyone was willing to give 110% to the work, which they could see was so vital. In 45 years, BackCare has always had to fight for every penny of funding because back pain is not an easy cause to raise money for. When you work for BackCare you get some understanding of the enormous burden on individuals, their families and society, of living long-term with pain. I was moved by the anguish of those who phoned the office in desperation; I was angered by the unhelpful and damaging things people with back pain were told by some medical professionals; I was inspired by the stories of those who had overcome their pain to achieve their goals; and I was encouraged by those who wrote to say we’d made a difference. It was a fascinating job – I might be stuffing envelopes and filing one minute, attending receptions at the Houses of Parliament the next, speaking to healthcare
professionals at a conference one day and updating the website the next. Boring it never was; exhausting and stressful often – but always worthwhile. I’d like to thank all those I worked with – too many to name – during my time at BackCare: the Trustees, staff, members and amazing volunteers who gave so much despite the pain they lived with. Back pain will never have a magic bullet that will cure. Improvements in the care and treatment will be by hard-earned small increments, better information and earlier treatment. I believe that BackCare, despite its limited resources, has an enormous role to play in that journey.
Everything was done on a shoestring, but we succeeded because everyone was willing to give 110% to the work Talkback l summer 2013
12 Talkback looks back
Stanley Grundy Obituary, The Guardian, Tuesday 18 April 2006
Founder’s vision propelled charity forward H
e had become aware of the pain, suffering and time wasted after his own back injury from a sailing accident in 1967. The Back Pain Research Association was formed in August 1968 and registered as a medical charity. Initially, progress was slow, not least because treatment for back problems was shared between so many disciplines. In the early days, the charity focused on persuading the professions involved to work together. This principle of a multi-disciplinary approach, for which the charity lobbied, was enshrined in the clinical standards advisory group report by the Department of Health in 1992.
A need also existed for educating the public in ways of preventing and alleviating back pain. Stanley’s vision was behind much of the work done by the charity over the last 38 years – from international seminars, publications, helpline, the network of branches supporting people with chronic back pain, and a website. After leaving Hampton grammar school, Stanley had joined his uncle’s architectural metalwork business. At an early age he took control, becoming expert at working with metals. In the Second World War, he worked on the production of Hawker Hurricane fighter aircraft. Having found a way to
weld aluminium, he introduced the aluminium beer barrels which replaced wooden casks in public houses, aluminium milk churns and aluminium trolleys for hospitals and schools. The Grundy Group of companies, which he created in the 1960s, employed more than 4,000 people, with an annual turnover in 1980 of £80m. He rewarded hard work with welfare benefits, profit sharing and co-partnership. His was the first private company to have a company pension scheme. Sturdily independent, Stanley refused to turn his private company into a public one, not wishing to be
answerable to shareholders. In 1960 he set up the Stanley Grundy Trust, which continues to make grants to other charities. As well as the National Back Pain Association, he set up a chess initiative that now boasts a million children playing chess in six Commonwealth countries; gave a science block to Hampton school; and was president and later patron of the Twickenham Conservative Association. He was awarded the CBE in 1983. He is survived by his wife Dora, whom he married in 1940, their daughter, three grand-daughters and two great-grandchildren.
Beryl Kelsey, chairman of the Hull and East Riding Branch
First small steps of a self-help group I
n 1995, the regional director, Dr Connell, put an appeal in the local newspaper regarding the possibility of a local self-help group for people with back pain. About eight people responded and the Hull and East Riding branch was formed. We had tremendous support from the National Back Pain Association (as it was called then), in particular from Chris Cotteril and Vera Manly, and the branch conferences. Our local Council for Voluntary Services also supported us and in no time we had a large membership taking part in a variety of
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activities. The first to form was a walking group and soon after an exercise session in a hydrotherapy pool. A swimming club for disabled people was granted a weekly session free of charge and they were pleased to extend their session to be available for exercise for people with back pain. This informal arrangement worked very well, but eventually the branch members wanted to develop and formed a group independent of the swimming club. Luckily, we are still receiving free pool time. Monthly speaker meetings and self-help days were well
attended and a group called ‘Listening Ear’ soon developed into a monthly line dancing session, with the dances chosen to suit people with health problems. A variety of social activities was organised: lunches, BBQs, petanque or croquet competitions, a dinner dance and a party at Christmas. Over the years, there have been several memorable events, such as taking part in the Lord Mayor’s Parade; winning the team trophy in a regional swimming gala for people with health problems; and then having a member
selected for the national finals competition in Wales; a holiday in the Lake District where several members reached the top of Helvellyn; and a walking holiday on the continent. It has been an eventful 18 years with downs as well as ups. Our branch has always consisted of mainly mature people and inevitably some valued members have died. Others have moved on to other interests. Encouraging new people to help organise events and serve on the committee is a problem, but one we have to work on if we are to survive another 18 years.
