There has been much in the news this week about the current approaches to resolving ‘back pain’. You may have seen the article in the Guardian I circulated this week (it has since been picked up as a story by the Independent and BBC) regarding new research into whether current approaches to back pain work. You can read the Guardian article here - https://www.theguardian.com/society/2018/mar/21/lower-back-pain-being-treated-badly-on-a-global-scale-study-says
I’ve been contacted by a number of friends and clients this week to gauge my opinion on the research. After having my thoughts bounce around this week I thought I’d put it in a blog post.
Let me start by saying I have a huge respect for the medical profession and I am not ‘medical’ myself so take anything I say as information based on my experience working with bodies and more importantly individuals for the last 10yrs. Let me be clear - I am not offering an alternative to medical care. If you have tried to resolve chronic back pain and feel you need medical attention you should seek it. That said, I do think there are some things that could be raised about chronic pain that could be thrown into the public arena that aren’t always raised and the general public don’t get to hear.
I should also state that I am not writing here about acute pain caused by an injury which can be pinpointed and requires a clear rehabilitation strategy. I am directing this at the instances of people experiencing ongoing chronic pain with no clear diagnosis or generic diagnosis such as ‘vertebral disc degeneration associated with wear and tear’ or ‘osteo-arthritis associated with aging’. This blog post is aimed at the ongoing process of trying to come out of the cycle of pain for people in this position.
In my opinion, once someone has been to see their GP and begins the process of ‘medicalising’ the problem the tools on offer can seem very blunt and can differ depending on the GP you see. It can also become disempowering very quickly. Indeed there is an argument that some of us actually want to give our power over to someone else in order to be ‘fixed’. In my opinion, this can cause ongoing issues.
Chronic pain is complicated. It can be heightened by stress, emotions, tiredness, whether we are eating well and staying hydrated, whether we have experienced pain in the past, our expectations of when and how it can be resolved, how supported we feel in being able to resolve it; in particular fear can have a huge effect. The psychology of the process cannot be separated from the physical aspect. Body cannot be separated from mind. We are one living organism and with a great capacity for healing and adaption. We need to see ourselves as this complete whole.
Now that you know this – ask yourself whether all of these issues can be covered in a 5-10min appointment with your GP. At best, they may have time to ask whether there is anything stressful happening in your life. They may ask about lifestyle, which often results in an understandably defensive reaction from the patient who has come for advice on back pain, not on lifestyle choices and whom is looking to be told there is a specific issue that can be resolved. That, I’m afraid, in most cases at least, is not how back pain presents.
And so, what can a GP do? They can advise you to move more, they can suggest taking measures to become less stressed, and they might offer advice about eating patterns or sleeping patterns. But, is this what most people want to hear from their GP? And what about those people that have tried to address these areas but still end up in a cycle of pain?
The answer up until now seems to have been to administer medication (again, I am not saying this can’t be helpful), refer for physiotherapy (a good option if people can engage with the process and take to the physio they receive), referral for x-rays or for an MRI or perhaps steroid injections for short to medium term relief. Often, patients understandably want to go straight to the MRI thinking this will get to the nub of the issue and put pressure on their GP to move in this direction.
Maybe it is worth noting here that studies seem to suggest MRI’s are not a fail-safe tool for diagnosis of back pain. Most of us over the age of 30 will show up as having wear and tear on an MRI of our spines. Herniated discs are a normal part of the aging process. Some people present on an MRI with what would appear to be severe wear and tear or disc herniation but have no pain. Others may show little or no issues on an MRI but be experiencing ongoing chronic pain. Why is this? We don’t really know other than to say it is no one factor.
Add to this that the area of pain is very rarely the cause of the issue. Habitual movement and holding patterns, lack of movement, restricted movement in one part of the body leading to stress on other areas, old injuries leading to adjusted movement patterns can all lead to pain presenting away from the actual cause of the issue. As movement specialists we can no longer look at specific areas in isolation – we need to look at the body as a whole. GPs and surgeons need to do the same. This is problematic in the NHS where specialists deal with one or maybe a few areas of the body in isolation.
