BACK PAIN What REALLY works — and what doesn’t
As new studies reveal many treatments actually do little to help, top doctors offer their advice on how to ease the agony
BacK pain is a modern-day plague, with four out of five adults experiencing it at some point. The causes range from a simple pulled muscle to a slipped disc — when one of the spongy cushions between the spinal bones ruptures, causing the disc’s interior to bulge out and press on nerves.
back pain accounts for seven million trips to the GP each year. Yet according to a series of studies recently published in The Lancet, most drugs or other treatments offered provide little benefit. many patients are needlessly prescribed strong painkillers (such as the opioids fentanyl, morphine and oxycodone), given spinal injections, wrongly told to rest or undergo surgery when research shows that simple exercises can be more effective.
‘We need to redirect funding away from ineffective or harmful tests and treatments, and towards approaches that promote physical activity and function,’ commented one of the authors, Nadine Foster a professor of musculoskeletal health from Keele university.
under NICE guidelines set out in 2016, doctors are meant to offer lifestyle advice and psychological therapies rather than jabs and surgery — but some experts believe the pendulum has swung too far.
‘The guidelines go too far in removing tried and tested methods of relief for people with back pain,’ says andrew baranowski, a consultant in pain medicine at university college London hospital and president of the british Pain Society.
‘Yes, we need to cut down on the number of people taking inappropriate prescription opioids for back pain, which have been shown to have limited effect, but prohibiting access to spinal injections leaves some patients without options.
‘We feel our voice wasn’t heard at the time the NICE guidelines were drawn up, and our members feel that some of their patients are suffering as a result.’
So what does work for back pain? We asked the experts . . .
GELS AND TABLETS
a SHORT course of non-steroidal anti-inflammatory (NSAID) painkillers, such as ibuprofen, is the first port of call for back pain.
or you could try paracetamol in conjunction with a comparatively weak over-the-counter opioid such as codeine, says Roger Knaggs, an assistant professor in chemical pharmacy practice at the university of Nottingham and spokesman for the Royal Pharmaceutical Society.
NSAIDS can be taken as tablets or used in a gel, cream or patch form, such as Voltarol medicated Plasters and Nurofen 5% Gel.
Whether taken as tablets or applied to the skin, NSAIDS work by reducing inflammation, blocking the action of an enzyme called cyclo-oxygenase which makes prostaglandins.
These prostaglandins are part of the body’s repair mechanism and cause pain, swelling and inflammation in response to injury or disease.
Paracetamol does not work as it is not a very effective anti-inflammatory, says Professor Knaggs.
Stronger opioids such as tramadol are generally not recommended because of the possibility of addiction to them. Studies, including a major review by researchers at the George Institute For Global health in Sydney, have also shown they provide ‘minimal benefit for low back pain’, says Professor Knaggs. Do they work? NICE recommends taking ibuprofen for up to three weeks to help with back pain. Yet a major study published last year in the annals of Rheumatic Diseases found that anti-inflammatories such as ibuprofen have little more benefit than a placebo on low back pain.
Professor Knaggs thinks the drugs have a role, but that gels are better at delivering relief where it is needed and are less likely to cause side-effects.
The adult recommended dose for tablets is 300-400mg, three or four times a day, with a maximum of 600mg four times a day if needed, according to NICE.
Patches and gels count towards the daily maximum dose, says community pharmacist Sid Dajani, and it is possible to overdose if you use them together with pills.
‘however, if you use gels or creams, very little active ingredient enters the bloodstream so the likelihood of overdosing is extremely low,’ he adds. ‘Patches, on the other hand, deliver a measured dose for up to 12 hours and can hold a much higher drug load — up to five to ten times that used in creams and gels.’
NSAIDS are not suitable for children under 12, or pregnant or breast-feeding women, and gels must be applied to clean, unbroken skin.
SPINAL JABS
THESE have long been used to ease pain that has not responded to firstline treatment. Injections typically contain cortisone, a steroid, to reduce inflammation, and lidocaine, a local anaesthetic, and are delivered using X-ray guidance or CT scans.
as they are delivered straight to the painful area, this is thought to be more effective than oral medication alone, says Dr baranowski.
Do they work? Spinal injections work for about 50per cent of patients with pain caused by a slipped or herniated disc, or those with spinal stenosis — a narrowing of the spaces within the spine which can put pressure on nerves running through the back.
It is thought the jabs calm the nerve inflammation, and effects can last for weeks or months.
Professor Knaggs says that steroid injections are not encouraged for the treatment of lower back pain without sciatica, because for this ‘there is no evidence that they are any more effective than tablets’.
‘Epidural steroid injections are the most common form of spinal injections,’ says Dr baranowski. ‘They are given for sciatica, and we do these injecting a steroid outside the dura — the sac around the nerve roots at the base of the spine.