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Looking forward to the next chapter
Alan Gardner Consultant Spinal Orthopaedic Surgeon and long-serving BackCare Trustee
From the Editor, Dr Adam Al-Kashi
Keep up the good work! B
ackCare, as it is now called, was set up as The National Back Pain Association in 1968 through the energy and imagination of Stanley Grundy, a successful industrialist afflicted by chronic back pain. He was motivated by the major difficulties he experienced in gaining a rational understanding of his back problem and its effects on his working and social life, and the difficulties at that time of obtaining evidencebased management of his condition. Chronic back and neck pain was becoming recognised as a major social and economic handicap in those countries whose healthcare systems were sufficiently developed to recognise and assess the challenges. As a successful businessman, Stanley Grundy applied his considerable energies and intellect to creating a charity which would bring together all those with an interest in back pain, whether as sufferers or as therapists. Over the course of its first five years, Stanley Grundy set up the National Back Pain Association as a registered charity. His own experience and good sense encouraged him to bring together a team of experts in back pain along with other successful and distinguished individuals who could provide impetus and access to the task of raising money and stimulating research. They were also tasked with highlighting successful methods of treatment and setting up a helpline for back sufferers who were uncertain which way to turn. I should explain where I am coming from. I trained at the Middlesex Hospital, London (now a smart housing precinct) in 1962, then worked as a junior doctor in St Andrew’s Hospital, Billericay (now an outpatient unit) and then at the Royal Portsmouth Hospital (now a car park and shopping precinct). By 1975, I had been appointed as a consultant orthopaedic surgeon with an interest in spinal surgery at Basildon Hospital. At Basildon, we set up a spinal unit with a three-strand approach, primarily to manage
those who needed surgery for severe and intractable pain and deformity (scoliosis), but also rehabilitation classes to treat the bio-psychosocial cases and physical therapy for those in need. I first came across the National Back Pain Association around 1980 when applying for a grant to finance our research. We were delighted to receive a £1,500 grant from BackCare, but this coincided with a period of financial stringency in the National Health Service and I had to return the £1,500 to the National Back Pain Association with grateful thanks for their consideration. I was very pleased to be invited to attend National Back Pain Association meetings and to become a Trustee and remain so to this day. Over the years, the National Back Pain Association has battled on, being re-named BackCare in 1998. The charity has supported many worthwhile research projects and helped countless back sufferers through its telephone helpline. BackCare has attended and sponsored many exhibitions and meetings. It also produces the high-quality quarterly magazine TalkBack [thanks Alan! – Ed.] and many other publications on all aspects of back and neck pain. So far as the future is concerned, BackCare will be launching an upgraded helpline imminently and hope and expect to resume funding research projects. BackCare will do its best to encourage intensive treatment units for chronic back pain and to speed up the evidence-based management of back pain wherever possible to prevent it becoming chronic. Through the remarkable efforts of Dr Brian Hammond, our CEO who knew Stanley Grundy well and treated his back pain, and Dr Adam AlKashi, our Head of Research & Education, along with their team in Teddington, BackCare is now back on course after a difficult time during the recession, ready to carry on with renewed vigour. Carry on BackCare and all good wishes for the splendid work which you do!
I have been involved with BackCare for only 18 months and yet I can identify a sense of participating in something rather substantial – the convergence of many lives toward one goal over what will soon become a half century. I’m honoured to be a part of this movement. Much has certainly changed over this period, both in terms of our knowledge and understanding as well as in our capacity to apply this understanding. But are we any closer to the goal? I feel we have reached a point in recent decades where it is no longer a knowledge deficit that holds us back but rather a capacity deficit that prevents us from uprooting what does not work and living into what has been established to generate health. There can be few in today’s world entirely unaware of the damaging impact of stress, inactivity, smoking and obesity. But this knowledge alone does not empower the individual to change. We must grow the capacity to actually feel this knowledge rather than merely understand it. I look forward to seeing the BackCare story further unfold and to playing a part in that process.
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14 talkback support
If you have a disability or long-term physical or mental health condition, Access to Work can provide practical and financial support to help you overcome barriers to starting or keeping a job.
Access to work – available help A
ccess to Work is provided when someone requires support or adaptations beyond the reasonable adjustments that an employer is legally obliged to provide under the Equality Act. If you’re an employer, Access to Work can also give practical advice and guidance to help you understand physical and mental ill health and how you can support your employees.
How can Access to Work help me?
Access to Work can help pay for support you may need because of your disability or long-term health condition, for example: ■ aids and equipment in your workplace ■ adapting equipment to make it easier for you to use ■ money towards any extra travel costs to and from work if you can’t use available public transport, or if you need help to adapt your vehicle ■ an interpreter or other support at a job interview if you have difficulty communicating, or ■ other practical help at work, such as a job coach or a sign-language interpreter. If you have a mental health condition, you can be offered assistance to develop a support plan. Your plan may
Talkback l summer 2013
include steps to support you whether you are going in to, remaining in or returning to work. The plan can suggest what reasonable adjustments could be needed in the workplace, for example: ■ flexible working patterns to accommodate changes in mood and impact of medication ■ providing a mentor to give you additional support at work ■ giving you additional time to complete certain tasks ■ providing you with additional training ■ regular meetings between you and your manager to talk about your concerns, or ■ a phased return to work, such as reduced hours or fewer days. Access to Work partners will also work with your employer to advise them how best they can support you in the workplace.
Do I qualify for this help?
