TalkBackISSUE 2 • 2014

■ NEWS■ EVENTS■ COMMUNITY

Puzzle of painStress, beliefs and triggers

Recovery casesBeyond pain management

Culture of painWork, relationships and stigmatisation

The Charity for Back and Neck Pain

www.backcare.org.uk

FREE TO MEMBERSQuarterly magazine of BackCare, the UK’s National Back Pain Association

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TALKBACK l ISSUE 2 2014

TALKBACK EVENTS

The Back Pain Show 2014 4 – 6 JULY

Proudly sponsored by BackCare, the 2014 event brings together the latest in back care products and techniques in an exciting three-day format. Visit the BackCare Stand, Olympia Exhibition Centre, London.

Prudential Ride London 1009 – 10 AUGUST

One of London’s newest mass-participation fundraisers. Cycling festival featuring 100-mile cycle challenge. Applicants must be confident cyclists who can ride safely in large groups. Contact events@backcare.org.uk or telephone 020 8977 5474. www.prudentialridelondon.co.uk

Therapy Expo 201412 – 13 SEPTEMBER

UK’s dedicated show for Clinic Therapists and Independent Practitioners. Manchester Central. Visit BackCare at Stand 16. www.therapyexpo.co.uk

British Conference of Acupuncture and Oriental Medicine 26 – 28 SEPTEMBER

Daventry Court Hotel in Rugby

National Back Exchange Annual Conference and Exhibition29 SEPTEMBER TO 1 OCTOBER

“Outside the box: Broadening horizons” – this is the “must attend” event of the moving and handling calendar. Hinckley Island Hotel, Leicestershire. www.nationalbackexchange.org

BackCare Awareness Week 2014, “Back in the Office”6 – 11 OCTOBER

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

Association of Sport Rehabilitators and Trainers, Annual Conference22 – 23 NOVEMBER

Join fellow Graduate Sport Rehabilitators and Allied Health Professionals for the annual “Pain to Performance” conference at the University of Hull. Visit www.basrat.org for more information.

BackCare Events Calendar 2014

Subscribe to TalkBack magazine for only £22.50 per yearIf you’ve picked up this magazine at an event and would like to become a subscriber, simply complete and return this form. By becoming a subscriber, you’ll get the latest news, research and educational content delivered to your doorstep quarterly, and you help to support the work of BackCare, the UK’s national back and neck pain charity.

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Contents

The culture of pain 4-7

Case study 8-9

The puzzle of pain 10-14

Harrogate celebrates 22

Marathon effort 16-17

Spring into health 18-19

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TALKBACK WELCOME

BackCare16 Elmtree Road, Teddington,Middlesex TW11 8STTel: +44 (0)20 8977 5474Fax: +44 (0)20 8943 53318Helpline: +44 (0)845 130 2704Email: info@backcare.org.ukWebsite: www.BackCare.org.ukTwitter: @TherealBackCareRegistered as the National Back Pain Association charity number 256751.TalkBack is designed by Pages Creative www.pagescreative.co.uk and printed by Severn, Gloucester.

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

Welcome back. I hope you have been enjoying the pleasant weather and long days. Perhaps you are gearing up for your summer holiday or have just returned. Either way, we have a great issue here for you.

First, allow me to congratulate all of the courageous individuals who ran the London Marathon to raise money for BackCare. Without your dedicated efforts in training and fundraising, BackCare would be unable to reach out to as many people. Special thanks go to the friends, family and supporters alike who make such events possible. Turn to page 16 for the complete report of race results and fundraising totals.

We continue with our round-up of the latest news. This includes extended commentary on newly-published research studies, as well as the announcement of BackCare Awareness Week with a teaser from BackCare’s 2014 research on back pain in the UK.

You’ll recall that we started a new segment in the last issue which presented real clinical case studies of chronic back pain recovery. As previously stated, the aim here is to deliver powerful insights into the nature of pain recovery medicine. In this issue, we visit physiotherapist and chronic pain researcher Matt Kinal in his Bristol clinic. More than a year after being discharged, his patient’s scores for pain, disability, depression and anxiety remain stable at zero.

Next up, do you know the three key determinants of back pain? Part six of the educational series, “Prevention is better than cure” continues with a look at the puzzle of pain. We take a thought-provoking tour of the evidence surrounding the onset of back pain and development of long-term disability.

Finally, we welcome a contribution from bodyworker and educator James Earls. Through his comprehensive grounding in whole-body movement theory and therapy, we get a fascinating insight into the relationship between the movement efficiency and health promotion.

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

By the time you read this, the Back Pain Show will be upon us. Why not come down and meet us (4-6 July at the Olympia, London). Otherwise you can catch us at the Therapy Expo event (see advert on page 15 for full details!). Until then, enjoy this magazine and I’ll see you in the next issue.

Welcome

Dr Adam Al-KashiHead of Research

& Editor of TalkBack

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The culture of painWe are frequently reminded

of the financial cost associated with medical conditions, but this can distract attention from the human cost. A new study – published in February, funded by Arthritis Research UK and led by a team of researchers at Warwick University – has delved deeply into the impact of chronic non-specific low back pain upon the individual and the role played by society’s culture.

Doctor Robert Froud and colleagues conducted an exhaustive review, whittling down more than 1,400 publications from five online research databases to find 42 studies that had used face-to-face interviews or focus groups.

The researchers analysed transcripts for common themes, using a “meta-narrative” approach to gather 1,000 voices (46% male; 54% female) into a coherent whole. Here are the themes they found from the perspectives of the sufferers themselves…

Theme 1: activitiesChronic back pain causes a loss of function that most commonly affects domestic chores and valued leisure activities. Compounding the impact, the pain impairs opportunities for rest and outlets for stress. The unpredictability of pain means that planning future activities becomes a convoluted mental

decision making process. The threat of pain calls for constant vigilance. Painkillers enable participation.

Theme 2: relationshipsChronic back pain damages relationships, especially with those closest. There is an internal emotional conflict between needing support

and avoiding dependence. Sometimes, family activities are avoided for fear of spoiling the experience for others. Sometimes, the need to maintain relations means participating in activities likely to trigger pain. However, there is a risk that participation will be seen as evidence that there’s nothing wrong after all. Loss of function means not being able to play with children and grandchildren, as well as loss of sexual relationship with partner or spouse.

There are internal conflicts between former and current social identities – on the one hand being sociable or wanting to be, while on the other hand withdrawing with

Preparations are under way for BackCare Awareness Week, which takes place on 6-12 October. The theme of the 2014 campaign is “Back in the Office”.

Office workers typically spend several hours a day seated in front of computer screens – we’ll be exploring the factors that can make this an unhealthy environment.

This year’s headline sponsor is ActiPatch ®, the unique electronic patch that provides 720 hours of drug-free relief for musculoskeletal pain and which is now available in Boots stores (and at www.boots.com).

This sponsorship has enabled the creation of new educational materials which will include new

BackCare research funded by Pfizer. The new research takes the form of a national survey combining several important assessments that relate to health, illness and pain.

Early analyses have already revealed

shocking statistics. One of the assessments that we incorporated was the PHQ-15, which is a symptoms checklist used widely in clinical research and by the NHS in the diagnosis of somatisation disorders (note:

“somatisation” is where psychological stress combines with faulty health beliefs to create physical symptoms).