I am not suggesting that any of the current treatment options should be withdrawn. MRIs are a useful tool, injections and medications work for some, surgery resolves some people’s issue. However, I would consider these last resorts. Interventions have their own risks and surely we should try other avenues first?
Another thing to consider is how we talk about our bodies and what is going on with them. The language used by medical staff or anyone else you approach to help with dealing with pain, can be very important. I have come to learn that the language of hope is key. Your body is very good at healing. Change is possible. You may be in pain right now but this can change. If we start talking about our bodies as though they are separate to us, as though they are fragile, vulnerable and susceptible to damage then we do them an injustice. Actually, we are very robust and even at times of pain our fantastic bodies will find ways to maintain life and keep going. Focusing on what is going well rather than purely what is not can be a very useful tool in rehabilitation.
When we are experiencing pain, it is a normal – even sub-conscious process, for our movement to become restricted. We ‘protect’ the area that feels painful. We might limit our movements and reduce our movement ‘box’ to accommodate. This is useful in the short term if there is inflammation and rest is required. If you have been suffering long-term pain and have noticed that you have greatly limited your day to day movements, it might be time to think about changing this. It is possible to down-regulate pain signals through the use of gentle movement and start to add movement back into your life. This can be a long process or can happen very quickly. In most instances, if re-injury is not occurring then gentle movement can be key to coming out of a cycle of pain.
So where does this leave us? What can we do to address chronic back pain? There are some things we know help. Maybe it is useful to focus on those:
· The body has a great capacity for healing. Let me say that again. The body heals. This is good news. There is potential for you to heal and come out of a cycle of pain. Belief in this should not be underestimated. The process may not be quick and it may not be linear but it is possible.
· Belief in whatever route you chose to take can impact the outcome. People that feel confident in their choice of action and trust the people they are relying on for help, e.g. a surgeon, GP, body worker, the list goes on - tend to have better outcomes than those that feel pressured and disempowered during the process. (I would caveat this by suggesting you seek out people that come with good referrals from people you trust and that anyone you turn to should leave you feeling empowered as part of the treatment).
· Keep moving. Movement really is fundamental. Perhaps this needs to be gentle movement to begin with as you come out of a ‘protective’ pattern of holding but with time (and perhaps the support of someone used to using movement as a technique) this will change. I would go so far as to say find something you love to do (yoga, Pilates, walking, martial arts, salsa dancing!) and enjoy it – preferably with a good teacher that knows how to work with you. If you lock down and restrict your movement now you will only regain that movement by re-introducing it. Seek help to do this if you need.
· Try to find support for the days when you feel down. This can be tough when you feel isolated but it is an important tool for the healing process.
· Keep a log of how you feel on a daily basis. Memory is not reliable. You may notice patterns that arise from your notes. In particular, women can experience great differences in sensation over the course of their menstrual cycle, patterns of which can be missed when relying purely on memory. Other factors can be sleep, amount of time spent sedentary, work stress, emotional stress, diet - in particular caffeine/sugar or alcohol. These are all things we know already but do we track them to how we feel?
· Bear in mind the process isn’t linear – you may take two steps forward and a step back but remembering how far you have come is important along the way.
· Understand that whilst others can shed light in certain areas for you, you may need to become your own expert. You may need to develop your instincts for what is right for YOU because there is no magic button and there is no one size fits all option.
How does this fit into my role as a Yoga Teacher working with a therapy model for some of my clients? Well, key to the process is understanding that there may be many layers to the discomfort they are experiencing. It is not my role to try and fix them. My role is to help them give time to being with themselves and seeing their patterns and habits. Maybe through working together we can bring awareness to the patterns that are helpful and those that are unhelpful. We can do this using the tools of movement, with connection to the breath, and through addressing how it is to be with their own body in a safe place in a manner that respects any discomfort – the rest usually unfolds from there.
I truly hope this has been helpful and welcome any thoughts and feedback you may wish to add. Remember, the body heals.