You can apply for Access to Work if you have: ■ a disability or long-term health condition that has a negative effect on your ability to do your job (long-term means lasting or likely to last at least 12 months), or ■ a mental health condition and need support in work, and: ■ you are aged 16 or over, and ■ you live in Great Britain (England, Scotland or Wales), and ■ you are already doing paid work, or ■ you are about to start work or become self-employed, or ■ you have an interview for a job, or ■ you are about to begin a work trial or start work experience under the Youth Contract arranged through Jobcentre Plus. You must also either: ■ need support when starting work ■ need support to reduce absence from work, or ■ need support to stay in work.
You do not usually qualify if you are working and claiming Employment and Support Allowance or Incapacity Benefit. However, you may qualify for Access to Work for a limited time if you are doing certain types of “permitted work” to help you move off benefits completely.
How does Access to Work help me as an employer?
Access to Work can help you: ■ retain an employee who develops a disability or long-term condition (keeping their valuable skills and saving you time and money recruiting a replacement) ■ meet your legal obligations under the Equality Act ■ demonstrate that you value your employees by having good employment policies and practices ■ support employees with a mental health condition.
Find out more at: www.gov.uk/access-to-work
HOW DO I APPLY? For more information about Access to Work, or to make an application, contact our customer service teams. South of England: Telephone: 020 8426 3110 Textphone: 020 8426 3133 Email: atwosu.london@dwp.gsi.gov.uk
Scotland or North of England: Telephone: 0141 950 5327 Textphone: 0845 602 5850 Email: atwosu.glasgow@dwp.gsi.gov.uk Wales or Central England: Telephone: 02920 423 291 Textphone: 02920 644 886 Email: atwosu.cardiff@dwp.gsi.gov.uk
talkback support 15
CASE study
‘
Jane Hatton
I had used Access to Work in a previous role and, due to my need to work lying down, they provided me with an adjustable platform to lie down on in my offices, and a wall-mounted laptop stand, meaning the laptop could be suspended above me, allowing me to type lying down. Circumstances changed and I had to start working from home. I found this very difficult as my bed is the only place I can work from lying down: in order to use the laptop, I had to raise my head on two pillows, causing tremendous neck pain. Also, typing while lying down means the shoulders and neck have to take the full weight of both arms, causing further strain and discomfort. On top of this, not being able to sit for long means not being able to drive very far – even in running an online business, some face-to-face meetings are necessary. The pain in my neck, recently operated on, was getting to the point where I wondered how I could continue to work at all. I had planned to expand my business (a not-for-profit job board for disabled job seekers, called Evenbreak) and hopefully take on staff, but if I was unable to use the computer I would have to fold the business and live on benefits – not a prospect I found at all appealing. I contacted Access to Work again, not really sure how they could help me this time. After a short telephone conversation, it was arranged for an assessor to come out to see me. She immediately understood the problem and suggested an adjustable bed, which could be raised at a slight angle during the day while I work and laid flat again at night for me to sleep. This meant my neck would be at a much more natural angle and under much less strain. In addition, she suggested voice-activated software (Dragon Naturally-Speaking) with some training in how to use it, so that I could use the computer without having to raise my arms all the time. I was also allowed a driver to be used on an ad hoc basis who could drive me, lying flat, to work-related events. These three actions made a huge difference. It meant that working on the computer was much less painful and for some tasks I could use the Dragon software. Also, I could attend meetings and conferences etc (either standing for short periods or taking a reclining chair I can lie down on). This was the difference between folding the business and forging ahead to expand it. Since these adaptations were implemented, I have taken on another (disabled) employee and am planning to take on two more this year. The whole process was simple and straightforward. Without Access to Work my life would have looked very different. I am always surprised, when talking to employers and self-employed disabled people, that there is such a low level of awareness about the support that Access to Work offers. More publicity is needed to ensure people know what support is available.
I have a degenerative spinal condition and successive spinal surgeries have left me in permanent severe pain in my lower spine and neck. I have very limited ability to sit or walk, and can stand with the aid of a back brace and neck collar. As I am unable to sit for more than a few minutes, I can’t sit at a desk to use a computer like most people.
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16 talkback campaigns
BackCare Awareness Week 2013
Caring for the carers Why carers?
The UK is home to seven million unpaid carers. These are people who provide ongoing care and support to an ailing or disabled family member, friend or neighbour. They represent an unpaid and often invisible workforce that saves the Government a staggering £119 billion every year – more than the Government’s entire annual NHS expenditure. Due to the nature of their role, unpaid carers are often exposed to higher than usual levels of physical and emotional stress which puts their own health at risk. Many help the person they care for with physical tasks, such as getting in and out of the bed, bath or chairs. Without advice and training in safe technique, the carer may be putting undue physical stress on their own bodies. In addition, the role of carer,
Talkback l summer 2013
especially when caring for a spouse or close family member, can create unique emotional stresses. Both parties can struggle with issues such as dependency and loss as they try to adapt to the changing relationship. More than 70% of the UK’s unpaid carers now suffer from back pain and are at greater risk of developing chronic pain, which is highly disabling in a third of cases and life-long for the majority.