While only 6% of people without back pain meet the diagnostic criteria for a moderate or severe clinical somatisation disorder, this jumps to 66% among people who are "bothered a lot" by back pain. The full report will be published as part of BackCare Awareness Week. We will also be raising awareness through a research-led radio day at the start of the week.

Spotlight on desk workers during awareness week

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Genes are only half the storyThe genetic revolution brought us the Human Genome Project and the concept of curing and preventing diseases by identifying and manipulating genetic risk factors. However, with the popularisation of these ideas came a dangerous misunderstanding.

Our genes are set at the moment of biological conception when the sperm and egg fuse, each carrying half our genetic information. The misunderstanding is that your genes are the final say in the matter. Many people take this information and fall into the trap of blaming their genes for their ill health – for example, if obesity is “in their genes” they have no control.

While your genes cannot change, what we now know from the field of epigenetics is that lifestyle, stress and traumatic experiences programme in patterns of “gene expression” – this basically means that your life experiences and your environment control which of your genes get switched on and off.

A recent landmark study conducted at King’s College London has brought this insight home for pain sufferers. Dr Jordana Bell and colleagues looked at pain responses in 25 pairs of identical twins. If genes were the whole story, we’d expect to find that genetically identical twins would respond identically to pain. However, the research team found that the twins had different pain thresholds and found “robust evidence” for a connection with differences in their epigenetic markers.

This means that your genes do not have the final say as epigenetic markers are known to change in response to life conditions. The same results have already been demonstrated for complex diseases such as schizophrenia and diabetes. It has been suggested that this kind of research could lead to new drugs and treatments. However, it is important to take note of the larger implication, which is a conclusive debunking of a dangerous myth that has long been entangled with the public understanding of genetics. (The research paper entitled, “Differential methylation of the TRPA1 promoter in pain sensitivity” is available on open access at www.nature.com).

continued on p6

uncomfortable feelings about what others may think. There is fear of having to sit in pain for long periods of time and fear of spoiling social events for others.

“I’ve given up on holidays because it spoils it for everyone else.”

“Your wife says, ‘Come on, get your act together’, and it makes you feel bloody terrible.”

“My oldest son, a four year old, says, ‘What is it Daddy, you used to hold me in your arms, why don’t you now?’”

“My wife even turned on me, thinking it was all put on... From that point on I’ve just lived on my own.”

“I don’t go out, I don’t answer the phone, I live at the back of the house and I dread it when the postman comes... I just feel embarrassed. You just think ‘What do they think of me?’”

Theme 3: workChronic back pain means having to change work tasks. There is a fear of losing employment. There is a fear of telling the boss and dealing with accusations from disbelieving co-workers. Dismissal from work feels related to telling employers about back pain or taking sick leave.

Sometimes, holiday time is used to recover from pain instead of taking sick leave to avoid risking a job. Co-workers seem to regard back pain claims as illegitimate. There is a battle to be believed while also making efforts to perform tasks in spite of pain. There is fear about not being able to afford time off and the balance between suffering pain and suffering financial insecurity. There is often concern about being able to pay the bills and about the cost of medical care.

“My reading is poor, I can’t spell for jack. It’s like I’m in a no-win situation. All my work is physical.”

“I don’t look sick, I don’t limp, I don’t have a cane, I’m not in a

wheelchair, I don’t look terrible … I look good. So people could have the perception that she’s not really sick, she’s just taking days off.”

“I can’t go off sick. I can’t afford to go on half-pay... I’ve got a mortgage to pay. How am I going to cope? You start thinking, what if it never goes, right? What if it gets worse? What am I going to do?”

Theme 4: stigmaThere are significant concerns about legitimacy, credibility and validation. There is a struggle to be believed by family, friends, employers and healthcare providers. This is largely felt to result from having nothing visibly wrong and having no physical diagnosis, because pain is invisible and non-specific pain is “medically unexplained” within conventional healthcare.

There is frustration over not having sufficient explanation for the pain and disability. Sometimes stigmatisation is so strong that it actively affects self-belief. Physical diagnosis brings a sense of legitimacy – there is a sense that self-acceptance and societal acceptance hinges upon visible explanations (physical diagnosis) for invisible feelings (pain).

When pain is variable, good days appear to contradict the legitimacy of bad days, fuelling the perception in others that the pain is not real. Sometimes, this leads to overstating the severity of pain just to redress the balance, or it may conversely lead to social withdrawal to avoid stigmatisation.”

“I remember at my sickness interview – you can see the disbelief in the manager’s eyes...”

“They automatically assume that there’s nowt wrong with you.”

“I just don’t appreciate them trying to tell me that the pain is in my head. You know, in so

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Friday, 16 May, was National Massage Day, which aimed to raise awareness of the positive touch and its role in health and medicine.

Massage therapists and proponents of therapeutic touch joined forces up and down the country, which included forming a conga line stretching across Westminster Bridge from St Thomas’ Hospital to the Houses of Parliament in London.

The event was organised by Gill Tree, who has been pioneering massage education in the UK for more than two decades. Her work has included training

nurses to deliver massage to premature babies, as well as bringing massage into schools. But, in true pioneering form, she now has her sights set on a bigger goal with the launch of her “Manifesto for a Pro-Touch Society” this year.

“Touch is part of our daily language: ‘keep in touch’, ‘that video touched me’. It is instinctive and natural,” says Gill. “It is part of human nature and yet, as a society, we often remain inhibited about touch and perceive massage as a luxury rather than a necessary treatment for a healthy lifestyle.

“So what are the likely consequences if, on a national scale, our institutions advise against touch? With media impressing on us almost daily the negative effect of inappropriate touch, we are failing to recognise the negative effects of not touching.”

The manifesto seeks to raise awareness and recognition of the massage profession and its contributions to health. There is also a petition to have massage become available on the NHS and through private health providers. For more information, visit www.gilltree.com.

Exponents of positive touch highlight Massage Day

many words they tell me the pain is in my head and I have feelings in my back...”

Theme 5: changing outlookComing to believe that the pain may never be justified by an “acceptable” (physical) diagnosis, can alter outlook on self and life. Psychosomatic explanations are felt to be unacceptable, and there can be anger and confusion if this is later followed by a second, more acceptable diagnosis.

Receiving an acceptable diagnosis, especially involving radiographic evidence (e.g. MRI scan), is often felt to be empowering and makes coping and adaptation easier. Conversely, coping can be more difficult when the degree or speed of improvement fails to meet initial expectations.

Depression and hopelessness are common with back pain. The emotional impact can also include feelings of embarrassment, imprisonment, inadequacy, frustration,

uselessness, shame and self-loathing, which can extend to suicidal thinking. There can be a fear of losing control and of an uncertain future.

Acceptance is felt to be important, and accepting that the pain may never go away often leads to specific practical adaptations such as “listening” to your back, relying on faith/positivity, or portraying oneself differently to others.

“I found out since that it’s not been diagnosed correctly. They’ve been giving me the

wrong exercises... for 10 years...”

“I mean, I’ve had days and weeks where I just got depressed over it, and I think, well, I can’t be bothered, there’s no point, it’s not getting better.”

“I’d love to be alone on a desert island... to be away from people and not to have to be something else you’re not – that would be bliss.”

“I would like to take medical retirement… it would be nicer to actually say to people ‘I’m retired’ rather than ‘I’m off sick’.”