What is BackCare doing about it? BackCare is working to help the UK’s unpaid carers with the launch of a national campaign called “Caring for Carers” during this year’s BackCare Awareness Week (7-11 October 2013). Radio day The week will kick off with a radio day of live interviews set to reach 4,000,000 listeners on
Carers represent an unpaid and often invisible workforce that saves the Government a staggering £119 billion every year
regional and national stations. The aim is to raise awareness of the key issues and of BackCare’s work in this area. Campaign pack BackCare will distribute a campaign pack featuring educational materials, including our preventative education: A Carer’s Guide to safe moving and handling of people, which comes with a free DVD featuring real carers demonstrating safe moving and handling techniques in their own homes. Training programme As announced in the last issue, BackCare has formed a new partnership with the training experts at Arc Learning who run the manual handling training for nursing and related degree programmes at Worcester University. They have created a training programme for carers (see facing page for details).
Research initiatives The campaign is being run in collaboration with several organisations, including Carer’s Trust, Arc Learning, Guideposts Trust, Carers of Epsom, Action for Carers and the White Lodge Centre. Through these and other collaborations, BackCare is involved in a few different research initiatives. We’ll be using surveys to understand more about how and why back pain impacts carers. We’ll also be piloting a group intervention to tackle the psychosocial stresses unique to carers. Supporter events BackCare members and partners will be running local events up and down the country in clinics and carer centres to co-ordinate with the campaign. To learn more about BackCare, visit www.backcare. org.uk, email info@backcare. org.uk or call 020 8977 5474.
talkback campaigns 17
BackCare launches Safe People Handling Courses BackCare now provides Safe People Handling Courses for professional and informal carers. The number of people being cared for in their own homes is growing, with friends and family playing a large part in the delivery of that care, especially when it comes to moving and handling. Accessing good quality, up-to-date people handling knowledge and skills is vital for carers to maintain their own health when assisting the people they care for to move. BackCare now offers practical, informative Safer People Handling Courses to help friends and families
provide care without putting themselves at risk. Run by two of the UK’s leading experts in people handling – Mandy Chadwick and Paul Titcomb from Arc Learning – the courses guarantee to deliver information and practical skills to help move individuals safely, in line with BackCare’s own professionally renowned publication The Guide to the Handling of People, 6th Edition. Training centres are located in Tyseley in the West Midlands, Enfield in north London and at BackCare’s own headquarters in Teddington, Middlesex. However, courses or information seminars may
Above and below: informal carers attending a training session be held at any location or venue such as GP surgeries or community centres, just as long as there is sufficient room to accommodate the session. BackCare’s Safe People Handling Courses last 3-4 hours and are excellent value for money at only £45 per person; minimum of eight people per course. Training may take place throughout the week, including evenings or weekends. Each session aims to cover all the essential information relating to what is, and what is not, acceptable, and looks at some of the practical skills necessary to move people in a safe and dignified manner.
BackCare also runs a number of Safe People Handling Courses for professional carers, including domiciliary and residential care staff and registered healthcare professionals. These include: ■ People Handling Risk Management ■ Train the Trainer ■ Practical People Handling Workshops Mandy Chadwick PGDip OHE, PGDip MHM, RGN, MHFC,FETC, TDLB, Cert IA, NEBOSH, NBE(RM) Mobile: 07793 279225 mandy@arclearning.co.uk
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18 talkback fundraising
2013 London Marathon: Team BackCare at Mile 16
Alex Elliott
Paul Bryenton and Olivia Corrie
Team BackCare runs up more than £28,000
Mike Dilke
Adam Al-Kashi
Talkback l summer 2013
This year’s London Marathon proved to be another fantastic one for BackCare, with our team of 18 runners raising more than £28,000. Our top fundraiser was Sasha Stack who raised more than Roy Allen £3,600. Our fastest runner was Richard Salmon who completed the distance in just under threeand-a-half hours. Congratulations to all the Richard Salmon runners in the 33rd London Ben Sweeting Marathon on 21 April and their Alex Elliott supporters. In all, about 36,000 Paul Maddock runners took part. Seema Rao-Reed The full results for Team Michelle Scott BackCare are in the table on Nick Clarke the right. Sasha Stack It’s now time to sign up for the 2014 London Marathon. Emma Richardson It’s not only a great way to Rebecca Reed raise money for beating back Charlie Woods pain but a tremendously John Ellis empowering event for runners Olivia Corrie themselves, especially first time Paul Bryenton marathoners and people new Mike Dilke to running. Plus, BackCare Adam Al-Kashi can support your training Sumit Judge and fundraising efforts with Roy Allen information and advice.
Raised £1,062.00 £1,575.22 £2,590.00 £2,055.00 £527.00 £1,550.22 £1,540.00 £3,621.25 £1,862.00 £1,361.00 £1,742.55 £1,580.00 £1,169.60 £1,169.60 £791.38 £1,623.00 £2,536.00 £165.00
Time Placing 3:29:22 4,612 3:42:52 6,891 3:59:47 10,919 4:10:57 13,226 4:19:27 15,162 4:23:45 16,201 4:23:53 16,203 4:40:57 20,285 4:42:16 20,589 4:45:26 21,284 4:53:38 23,111 5:18:31 27,346 5:33:07 29,135 5:33:08 29,138 5:37:02 29,582 5:52:51 31,032 5:57:51 31,407 7:30:05 34,065
talkback support 19
The Society for Back Pain Research ANNUAL GENERAL MEETING 2013
14-15 NOVEMBER 2013 GOVERNORS HALL, ST THOMAS’ HOSPITAL, LONDON
TITLE: SPOTLIGHT ON SCIATICA Including this year a debate: “This house believes surgery is the optimal treatment for sciatica” INVITED SPEAKERS: DR NEFYN WILLIAMS PROFESSOR PETER FRITZELL DR HANNE ALBERT MR STEVEN VOGEL DR MELINDA CAIRNS MR DOUGLAS WARDLAW DR DEBORAH FITZSIMMONS Full details and registration are available at www.sbpr.info ONLINE REGISTRATION IS NOW OPEN
Photo © Nick Weall
Being held in conjunction with the meeting is the HENRY V CROCK LECTURE 2013, named after the founder of DISCS. The lecture, to be given by Professor David Hukins, is entitled: Engineering, physics, the spine and back pain, and will take place on Wednesday, 13 November 2013, at 17.15 in the Governors Hall, St Thomas’ Hospital. Full details will be available on the DISCS website www.discsfoundation.org
20 talkback research
Prevention is better than cure Part 3
Rethinking chronic pain “Prevention is better than cure”, so the old adage goes. And 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 this latest instalment of the ongoing educational series, we’ll be reviewing and rethinking chronic pain – its meanings, consequences and resistance to mainstream medical approaches. Back pain represents half of all chronic pain1, so it’s certainly pertinent for us and not surprising that back pain has informed the majority of thought and research on this topic. Snapshot: The human cost of chronic pain Every year, five million people in the UK will develop chronic pain. That’s a further 8% of the population succumbing to chronic pain every year. ■ 75% will get divorced ■ 25% will lose their job ■ 22% will develop depression ■ 20% will consider suicide ■ 10% will attempt suicide If their chronic pain becomes “highly disabling”, their risk of death is greatly increased: ■ 50% increased risk of terminal cancer ■ 90% increased risk of fatal heart attack ■ 250% increased risk of fatal lower respiratory disease ■ 370% increased risk of fatal coronary heart disease
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Back pain doesn’t kill
All too often we’re told that back pain and chronic back pain is too expensive, costing billions in NHS treatments and disability benefits. True as this may be, it tends to detract from the humanity and human cost of pain. Patients suffering chronic pain are at high risk of suffering long-lasting emotional disturbances characterized by persistent low mood and anxiety2. In fact, they carry three times the average risk of psychiatric disorders3, and 22% of cases lead to depression4. Perhaps most unsettling is that a review of a dozen different studies conducted in 2006 showed that chronic pain doubles the risk of suicide – around one in five chronic pain patients think about suicide, and one in ten will attempt to take their own life5. In fact, several studies have shown the profound impact of chronic pain on mortality. Chronic pain doubles the all-cause death rate, independent of socio-demographic factors (such as
The chronic pain epidemic
So it appears that chronic pain is far more lethal and destructive than is often realised, but how common is it? Well, there are an estimated 100 million chronic pain sufferers in Europe13, including one third of adults in England7. In America, one third of the entire population is estimated to suffer chronic pain14. So that’s around a quarter of a billion people in just the Western world. Chronic pain is certainly a global issue and by several accounts it’s getting worse. In Britain, the prevalence of total back pain increased across all age groups, social classes and regional areas from 35% in 1987 to 50% in 199715. Between 1992 and 2006, the prevalence of chronic lower back pain (CLBP) in North Carolina more than doubled, from 4% to 10% – increasing in all age, gender and ethnicity groups16. An identical more-than-doubling (also from 4% to 10%) was recorded between 2002 and 2010 in the medium-sized Southern Brazilian city of Pelotas – growing fastest in younger individuals with more years of education and higher economic status17. The 2011 Health Survey for England revealed that 15 million adults in England have chronic pain, but this appears to be a rapidly growing figure. In 2009, former Chief Medical Officer Sir Liam Donaldson reported that more than five million people develop chronic pain in the UK every year, from which a third will never recover. Put another way, a further 8% of the UK population succumb to chronic pain every year. If news broke tomorrow that a new treatment resistant virus, carrying an increased risk of heart attack, cancer and suicide was infecting millions of people a year, I think we’d all be rather alarmed.