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The culture of pain – Editor’s discussionAuthors of the 42 studies highlighted the pervasive nature of living with back pain which could dominate lives and have life-changing psychological and social consequences. The stigmatisation around pain often seemed responsible for a large proportion, if not the majority, of suffering incurred by those with chronic non-specific low back pain.

Doctor Froud writes: “We have found that social factors can be central to the concerns of those with lower back pain and could be drivers for more costly (to both individual and to society) and complex sequelae, such as depression.” There seems to be a failure in research and healthcare to recognise the role of society in the course of illness. In a publication entitled “Sick Individuals and Sick Populations”, eminent epidemiologist, Professor Geoffrey Rose discusses the need for strategies that change a society’s ingrained tendency to worsen the health of its own members. Froud concurs: “The more lateral thinking might be tempted to develop a back pain intervention that is aimed at changing population attitudes to back pain,” citing the example of “Time to Change” (www.time-to-change.org.uk; a programme led by charities, Mind and Rethink Mental Health, which aims to challenge mental health stigma and discrimination). And his citation is apt because, as readers of TalkBack will surely know, overwhelming clinical evidence informs us that the only consistent and independent predictors of back pain are psychological factors, not physical factors. Indeed, almost all back pain is stress-induced, just like almost all headaches.

So, through the aforementioned channels of stigmatisation, the back pain sufferer can fall victim to a society that finds the mind to be unreal and even shameful. However, the individual is also a member of that society and they’re own inability to relinquish ingrained social norms fuels their rejection of a psychophysiological diagnosis. The sad irony here is that in rejecting the psychophysiological diagnosis, the chronic pain patient may be closing the door on their own recovery – we have curative interventions for psychophysiological pain but only coping strategies for chronic pain that is mistakenly attributed to physical causes.

For new readers, “stress-induced” or “psychophysiological” back pain means that maladaptive signals from the brain are triggering the painful physical processes, such as muscle spasm, in the otherwise healthy back.

This present study in question interprets chronic pain through the biopsychosocial lens. Readers must appreciate that the biopsychosocial model of medicine is an enormous leap forward

from the now archaic biomedical model, with the vital inclusion of the patient’s own experience (the “patient centred approach”).

However, a common trap built into the blind spot of the biopsychosocial model is that of effectively mistaking medicine for marketing – the customer may always be right, but the patient is by definition at odds with their own health. Case in point, patients report a sense of empowerment associated with a radiographic diagnosis of their chronic pain, but we have two decades of studies showing that spinal degeneration is very common in pain-free individuals and likely coincidental when it is found it back pain sufferers.

Sadly, the empowering “false positive” only serves to draw the patient deeper into their patienthood, as we know that “non-specific” or “medically unexplained” symptoms are associated with lack of insight into psychological causation. Patients may desperately seek a “real” (physical) diagnosis, but it is the duty of the clinician and healthcare system to orient the patient (and society) continually towards the leading edge of medical reality.

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IntroductionThe stress illness approach to chronic pain recovery is based on the work of Dr John Sarno, a pioneering doctor in the United States. He wrote the book Healing back pain, which helps people to understand how emotions and negative thoughts can cause pain (what he termed TMS or Tension Myositis Syndrome), particularly when they are repressed.

This approach is now gaining more support from contemporary literature. Emotional suppression, particularly of anger, leads to increased pain intensity1. Depression/low mood has also been shown to increase pain intensity2, as has anxiety3 and stress has been shown to increase superficial muscle activity4.

Here is a case study of a woman who recovered from her chronic lower back pain with the help of the stress illness approach.

History and presentation The case was a 43-year-old woman reporting a 10-month history of lower back and left buttock pain. She worked part-time as a community support worker and sought help as she had read Dr John Sarno’s book and was looking for a stress illness practitioner in the UK.

During the previous three months, she reported that the pain had become gradually more intense. She could not remember a specific incident that triggered her initial pain. It was aggravated by sitting for long periods and by bending forwards. She had previously seen seven other practitioners, including her GP, three physiotherapists, an osteopath, a Shiatsu therapist and a Bowen therapist. All of these had given her short-term relief, but not long-term. Three months earlier she had an MRI scan, which showed a centre-left prolapsed disc at L5/S1.

On initial assessment, she could only forward flex to mid-thigh range, there was

pain at end range extension and left side flexion was 50% of right side flexion. Her left straight leg raise was 35˚ compared to 70˚ on the right. Neurological testing of reflexes, sensation and power were all unremarkable. When palpating her lower back there was over-activity of the muscles erector spinae, left quadratus lumborum and left superficial gluteals.

InterventionA stress illness pre-assessment form was sent to this woman, to help her to timeline any previous pain or conditions and link them to stressful events. It also encouraged her to think about her personality type and relationships with friends and relatives and to report any activities she was avoiding due to her pain.

Through doing this, it soon became apparent to both parties that she had been causing herself stress (mostly low level) on a regular basis. It also became apparent that she had conditioned herself to believe that certain activities would cause her damage and increase the pain and therefore had stopped doing them.

Through her own research on stress illness and TMS, she had already begun to use mindfulness meditation and therapeutic journaling to help manage her stress. Research into mindfulness meditation in particular shows that it can have a positive impact on pain levels5. She was encouraged to continue with these and specific events were highlighted for focus during her journaling to help offload negative thoughts or emotions that had developed. Although she had a prolapsed disc, these have been shown in MRI studies to be incidental6,7 and when an abnormality is known about it can potentially enhance the fear of doing certain activities8. So, the patient was gradually encouraged to begin doing activities she had been avoiding, like bending forward and gardening. Each time she did this she was asked to use positive affirmations to reassure herself that it was OK to move.

OutcomeThis woman was seen on four occasions over a two-month period and made excellent progress by putting the advice into practice and working on reversing her conditioned responses. On her last visit, her

Beyond pain managementCase study by Matt Kinal BSc MSCP

ABOUT THE CLINICIANMatt Kinal is a chartered physiotherapist who works in Bristol and specialises in chronic pain and how people develop chronic pain.

In June 2012, he trained in the stress illness approach to chronic pain recovery through the Stress Illness Recovery Practitioners Association (SIRPA). It is a different way of thinking about pain than the traditional posturalbiomechanical model most often used by physiotherapists, osteopaths and chiropractors.

It works on the basis that chronic pain is often stress-induced, whereby the brain and nervous system produce pain and other physiological changes like increased muscle tension as protective mechanisms.

Matt is currently coming towards the end of an MSc in Pain Science and Management at Keele University and has recently created a new multi-disciplinary pain service, the Bristol Pain Relief Centre, which incorporates this work into its programme.

range of movement was restricted but had improved, lumbar flexion was now mid-shin and she reported that she was having more pain-free episodes. At this stage, we both agreed that she was making good progress and could continue on her own with the techniques she already put into practice. Two weeks after our last session, she emailed me to say that she had continued with the journaling and that her range of movement was much improved.

One month after the last session, she was contacted again to see how she was doing. She reported: “Feeling fitter and stronger than ever and enjoying running, also sleeping better than I ever have!”

Editor’s discussionThis case study marks a continuation of the “Beyond Pain Management” segment that began in the previous issue. What we have here is another case of chronic pain and disability being reversed by a deliberate psychoeducational intervention. Triggers are disarmed by re-orienting faulty beliefs and unconscious emotional burden is recognised as causal and then released through evidenced procedures such as written emotional disclosure (guided therapeutic journaling).