If news broke tomorrow that a new treatment resistant virus, carrying an increased risk of heart attack, cancer and suicide was infecting millions of people a year, I think we’d all be rather alarmed.
talkback research 21
age, gender, education, income and occupation)6. Sufferers who are highly disabled by their condition (33%7) are at even greater risk of death, particularly from heart attacks, coronary heart disease and lower respiratory diseases8. The slogan, “back pain doesn’t kill, it tortures” wasn’t coined by BackCare but we did adopt it in several instances over the last couple of years as a means of highlighting the fact that back pain continues to destroy so many lives. However, upon delving more deeply into the research literature, we find that even this seemingly stark slogan is an underestimate, particularly in the context of chronic back pain – in short, it literally increases death rate. And if it doesn’t kill you, pain and disability impacts every area of life. According to the Chronic Pain Policy Coalition, one quarter of sufferers will lose their jobs. The impact upon daily functioning can be severe and the strain placed on relationships can reach
breaking point. Around 40-50% of all marriages in the UK and America end in divorce9, 10, but this figure rises to more than 75% where one partner is chronically ill11. “Physical pain, psychological distress and the deleterious effects of medical procedures all cause the chronically ill to suffer as they experience their illnesses. A fundamental form of that suffering is the loss of self in chronically ill persons who observe their former self-images crumbling away without the simultaneous development of equally valued new ones. As a result of their illnesses, these individuals suffer from (1) leading restricted lives, (2) experiencing social isolation, (3) being discredited and (4) burdening others”12. In conclusion, it has been said that “back pain doesn’t kill”, but chronic pain is, in fact, associated with an increased risk of death, disability, depression, divorce, and numerous other direct and indirect sequelae.
More than 1 in 10 is highly disabled by chronic pain
Rethinking chronic pain As discussed, around a third of people have chronic pain, a third of these are highly disabled by their condition and this disablement carries a dramatically increased risk of death from heart attacks, coronary heart disease, lower respiratory diseases (such as chronic bronchitis and emphysema). Astute readers may have spotted that these particular diseases are classically associated with stress, smoking, physical inactivity, unhealthy diet and drug dependence. Indeed, chronic pain sufferers are at higher risk of opioid18 and alcohol19 dependence. Smoking is three-times more prevalent among chronic pain patients than the general population – 60%20 and 20%21, 22 respectively – and causes 80% of chronic bronchitis and emphysema cases 23. Indeed, the full consequences of pain are so often overlooked. There is a tendency within our modern mainstream conception
of medicine to classify disease as something that happens to the body and within the body. Making any medical progress at all is in part dependent upon mustering the “escape velocity” needed to leave behind this antiquated definition. Chronic pain is not simply something that happens to and within the body; rather it is the common name for syndrome or pattern of interrelated processes that encompass physical, psychological and social dimension. In no uncertain terms it controls how the person thinks, feels, behaves and functions. Obviously, not all chronic pain patients are addicted to cigarettes, alcohol and prescription painkillers. The point is that these, and an entire catalogue of far less obvious negative behavioural adaptations, serve as coping mechanisms for the ongoing experience of pain, disability and loss of self. These cannot be considered somehow separate from the pain itself. continued on p22
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22 talkback research
Prevention is better than cure: rethinking chr from p21
The physical fixation
While most people experiencing headache do not tend to attribute it to a physical problem with their head, our assumptions about back pain are quite different. It is common for back pain patients to absolutely fixate on relatively insignificant physical and anatomical details, often from an over-interpretation of diagnostic imaging results. Most pain-free people have some form of spinal disc degeneration (including bulges, herniations, protrusions, prolapses) from harmless wear and tear and as a normal part of aging24-26. A patient may classify their issue as “I slipped a disc at L4-L5 in 1995” rather than grasping that the chronicity of their pain is far more significant than its bodily location. In short, if a patient has had constant pain or recurrent episodes of pain for a long period of time (from three months to years), then their primary issue and the biggest medical threat to their future health and to their life itself is “chronic pain” not “slipped disc”. In fact, as shown by Professor Sir Simon Wessely and colleagues at the Institute of Psychiatry, you are almost 70% more likely to develop and suffer from medically unexplained symptoms (such as chronic back pain) if you attribute your condition to physical causes rather than lifestyle and behavioural factors27. We have fallen foul of modern science’s tendency to “atomise” reality – cutting our experience into smaller and smaller fragments to be labelled with the hope of better understanding our world. Chronic pain has not escaped the resulting
obfuscation as we now have at least six different labels that identify parts of this syndrome: chronic, persistent, long-term, recurrent, non-specific, and medically unexplained. No, they don’t all mean the same thing, yet they are all facets of the chronic pain syndrome. And yes, even with a slipped disc or similar imaging-based diagnosis, the pain is non-specific and medically unexplained as normal spinal degeneration does not constitute adequate or plausible cause for lasting pain.
Adaptations of the brain
The last decade has seen considerable research associating specific skills and traits to brain structure. A rather elegant demonstration of this is that London taxi drivers who have “the knowledge” (i.e. learned the entire roadmap of London) show altered structure in the anterior hippocampus of the brain by MRI scan28. Even political orientation has been found to relate to distinct structuring of the brain: greater liberalism is associated with greater grey matter in the anterior cingulated cortex (a part of the brain involved in empathy and impulse control), whereas greater conservatism is associated with increased grey matter in the right amygdala29 (a part of the brain that mediates subconscious fear30, 31). In a recent breakthrough, Professor Sean Mackey and colleagues at Stanford University found they could detect chronic lower back pain with 76% accuracy by brain scan32. Chronic lower back pain sufferers were found to exhibit restructuring of the cerebral cortex (a part of the brain
involved in perception, awareness and thought). We have long known that the brain changes its physical structure as an adaptive, learning response to stimuli – a process termed “neuroplasticity” – but this new research supports the understanding that the chronic pain syndrome is an adaptation (arguably a maladaptation) acquired in the same way as other capacities are learned. Single-site chronic pain is rare and 92% of chronic back pain sufferers feel pain in other parts of their body1. For example, chronic lower back pain (CLBP) accounts for 25% of all chronic pain, but singlesite CLBP is only 3%. Of course, it needs to be appreciated that it is common to experience referred and radiating pain. However, even when all lower limb pain is included with lower back pain, the figure only rises to 7% (falling well short of the 25% mark). In brief, more often than not, the chronic pain syndrome manifests pain in multiple sites of the body (even when we account for referred and radicular pain). This is important because it supports the emerging understanding that chronic pain is a systemic syndrome primarily driven by the brain.