More than a year post-discharge, the scores for pain, disability, depression and anxiety remain stable at zero. And yet this is not the common outcome for the hundreds of millions of chronic pain sufferers worldwide. New approaches to solving any problem take time to be integrated into practice. The purpose of this series is to render chronic pain recovery an achievable clinical outcome in the minds of patients, practitioners and policymakers alike. As ever, we welcome contributions. If you are a clinician and wish to present cases of chronic pain recovery by deliberate intervention, submissions can be made for consideration by email to yourstory@backcare.org.uk

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Date Pain and Function(MYMOP Assessment)

Depression(PHQ-9 Assessment)

Anxiety(GAD-7 Assessment)

Initial assessment(12/02/13)

4.25 10 8

1-month post-discharge(02/05/13)

0.75 0 0

14-months post-discharge(18/06/14)

0 0 0

Changes in clinical outcome measures:

The Bristol Pain Relief Centre

References1 Lumley MA, Sklar ER & Carty JN. Emotional

disclosure interventions for chronic pain: from the laboratory to the clinic. Transl. Behav. Med. 2, 73–81 (2012).

2 Berna C et al. Induction of depressed mood disrupts emotion regulation neurocircuitry and enhances pain unpleasantness. Biol. Psychiatry 67, 1083–1090 (2010).

3 Thibodeau MA, Welch PG, Katz J & Asmundson GJG. Pain-related anxiety influences pain perception differently in men and women: a quantitative sensory test across thermal pain modalities. Pain 154, 419–426 (2013).

4 Marras WS, Davis KG, Heaney CA, Maronitis AB & Allread WG. The influence of psychosocial stress, gender, and personality on mechanical loading of the lumbar spine. Spine 25, 3045–3054 (2000).

5 Zeidan F et al. Brain Mechanisms Supporting the Modulation of Pain by Mindfulness Meditation. J. Neurosci. 31, 5540–5548 (2011).

6 Boden SD, Davis DO, Dina TS, Patronas NJ & Wiesel SW. Abnormal magnetic-resonance scans of the lumbar spine in asymptomatic subjects. A prospective investigation. J. Bone Joint Surg. Am. 72, 403–408 (1990).

7 Jensen MC et al. Magnetic resonance imaging of the lumbar spine in people without back pain. N. Engl. J. Med. 331, 69–73 (1994).

8 Flynn TW, Smith B & Chou R. Appropriate use of diagnostic imaging in low back pain: a reminder that unnecessary imaging may do as much harm as good. J. Orthop. Sports Phys. Ther. 41, 838–846 (2011).

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TALKBACK EDUCATION

Yellow flags are routinely used

by NHS GPs and physiotherapists

PART 6

Prevention is better than cure

The puzzle of pain

What are psychosocial factors?The term “psychosocial” refers to the interaction between a person’s own psychology and their social environment. Psychosocial factors can take the form of problems, tensions, agreements and expectations within our relationships with our parents, children, friends, family, neighbours, teachers, peers, partners, household, supervisors, workmates and society at large.

Studies have shown that “pre-morbid” psychosocial factors (i.e. present before the onset of pain or illness) can not only predict who will develop back pain, but also whether people who do develop back pain will recover or become chronically disabled. One study of 180 patients in Manchester (UK) found that having high levels of psychological distress, low self-rated health*, and job dissatisfaction tripled the likelihood of having a persistent disability at the 12-month follow-up appointment1.

* Note: even a single self-rated health question can have significant predictive power. Data from several hundred thousand patients have shown that, when asked the question, “In general, how would you rate your health?”, those who answered “poor” had double the all-cause risk of death compared to those who answered “excellent”2.

Another study, this time with 200 chronic back pain patients in Texas (USA), showed that 77% met the lifetime diagnostic criteria for at least one psychiatric disorder, significantly higher than the general population. And 95% of those with current anxiety disorders had them before the onset of their back pain3.

In short, pre-existing psychiatric diagnoses (e.g. depression) but also non-clinical psychosocial factors (e.g. job dissatisfaction) have been shown to increase massively the likelihood that an individual will develop chronic pain and disability in the future.

What are yellow flags?Yellow flags are a specific set of psychosocial themes that have been found to be particularly relevant for predicting whether existing musculoskeletal pain – for example, a new case of acute back pain – will develop into a chronic (long-term persistent, recurrent or continuous) disability.

Yellow flags are routinely used by NHS GPs and physiotherapists and have been adopted by occupational health in recent years. There are various descriptions of the yellows flags, but they broadly include the themes in the chart on the facing page.

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

What are the key determinants of health? What determines who will develop long-term pain and disability? In this episode, we’ll be exploring the role of stress, beliefs and triggers in the “puzzle of pain”.

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TALKBACK EDUCATION

Those at low risk may

require nothing more than the reassurance

that their pain is not serious

or harmful

Subgrouping for targeted treatment“Most cases [of low back pain] resolve regardless of the course of therapy, and some do not get better no matter what is done. Therein lies the problem for practitioners, patients, and policymakers”4.

Some patients recover while others do not, and the only factors known to predict this difference are psychological, psychosocial or psychiatric. Thus, it follows that these factors should be assessed in new back pain patients as a means of tailoring treatment. Indeed, the STarT Back Screening Tool (SBST; developed at Keele University) is such an assessment, designed to: “screen primary care patients with low back pain for prognostic indicators that are relevant to initial decision making” 5,6.

STarT refers to “Subgrouping [or Stratification] for Targeted Treatment” and, in essence, the assessment determines whether a given patient with low back pain is at high, medium or low risk of becoming chronically disabled and, thus, what kind of treatment they should receive.

Those at low risk may require nothing more than the reassurance that their pain is not

serious or harmful and that they should expect swift and complete recovery. However, those at high risk are deemed to have more significant psychological obstacles to recovery.

The STarT Back tool consists of nine statements that the patient must rate for agreement (from “not at all” to “extremely”). See the illustration on the next page. The themes assessed here are: whether the pain is confined to your back or has spread (Q1&2); how disabled you have already become (Q3&4); faulty beliefs about risk and permanent damage (Q5&7); anxiety and depressed mood (Q6&8); and how much your pain is bothering you (Q9). Note that the first four questions only help distinguish between low and medium risk, while it is the latter five questions (presented here in green) that determine whether there is a high risk of developing chronic disability.

It is important to re-emphasise that it is psychological factors such as beliefs and anxiety that have been shown to predict long-term pain and disability, not radiological or anatomical trivia. Back pain patients often feel a sense of empowerment when they receive a positive radiological test, such as a lumbar MRI scan

Faulty beliefs, negative attitudes or pessimism

For example: believing or thinking that physical pain is harmful or necessarily disabling; catastrophising (worst-case thinking) and rumination (negative cyclic thinking with no positive conclusion).

Fear avoidance behaviourFor example: reducing specific or general activities to avoid pain or to avoid perceived risk of re-injury.

Tendency towards passive engagement

For example: expecting that recovery will occur through rest and passive treatments rather than through active engagement with recovery.

Tendency towards psychological issues

For example: current signs or past history of anxiety, depression, low morale, stress or associated behaviours like social withdrawal.

Social problemsFor example: trouble within relationships with friends, family, or in relation to supervisors or colleagues at work; “negative” work life or family life; relationships may be overbearing or under-supportive.

Financial problemsFor example: through job loss or insecurity, declined benefits or disorganised and inadequate personal financial resources.

Medicolegal factorsFor example: suing an employer; claiming compensation; awaiting payment for injury at work or road traffic accident.

Disability Prior work disability or anticipation of future disability.

continued on p12

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TALKBACK l ISSUE 2 2014

TALKBACK EDUCATION

revealing a prolapsed disc7. However, while patients with an uncertain diagnosis tend to experience more depression and disability,8 research has demonstrated time and again that such spinal degeneration is very common among healthy people and likely to be coincidental in pain patients9–11.

The bottom line is that scans showing coincidental and unrelated spinal degeneration fuel the faulty belief that back pain is caused by physical damage or dysfunction. In fact, research has shown that the belief in physical causes is associated with an increased risk of “medically unexplained symptoms” (such as chronic pain) – “patients with medically unexplained symptoms tend to attribute their illness to physical causes”12.

Recognising and addressing psychological obstacles is more effective than not doing so. In a clinical trial of the StarT Back concept, physiotherapists were trained to improve psychological functioning in high-risk patients by challenging and reshaping their disempowering expectations and mistaken beliefs13.

The trial involved patients from 64 GPs in England and compared usual care to a targeted approach. They found that tackling psychosocial factors in high-risk patients significantly reduced pain, disability, depression and time off work14.

And to give a sense of scale, 20% of the 922 participants in this study were classed as high-risk, i.e. unlikely to recover.

What stage of medicine is this?Readers who have been following this

educational series will be familiar with the idea that our capacity to engage with health is subject to our growth and development through a series of distinct stages (see the spiral diagram above as a reminder).

For some, health is simply the removal of symptoms, best achieved with medication (Stage 1: Symptom Suppression). For others, health is quality of life despite incurable illness, best achieved through a good self-management regimen comprising a variety of positive and preventive activities (Stage 2: Disease Management). For

others still, symptoms are understood to be functional, and thereby resolvable/’curable’, expressions that signify unconscious emotional burden (Stage 3: Curative Medicine).

It’s important to understand that each of these perspectives has its own evidence and make coherent sense within its own boundaries. And yet each is essentially opposed to the others by their very founding definitions such as “What is health?”, “What is disease?” and “What is the goal of medicine?” For this reason, “inter-partisan” debates (i.e. between opposing perspectives) seeking the “one right answer” are largely futile and irresolvable by the mere providence of “sufficient” evidence.

So, it is not a question of which approach to medicine is correct, but rather a question of which approach to medicine is conducive to unlocking the impasse and accessing these higher order clinical outcomes, such as recovery from chronic pain.

The use of psychosocial factors to predict prognosis and guide treatment is very much an example of management thinking (Stage 2: Disease Management), which includes prevention through risk management. But while management thinking cannot cure chronic pain, it does represent the predominant “operating system” among the general public and within today’s large healthcare systems so there remains a need for best practice.

STarT Back statements:

1. My back pain has spread down my leg(s) at some time in the last two weeks2. I have had pain in the shoulder or neck at some time in the last two weeks3. I have only walked short distances because of my back pain4. In the last two weeks, I have dressed more slowly than usual because of back pain5. It’s not really safe for a person with a condition like mine to be physically active6. Worrying thoughts have been going through my mind a lot of the time7. I feel that my back pain is terrible and it’s never going to get any better8. In general, I have not enjoyed all the things I used to enjoy9. Overall, how bothersome has your back pain been in the last two weeks?

Patient has a choice between five levels of agreement:

“Not at all”(zero points)

“Slightly”(zero points)

“Moderately”(zero points)

“Very much”(1 point)

“Extremely”(1 point)

Scoring guide:

l If you score 4 or more points from questions 5-9, you are at “high risk”.l If you score 4 or more points overall, you are at “medium risk”.l If you score less than 4 points overall, you are at “low risk”.

STRESS

TRIGGER

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TALKBACK EDUCATION

Stress and beliefsThe psychosocial factors which predict chronic pain and other clinical outcomes can be reasonably distilled into the causes and consequences of two broad categories: (1) Emotional/stress; and (2) Cognitive/beliefs. In essence, our future health is governed by how we think and how we feel. There is a common misconception that our thoughts and feelings can only influence our health indirectly through our outward behaviours (e.g. smoking, unhealthy diet, lack of exercise).

However, unhealthy behaviours are only a part of the puzzle. Research has demonstrated that our beliefs govern physiological responses to our environment. One recent study conducted at Oxford University showed that the effect of an opioid painkiller given by intravenous infusion was determined by the recipient’s expectation15. Participants were informed that “remifentanil is a widely used opioid that relieves pain when infused intravenously, but can worsen pain when the infusion ceases”. After their beliefs and expectations had been primed in this way, the following three effects were observed:l when participants didn’t know they were receiving the infusion, there was a significant “intrinsic” analgesic effect of the drugl when participants knew they were receiving the infusion, the intrinsic analgesic effect doubled (placebo effect)l when participants were misinformed that the infusion had been stopped, the intrinsic analgesic effect was abolished (nocebo effect).

This study was particularly useful because participants also underwent fMRI brain scan during the experiment, which showed that positive and negative beliefs activated different parts of the brain. In short, pre-existing beliefs directly govern our physiological responses to environmental triggers without any involvement of intermediary outward behaviours (i.e. our beliefs can directly activate and deactivate physiological responses to our environment).

Beliefs are perhaps the most insidious health factor. Unlike psychosocial stress, which may be obvious to the individual and those around them, beliefs are invisible, built into what we think is real. “If everyone smoked 20 cigarettes a day, [we would] conclude that lung cancer was a genetic disease”, says thought-leading epidemiologist, Professor Geoff Rose16. He adds: “The hardest cause to identify is the one that is universally present.”

A study conducted in Germany showed that a psychometric test could predict with 92% accuracy which volunteers would have whiplash associated disorder four-weeks after a placebo rear-end car collision17. This study showed the involvement of psychological traits and perceived risk exposure. However, they did not record whether participants held the specific belief that car crashes carry a risk of whiplash injury. Nonetheless, there is no

placebo or nocebo effect without specific beliefs and expectations.

Additionally, we can perhaps all feel into the fabric of our societal mythology and appreciate that this belief (namely, “car accidents cause whiplash injury”) is a likely candidate for Rose’s “universally present” cause. Actually, BackCare’s own research (2013)

has shown that 70% of people in the UK believe that physical

factors such as posture, lifting and injury are the leading causes of

back pain; only 6% correctly identified

stress as the culprit. So, we do have direct evidence that the population at large holds faulty beliefs about the causes of back pain, and this belief itself predisposes them to back pain and long-term disability. It would appear that faulty beliefs about health and risk do, indeed, predominate in public awareness.

The final piece of the puzzleWe are almost at the end of the road. We have identified stress and beliefs as key determinants of chronic pain and non-recovery. Now, we add in the third component, namely exposure to the trigger. As the aforementioned studies have collectively indicated, the pain episode or syndrome is activated when the individual with pre-existing stress and pre-existing faulty risk beliefs encounters the assumed risk (the trigger). When we believe or expect that a certain event will have a certain effect upon us, we must then encounter that event in order to activate the expected response.

It is important at this point to touch upon the distinction between trigger and cause. Patients will frequently fixate upon a specific physical event that immediately preceded the onset of their back pain. For example, they may have lifted a heavy or awkward object, felt a sensation in the lower back and then developed back pain. When the patient is grounded in a solely biomechanical model of back pain, this physical trigger event is mistaken to be the cause.