Unlearning the maladaptive stress response
As noted, our mainstream conception of medicine harbours the notion that disease is something that happens to the body and within the body. A further misconception, again very much deleterious to progress, is that physical symptoms can only be
References 1 D, Carnes. “Chronic musculoskeletal pain rarely presents in a single body site: results from a UK population study.” Rheumatology (PMID:17488750), 2007: 1168-70. 2 C, Alba-Delgado. “Chronic pain leads to concomitant noradrenergic impairment and mood disorders.” Biological Psychiatry (PMID:22854119), 2013: 54-62. 3 Harvard Medical School. “Depression and pain.” Harvard Mental Health Letter, September 2004. 4 Chronic Pain Policy Coalition; http://www. policyconnect.org.uk/cppc/ 5 NK, Tang. “Suicidality in chronic pain: a review of the prevalence, risk factors and psychological links.” Psychological Medicine (PMID:16420727), 2006: 575-86. 6 HI, Andersson. “Increased mortality among individuals with chronic widespread pain relates to lifestyle factors: a prospective population-based study.” Disability and Rehabilitation (PMID:19874076), 2009: 1980-7. 7 The Health and Social Care Information Centre. The Health Survey for England 2011. NHS, 2011. 8 N, Torrance. “Severe chronic pain is associated with
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increased 10 year mortality. A cohort record linkage study.” European Journal of Pain (PMID:19726210), 2010: 380-6. 9 Office for National Statistics; http://www.ons.gov.uk/ 10 PolitiFact; http://www.politifact.com/ 11 National Centre for Health Statistics; http://www.cdc. gov/nchs/ 12 K, Charmaz. “Loss of self: a fundamental form of suffering in the chronically ill.” Sociology of Health & Illness (PMID:10261981), 1983: 168-95. 13 H, Breivik. “Survey of chronic pain in Europe: prevalence, impact on daily life, and treatment.” European Journal of Pain (PMID:16095934), 2006: 287-333. 14 Institute of Medicine. Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research. IOM, 2011. 15 KT, Palmer. “Back pain in Britain: comparison of two prevalence surveys at an interval of 10 years.” British Medical Journal (PMID:10845966), 2000: 1577-8. 16 JK, Freburger. “The rising prevalence of chronic low back pain.” Archives of Internal Medicine
(PMID:19204216), 2008: 251-8. 17 RD, Meucci. “Increase of chronic low back pain prevalence in a medium-sized city of southern Brazil.” BMC Musculoskeletal Disorders (PMID:23634830), 2013. 18 C, Littlejohn. “Chronic non-cancer pain and opioid dependence.” Journal of the Royal Society of Medicine (PMID:14749399), 2004: 62-5. 19 M, Egli. “Alcohol dependence as a chronic pain disorder.” Neuroscience and Biobehavioural Reviews (PMID:22975446), 2012: 2179-92. 20 DA, Fishbain. “Are chronic low back pain patients who smoke at greater risk for suicide ideation?” Pain Medicine (PMID:19254332), 2009: 340-6. 21 Action on Smoking and Health; http://www.ash.org.uk/ 22 Centers for Disease Control and Prevention; http:// www.cdc.gov/ 23 National Clinical Guideline Centre. “Chronic obstructive pulmonary disease: management ~”. National Institute of Health and Clinical Excellence, 2010. 24 MC, Jensen. “Magnetic resonance imaging of the lumbar spine in people without back pain.” New
talkback research 23
ronic pain The brain: the master organ
caused by physical problems and can only be adequately met with physical interventions such as drugs, surgery or hands-on therapies. The research, however, tells a very different story. In 1995, researchers at the University of Texas started tracking 421 employees with acute back pain to understand better why some people don’t recover33. Using a psychological test, they were able to classify who would be disabled by chronic pain a year later. The test had a predictive accuracy of 91%. In 2000, researchers at Sydney University recruited 694 nursing students to learn about the factors that precede and predict lower back pain34. Volunteers were assessed every six months for four years with measures of physical (body weight, strength, flexibility), psychological (stress, nervousness, health perception) and lifestyle factors (exercise, smoking). The only factor found to predict new cases of lower back pain was acute psychological distress. In 2001, researchers in Germany recruited 51 volunteers through local newspaper advertisements and subjected them to low-velocity “placebo” rear-end car collisions with no actual biomechanical potential for injury35. The 10 volunteers who had scored highest on their psychometric test reported the symptoms of “whiplash injury” at the follow up appointment three days after the placebo collision. By true definition, the researchers had effectively re-created a “nocebo” effect, whereby a harmless stimulus generates actual harm. Although the term “placebo effect” has