Of course, we can argue the hypothetical case that a spinal fracture from a rooftop fall should hurt – however, almost all actual

continued on p14

The puzzle of pain

STRESS

BELIEF

TRIGGER

Trigger and cause are distinct but often confused

14

TALKBACK l ISSUE 2 2014

TALKBACK EDUCATION

cases of back pain are “non-specific” with no identifiable physical origin. When we expand our understanding of health and illness to include such evidences as cited here, we begin to realise that the physical event is a trigger that has been primed only by a pre-existing faulty belief in its intrinsic risk value.

References1 Thomas E et al. Predicting who develops

chronic low back pain in primary care: a prospective study. BMJ 318, 1662–1667 (1999).

2 DeSalvo KB, Bloser N, Reynolds K, He J & Muntner P. Mortality prediction with a single general self-rated health question. A meta-analysis. J. Gen. Intern. Med. 21, 267–275 (2006).

3 Polatin PB, Kinney RK, Gatchel RJ, Lillo E & Mayer TG. Psychiatric illness and chronic low-back pain. The mind and the spine--which goes first? Spine 18, 66–71 (1993).

4 Shekelle PG & Delitto AM. Treating low back pain. The Lancet 365, 1987–1989 (2005).

5 Hill JC et al. Comparison of stratified primary care management for low back pain with current best practice (STarT Back): a randomised controlled trial. The Lancet 378, 1560–1571 (2011).

6 Hill JC et al. A primary care back pain screening tool: identifying patient subgroups for initial treatment. Arthritis Rheum. 59, 632–641 (2008).

7 Froud R et al. A systematic review and meta-synthesis of the impact of low back pain on people’s lives. BMC Musculoskelet. Disord. 15, 50 (2014).

8 Serbic D & Pincus T. Diagnostic uncertainty and recall bias in chronic low back pain. Pain (2014). doi:10.1016/j.pain.2014.04.030

9 Jensen MC et al. Magnetic resonance imaging of the lumbar spine in people without back pain. N. Engl. J. Med. 331, 69–73 (1994).

10 Kim SJ, Lee TH & Lim SM. Prevalence of disc degeneration in asymptomatic Korean subjects. Part 1: lumbar spine. J. Korean Neurosurg. Soc. 53, 31–38 (2013).

11 Matsumoto M et al. Tandem age-related lumbar and cervical intervertebral disc changes in asymptomatic subjects. Eur. Spine J. Off. Publ. Eur. Spine Soc. Eur. Spinal Deform. Soc. Eur. Sect. Cerv. Spine Res. Soc. 22, 708–713 (2013).

12 Nimnuan C, Hotopf M & Wessely S. Medically unexplained symptoms: an epidemiological study in seven specialities. J. Psychosom. Res. 51, 361–367 (2001).

13 Foster NE et al. IMPaCT Back study protocol. Implementation of subgrouping for targeted

treatment systems for low back pain patients in primary care: a prospective population-based sequential comparison. BMC Musculoskelet. Disord. 11, 186 (2010).

14 Foster NE et al. Effect of stratified care for low back pain in family practice (IMPaCT Back): a prospective population-based sequential comparison. Ann. Fam. Med. 12, 102–111 (2014).

15 Bingel U et al. The effect of treatment expectation on drug efficacy: imaging the analgesic benefit of the opioid remifentanil. Sci. Transl. Med. 3, 70ra14 (2011).

16 Rose G. Sick individuals and sick populations. Int. J. Epidemiol. 30, 427–432; discussion 433–434 (2001).

17 Castro WH et al. No stress – no whiplash? Prevalence of ‘whiplash’ symptoms following exposure to a placebo rear-end collision. Int. J. Legal Med. 114, 316–322 (2001).

18 Kleinman A. Culture and depression: studies in the anthropology and cross-cultural psychiatry of affect and ... (Univ Of California Press, 1985).

19 Bass C & Benjamin S. The management of chronic somatisation. Br. J. Psychiatry J. Ment. Sci. 162, 472–480 (1993).

20 Patel V. Psychological approaches to somatisation in developing countries. Adv. Psychiatr. Treat. 12, 54–62 (2006).

STRESS

Pre-existing psychosocial or psychiatric

ExampleBeing a carer for a

close family member

ExampleI hate my job but need the money

Example Psychiatric

diagnosis of anxiety or depression

BELIEF

Faulty beliefs about risks

to your health

ExampleRear end car collision causes whiplash injury

ExampleRepetitive movement

causes injury

ExampleHeavy lifting causes

back pain

TRIGGER

Exposure to the assumed

risk factor

ExampleBeing involved in a car crash

ExampleBeing a sedentary

office worker

ExampleLifting something heavy or awkward

PAIN

The trigger is mistaken as the

cause

ExampleWhiplash injury

syndrome

ExampleRepetitive strain

injury

ExamplePersistent back pain

15

TALKBACK l ISSUE 2 2014

16 TALKBACK FUNDRAISING

TALKBACK l ISSUE 2 2014

For many charities, including BackCare, the London

Marathon is the highlight of the fundraising calendar. We are very grateful for the courageous efforts of our runners and all who supported them.

BackCare purchases packs of “Golden Bond” marathon places from Virgin which it gives to runners who commit to raising the agreed pledge (this year: £1,300). Including unfilled “roll-over” places from previous years, we had a total of 45

places this year, of which 28 were filled (62%).

With the addition of celebrity runner Tim Ford, who had his own place, this year’s BackCare team was 29-strong.

Benjamin Guest was our fastest male and fastest overall runner with a time of 03:01:45. Ailish Toomey was our fastest female runner, completing the race in 03:44:44.

The efforts of Team BackCare raised more than £40,000 (which included

almost £1,000 in sponsorships from the BackCare branches). Special congratulations go to BackCare professional member Mags Clark-Smith who was this year’s top fundraiser with £2,026. You can see all our runners’ times and money raised on the facing page.

Special thanks goes to the British Acupuncture Council – this year’s official sponsor of Team BackCare. Again, many thanks to all who took part and we’ll leave you with some

messages from the runners themselves...

A real marathon effort!

RACE FACTSThe first London Marathon was held in 1981 and has been run from Greenwich Park to The Mall every spring since.

With 36,000 runners participating this year, the London event is one of the world’s largest marathons.

START

FINISH

Mags Clark-Smith: “Although exhausted, I recovered well. My legs were as good as new within 24 hours and I don’t have any blisters.

“A big thank you to the BackCare team and all the other BackCare runners who were so encouraging, it was a fabulous experience. Total strangers yell your name and offer you goodies as you pass by. It’s like being part of a big happy carnival! I loved it.”

Michael Jones: “It was a privilege to run for BackCare and I hope the funds I’ve raised will benefit the valuable work undertaken by all at the charity.”

Jackie Carver: “This was my fourth London Marathon and the support just gets better and better. The sights of London came and went: the Cutty Sark,

a man carrying a fridge, 88-year-old Fred who was the oldest runner, Tower Bridge, half a dozen rhinos, Canary Wharf, Batman, Spiderman and Mankini man!! Big Ben, Buckingham Palace and that great red gantry to show the finish! The best bit... that hug from the family and an ice cream in the park afterwards.”

Juliet Brown (pictured): “Well, I did it! It was certainly the perfect day for a marathon – blue skies and a bit of a breeze. I spotted the BackCare flag just after mile 16 and started waving frantically to alert the supporters that I was about to pass. The support for London Marathon runners all along the route makes every participant feel like an Olympian – with crowds often several people deep – cheering and shouting their encouragement. It’s particularly emotional when you realise you

are part of that famous image of crowds of runners crossing Tower Bridge, and later passing Buckingham Palace to the finish.

“I started out from Greenwich Park at an ambitious pace and suffered for it in the last few miles. However, I still managed a sprint up The Mall and had a huge smile on my face as I crossed the line in 4hrs 56 mins.

“The London Marathon is the most incredible event – a real privilege to participate in and I am so grateful for BackCare for giving me a place, and for offering so much support.”

17

Runner Marathon

Time

Total Raised

Ailish Toomey 03:44:44 £1,613 Fastest Female Runner

Andrew Brammer 05:50:05 £1,083

Aravind Menon 04:57:46 £1,376

Benjamin Guest 03:01:45 £795 Fastest Male Runner

Claire Hunnable 05:12:08 £516 Agreed fundraising extension

Claire Macklen 04:25:00 £1,408 Inc. £85 from Swansea Branch

David Cox 04:46:31 £1,602 Inc. £52 from Winchester Branch

Dean Shepherd 06:29:09 £1,331

Ian Baker 03:44:27 £1,720 Inc. £100 from Lothian Branch

Ibolya Toth 04:51:04 £1,370

Jackie Carver 04:57:06 £1,492

James Gleave 03:11:47 £1,521

Jane Dougherty 05:02:16 £1,313 Inc. £100 from Lothian Branch

Jasvir Sekhon 05:21:53 £1,915 Inc. £52 from Winchester Branch

Joanne Wakeling 04:54:26 £1,670

Juliet Brown 04:56:30 £1,914 Inc. £500 from Southampton Branch

Lesley Bartholomew 05:46:14 £1,445

Mags Clark-Smith 06:22:24 £2,026 Highest Fundraiser

Malcolm Edwards 05:15:32 £1,360

Michael Jones 04:17:35 £1,690

Michaela Cutmore 05:31:56 £1,430

Neil Griffiths 03:58:11 £1,487

Neil Mason 04:25:32 £1,250

Paul Horner 04:54:11 £1,542

Rawdon McMaster 04:27:22 £1,490

Sandy Joyner 04:41:49 £1,468

Tim Ford 05:04:14 £300 Celebrity runner with own place

Toby Joiner 04:24:05 £1,300 Inc. £100 from Lothian Branch

Zack Harris 06:23:00 £1,546

£40,973

18

TALKBACK l ISSUE 2 2014

TALKBACK FEATURE

Getting the spring back in your stepby James Earls

“Above all do not lose your desire to walk. Every day I walk myself into a state of well being and walk away from every illness. I have walked myself into my best thoughts and I know of no thought so burdensome that one cannot walk away from it. But by sitting still, and the more one sits still, the closer one comes to feeling ill…if one keeps on walking everything will be all right”Soren Kierkegaard

Figure 1: Long stride length – this would be enhanced by having a celebration pose as the race winner crosses the line

Do you remember the days of youth when moving was easy? A walk along the promenade, a stroll by the river, or striding out along the canal path all brought about a sense of ease, rejuvenation, or even invigoration. What was different back then? And why can’t we regain some of that ease?

Being in pain has long been associated with our mental and emotional wellbeing. The downward spiral it creates can seduce us into a sedentary life with each element – pain, depression and lack of exercise – being interrelated and feeding the others. Breaking one element in a dynamic like this can, hopefully, encourage the spiral to reverse itself.

In 2012, a review of eight studies analysed the connection between symptoms of depression and the most common of all exercise therapies, walking. Despite a cumulative sample size of 341 participants, few, if any, guidelines could be drawn on how long, fast or frequent a “prescription” of walking would need to be to be effective1.

One of the missing ingredients in the list of variables, however, is how we should walk. The slow drudgery suggested in Shakespeare’s second age of man – “creeping like snail unwillingly to school” – will hardly have the requisite uplifting effect and is in stark contrast to Dickens’ “If I could not walk far and fast, I think I should just explode and perish”.

Movement teacher and manual therapist Mary Bond tells us that “walking is posture in motion” and we know from many sources, especially our own experience, that posture is an outward reflection of our inner emotional state. This theme was

the eye is clear, the step is firm, and a day’s exertion always makes the evening’s repose thoroughly enjoyable” – David Livingstone.

When we look at movement, we make similar associations. When feeling free, happy, confident and, often, successful, the front of the body is open and stride length is long if we are walking or running (Figure 1). Opening our bodies in this way may not only feel better but may also take advantage of anatomical mechanisms to make movement easier.

Within the history of anatomy we have tried to understand the body by looking at parts of the body. Anatomy even means to “cut up”. We have come to understand movement as a collection of individual muscles working to create various forms of locomotion. However, recent research is beginning to show us new ways of visualising how the body really works.

Thomas Myers, author of Anatomy

explored in the work of social psychologist Amy Cuddy and her work on “power postures”.

After years of research, Cuddy and her Harvard team have shown that using certain postures lead to the release of associated endorphins. Testosterone, associated with power and ability to deal with stress, is released in “power postures”. Conversely, cortisol, a stress hormone, is released in “low power poses”2.

Cuddy’s outline of ‘power poses’ would correlate with many people’s idea of confident stances and positions. Confident postures are characterized by the front of the body being open, while the reverse is true for those demonstrating less power. Her work does show that our bodies can change our minds and that our minds can change our bodies.

“…brisk exercise imparts elasticity to the muscles, fresh and healthy blood circulates through the brain, the mind works well,

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TALKBACK l ISSUE 2 2014

TALKBACK FEATURE

Trains3, has mapped out a series of linked tissues through the body’s muscular system (for a summary of the full system, see Figure 2). And it is the material that joins the muscles that is of particular interest if we are to regain some of that elasticity Livingstone refers to.

Each muscle is held together and connected to its surrounding tissues by something called fascia. It has various forms depending on its role and various names argued over by those who make a career out of such things. For our purposes, it is most easily experienced by a quick visit to the fridge or your local butcher. It is the grey/silver film surrounding any meat, which gathers together to form dense tendons and divides out to create thin supporting walls.

These fascial tissues have many roles in the body. They allow the pull of the muscles to be transferred from one end to the other and from one muscle to the next. They hold everything together, but, by creating walls between the different layers of tissue, they also maintain separation to protect from the spread of disease and injury. A major component of fascia’s structure is collagen fibre, which, though stronger than steel, is also highly elastic meaning that the fascia will absorb, store and recoil kinetic energy produced through movement.

When we compare the long and open strides of Figure 1 with the continuous line of myofascia (the term used to denote the combination of muscle – myo – and fascia) in Figure 2, we can see the line from the top of the foot to the back of the head as one long, potentially elastic spring.

myofascial expert to clear any physical restrictions and getting some advice on appropriate footwear will hopefully put that “spring” back in, not just in your step but in the rest of your body as well.

About James Earls

James Earls is a writer, lecturer and bodyworker specialising in Myofascial Release and Structural Integration. Following three years of research, James recently published Born to Walk (Lotus Publishing, RRP £19.99, www.amazon.co.uk), an exploration of the Anatomy Trains, myofasciae and how they relate to walking. The book gives a full three-dimensional understanding of the interaction of forces through the human body and uses comparative anatomy to explain how and why the genus homo may have developed bipedalism. James can be contacted at james.earls@anatomytrains.co.uk

References1 Robertson R, Robertson A, Jepson R

& Maxwell M. Walking for depression or depressive symptoms: A systematic review and meta-analysis. Ment. Health Phys. Act. 5, 66–75 (2012).