become highly popularised in modern culture, there is actually a gross underrealisation of the brain’s significance, and, indeed, the mind’s significance, in physical health. What we have to remember is that non-specific pain refers to pain for which there is no recognised physical cause and which is likely to be stress induced. Note, “stress induced” (which suggests that stress is activating physical pain-related processes in the body) should not be confused with “imaginary” (which suggests that there is absolutely no relationship between the pain perception and bodily processes). The brain – which automatically breathes for you while you sleep, automatically raises your pulse rate in response to fear, and automatically increases blood flow through the face (blushing) in response to embarrassment
– can certainly activate pain pathways. The brain is simply the master organ of the body, and its “software” (the largely unconscious mind) holds predominant governance. In fact, physical pain is a very common symptom of psychological stress. Around 96% of people will experience headache during their lifetime and nearly 90% of these will be stress induced tension headaches36. Similarly, as many as 84% of people will experience lower back pain during their lifetime and around 90% of these cases are stress induced nonspecific back pain37, 38. The symptoms of several chronic diseases including chronic pain, cancer and diabetes are improved by general stress reduction39. However, while general stress reduction may allow the patient to get more comfortable within their chronic illness, it does not appear to foster recovery outright. There is a world of difference between effective pain management and actual recovery. It is already well accepted that stress influences physical health. Nevertheless, despite all the evidence, it is not widely realised that chronic and nonspecific pain is caused and driven by the brain, and that recovery must ultimately be psychological. Research from the emerging field of “post-traumatic growth” 40, 41 suggests that recovery from chronic pain may involve specific new learning and growth by the patient – in essence, to “unlearn” the maladaptive stress response. Sadly, this remains unbelievable, and thereby out-ofbounds, to most people at this time in our development.
England Journal of Medicine (PMID:8208267), 1994: 69-73. 25 M, Matsumoto. “Tandem age-related lumbar and cervical intervertebral disc changes in asymptomatic subjects.” European Spine Journal (PMID:22990606), 2013: 708-13. 26 SJ, Kim. “Prevalence of disc degeneration in asymptomatic korean subjects. Part 1 : lumbar spine.” Journal of the Korean Neurosurgical Society (PMID:23440899), 2013: 31-8. 27 C, Nimnuan. “Medically unexplained symptoms: an epidemiological study in seven specialities.” Journal of Psychosomatic Research (PMID:11448704), 2001: 361-7. 28 K, Woollett. “Acquiring “the Knowledge” of London’s layout drives structural brain changes.” Current Biology (PMID:22169537), 2011: 2109-14. 29 R, Kanai. “Political orientations are correlated with brain structure in young adults.” Current Biology (PMID:21474316), 2011: 677-680. 30 L, Lanteaume. “Emotion induction after direct intracerebral stimulations of human amygdala.” Cerebral
Cortex (PMID:16880223), 2007: 1307-13. 31 J, Gläscher. “Processing of the arousal of subliminal and supraliminal emotional stimuli by the human amygdala.” Journal of Neuroscience (PMID:14614086), 2003: 10274-82. 32 H, Ung. “Multivariate Classification of Structural MRI Data Detects Chronic Low Back Pain.” Cerebral Cortex (PMID:23246778), 2012. 33 RJ, Gatchel. “The dominant role of psychosocial risk factors in the development of chronic low back pain disability.” Spine (Phila Pa 1976) (PMID:8747248), 1995: 2702-9. 34 AM, Feyer. “The role of physical and psychological factors in occupational low back pain: a prospective cohort study.” Occupational and Environmental Medicine (PMID:10711279), 2000: 116-20. 35 WH, Castro. “No stress--no whiplash? Prevalence of “whiplash” symptoms following exposure to a placebo rear-end collision.” International Journal of Legal Medicine (PMID:11508796), 2001: 316-22. 36 BK, Rasmussen. “Epidemiology of headache in a
general population--a prevalence study.” Journal of clinical epidemiology (PMID:1941010), 1991: 1147-57. 37 LA, Machado. “Analgesic effects of treatments for non-specific low back pain: a meta-analysis of placebocontrolled randomized trials.” Rheumatology (Oxford, England) (PMID:19109315), 2009: 520-7. 38 M, Krismer. “Strategies for prevention and management of musculoskeletal conditions. Low back pain (non-specific).” Best Practice and Research. Clinical Rheumatology (PMID:17350545), 2007: 77-91. 39 AK, Niazi. “Mindfulness-based stress reduction: a non-pharmacological approach for chronic illnesses.” North American Journal of Medical Sciences (PMID:22540058), 2011: 20-3. 40 G, Skaczkowski. “Complementary medicine and recovery from cancer: the importance of posttraumatic growth.” European Journal of Cancer Care (PMID:23730795), 2013: 474-83. 41 S, Joseph. “An Affective-Cognitive Processing Model of Post-Traumatic Growth.” Clinical Psychology and Psychotherapy (PMID: 22610981), 2012: 316-25.
The only factor found to predict new cases of lower back pain was acute psychological distress.
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