2 Carney DR, Cuddy AJC & Yap AJ. Power Posing: Brief Nonverbal Displays Affect Neuroendocrine Levels and Risk Tolerance. Psychol. Sci. 21, 1363–1368 (2010).

3 Myers TW. Anatomy trains: myofascial meridians for manual and movement therapists. (Elsevier, 2014).

4 Dalton E, Bishop M, Tillman MD & Hass CJ. Simple Change in Initial Standing Position Enhances the Initiation of Gait: Med. Sci. Sports Exerc. 43, 2352–2358 (2011).

Some of the benefits of this line may explain the results in a 2011 study looking at initiation of gait for people with Parkinson’s disease4. The study showed that by placing the foot of the first “swing” leg half a foot’s length behind the other prior to starting helped to increase propulsion and decrease initiation time. By taking the foot back, more tension is created through the anterior tissue Myers refers to as the “Superficial Front Line” (SFL; see Figure 3).

In order to use the SFL and the many other similar “springs”, our bodies have to be able to open in certain ways. To use the efficiencies inherent in the Superficial Front Line, for example, we need to be able to extend the toes, move through the ankle joints, and extend our knees and hips while keeping our chest and head lifted. Losing any one of these ranges of motion will shorten the spring, giving us less elasticity, and therefore require more muscle work.

Restricted movement – whether from physical limitations, footwear or emotional folding – can reduce the role of the elastic tissues. Again, we have the potential for a downward spiral: if we are unable to open the front of the body, it can have significant physical and emotional consequences. Therefore, checking with your physiotherapist, osteopath, or other

Figure 2: Anatomy Trains

Figure 3 – Superficial Front Line

Thirsty?Thirst

is a poor test for

dehydration

Even mild dehydration puts stress on the body

Dehydration increases

pain, anxiety and fatigue

You may need to drink

more than you’re

used toUse a

bottle to build positive habits easily

Aim for five clear urinations

per day

21TALKBACK EDUCATION

TALKBACK l ISSUE 2 2014TALKBACK l SPRING 2013

21TALKBACK RESEARCH

A recent study involving more than 5,000 back pain patients has shown that back pain treatments tend to fail if you continue smoking.

Dr Glenn Rechtine and colleagues at New York’s University of Rochester looked at both surgical and non-surgical treatment outcomes in both smokers and non-smokers.

While non-smokers were able to improve with treatment, those who continued to smoke during treatment saw no clinically significant improvement in their pain.

However, smokers who quit during treatment were able to achieve successful treatment outcomes.

The researchers concluded: “This study supports the need for smoking cessation programmes for patients with a painful spinal disorder.”

REFERENCETitle: Smoking Cessation Related to Improved Patient-Reported Pain Scores Following Spinal CareAuthors: Behrend C, Prasarn M, Coyne E, Horodyski M, Wright J, Rechtine GR.Journal: Journal of Bone and Joint Surgery, 94(23):2161-6.Publication Date: 5th December 2012Online record: www.pubmed.gov/23095839

Your back pain treatment probably won’t work... if you keep smoking

22

TALKBACK l ISSUE 2 2014

TALKBACK BRANCHES

CAMBRIDGE • 56 membersContact: Ms Mary GriffithsTelephone: 07787 990214Email: blincomary@hotmail.co.uk

SOUTHAMPTON • 32 membersContact: Mrs Irene BowronTelephone: 01794 340256Email: irene@macgregors-shadeplants.co.uk

DERBY • 61 membersContact: Mrs Christine SissonsTelephone: 01332 763 636Email: chris.sissons@btinternet.com

WEST LONDON • 15 membersContact: Mrs Teresa SawickaTelephone: 020 8997 4848Email: tere_ss@yahoo.co.uk

HARROGATE • 38 membersContact: Mrs Linda TippeyTelephone: 01423 865946Email: keithandlin2@btinternet.com

WEST MIDLANDS • 11 membersContact: Mrs Thelma PearsonTelephone: 01902 783537

HULL & EAST RIDING • 76 membersContact: Mrs Beryl KelseyTelephone: 01482 353547Email: kelsey59@kelsey59.karoo.co.uk

WINCHESTER • 39 membersContact: Ms Gillian RoweTelephone: 023 8025 2626Email: gillianmrowe@hotmail.com

POOLE & BOURNEMOUTH • 5 membersContact: Mrs Patricia BowmanTelephone: 01202 710308Email: patriciabowman@ntlworld.com

LOTHIAN (SCOTLAND) • 66 membersContact: Mrs Jean HoustonTelephone: 0131 441 3611 Email: jean.houston@blueyonder.co.uk

READING • 24 membersContact: Mr David LairdTelephone: 0118 947 0709Email: davidlaird@talktalk.net

SWANSEA (WALES) • 56 membersContact: Ms Gloria MorganTelephone: 01792 208290Email: gloriamorgan@talktalk.net

SALISBURY • 122 membersContact: Mrs Barbara WhiteTelephone: 01722 333925Email: white.alan@btinternet.com

The Harrogate Branch recently celebrated 25 years of working in partnership with Harrogate Health Care to provide support and activities for people with chronic back pain.

Cutting the cake at the special celebration party at Harrogate Golf Club was one of the branch’s founder members, Keith Tippey, who said: “The original aims of the society remain the same today and we are achieving our objectives in Harrogate of reducing the burden of back pain by providing information and education to everyone affected by back pain.”

Retired GP Dr Chris Watson (pictured above, second right) was the first treasurer and the speaker at the first branch meeting at Harrogate Hospital in 1989.

Members and guests turned out in force (some pictured above) and enjoyed a hot buffet, a pictorial presentation of Harrogate BackCare’s history, and concluded with an entertaining session of Scottish country dancing, proving back pain doesn’t have to stop you from having fun. Keeping active is the key here and the branch will continue to provide social activities and run the hydrotherapy classes which have helped many members to reduce and manage their back pain.

The BackCare branches are a network of local support groups up and down the country. They are run by local members who organise educational, social and fundraising events. You can find your local branch in the listing below. If you’d like to start a branch in your area, please contact info@backcare.org.uk

BACKCARE BRANCHES

HARROGATE CELEBRATES 25 YEARS

Left to right: Fiona Steele, Sue Wilcox, Ann White, Olive Harrison, Lin Tippey, Keith Tippey, David Laverack, Dr Chris Watson and Alan Richardson at the Harrogate party

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TALKBACK l ISSUE 2 2014

Why Back Pain?

Why BackCare?

Why Not Donate?

The Charity for Back and Neck Pain.org.ukwww.

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

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

Because back pain is so common, most people have no idea how serious it can be. Yes, most back pain is not serious and goes away by itself just like headaches and the common cold. But for hundreds of millions of people worldwide, the pain becomes chronic and never goes away. For many it is torture, all day, every day, forever.

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

BackCare is the UK’s national back pain charity. Our mission is to turn the tide on back pain through our research, education and outreach initiatives. We are a unique charity and no one else is doing the same work. Just by reading and sharing this magazine, you are helping to support our work – thank you.

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

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

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

http://www.actipatch.com