‘although the patient is often awake, a local anaesthetic is usually used to numb the skin.’
Where back pain is related to the facet joints (each vertebra has one disc at the front and two facet joints at the back which help to support the spine), the injection is given around the problem joint.
under NHS England guidelines, facet joint injections are available when there is inflammation within the joint identified by an MRI, or cysts in the facet joints.
another option for facet-joint related pain is a medial branch nerve block injection. These are aimed at
the nerves which feed out from the facet joints and temporarily block them transmitting pain signals.
Possible complications include a headache and a small risk of infection at the injection site.
Can I get it on the NHS? Spinal injections are only recommended by NICE for those with low back pain that causes sciatica or back pain linked to problems in the facet joints. For private treatment, expect to pay £2,000 or more.
TALKING THERAPY
COGNITIVE behavioural therapy (CBT) is a form of talking therapy designed to change your reaction to life events. Chronic back ache is linked to psychological issues such as anxiety and depression, possibly because these conditions can exacerbate the sense of pain.
Does it work? A review of nine studies published in 2015 in the journal PLOS One found that CBT does reduce pain and improve quality of life in the long term. This applied to patients of all ages who had suffered long and short-term back pain.
Can I get it on the NHS? CBT is available for people who have had chronic pain for more than a few months, but waiting lists are long. For private treatment, contact the British Association For Counselling And Psychotherapy which has a ‘find a therapist’ directory: bacp.
co.uk/search/therapists. Expect to pay £40-£100 per session.
ELECTRIC ZAPPERS
ELECTROSTIMULATION uses electrical currents to mask or stop pain signals before they reach the brain. This can be done non-inva- sively, with a TENS (Transcutaneous electrical nerve stimulation) machine, which passes a small electrical current through the skin via sticky pads. With spinal cord stimulation, a small device is surgically implanted under the skin to send high frequency electrical currents to the spinal cord.
Does it work? TENS machines are not recommended by NICE for back pain. ‘There has never been much evidence that TENS machines work in the long term but they do seem to work for some people,’ says Dr Baranowski. But he adds that spinal cord stimulation does work for people with sciatic pain that hasn’t responded to injections or surgery. ‘Both TENS machines and spinal cord stimulation may also help people reduce dependence on pain medications,’ says Dr Baranowski.
Can I get it on the NHS? Spinal cord stimulation is available on the NHS for those who have chronic low back pain with sciatica, or nerve pain, which has not responded to other therapy including surgery or injections.
You might be able to borrow a TENS machine from the NHS but people tend to buy their own for home use: they cost £60-£100 from most pharmacies.
SURGERY
TWO types of surgery are typically used to treat back pain: lumbar decompression and spinal fusion.
LUMBAR DECOMPRESSION: This involves releasing the pressure on nerves compressed as a result of slipped discs or other damage in the lower spine.
‘Around 5 per cent of people with slipped discs will need surgery,’ says Anthony Quaile, a consultant in spinal orthopaedic surgery based at the Hampshire Clinic in Basingstoke. Techniques include laminectomy, when part of the bone from a vertebra is removed, or a microdiscectomy, when a small section of damaged disc is removed. Decompression surgery is also used for stenosis.
Does it work? A study published in The Spine journal in 2015 which looked at 173 patients with chronic low back pain found 70per cent who underwent disc replacement had significant improvements in their pain and disability eight years after surgery. Nearly one quarter of patients in the surgery group reported full recovery compared with just 6 per cent of the group who underwent rehabilitation without surgery. Can I get it on the NHS? Under 2016 NICE guidelines, lumbar decompression is only available for those with low back pain and sciatica when noninvasive treatments such as spinal injections have failed. Khai Lam, a consultant orthopaedic surgeon at the private London Bridge Hospital, says this was a poor decision, arguing that those who drew up the guidelines ‘didn’t understand the profound difference some surgical interventions can make’. Possible complications include infection, deep vein thrombosis and — rarely — paralysis. An operation done privately can cost upwards of £20,000, and MRI scans, to assess the extent of the problem, can cost up to £1,000 each.
SPINAL FUSION: Surgeons implant rods and screws into vertebrae to hold them in place and reduce pressure on a nerve irritated by a bulging disc. The aim is the same as lumbar decompression surgery: to reduce pressure on the nerve by reducing movement between the vertebrae, allowing it to heal. ‘Spinal fusion involves removing the damaged disc and putting a metal strut in its place, and then stapling it firmly in place so it can’t move,’ says Mr Lam. ‘This can reduce pain but it also reduces mobility. You lose about 5 per cent of movement in the back every disc that is fused.’ He says the procedure is reserved for people with severe and disabling lower back pain — ‘not young, fit people who want mobility’.
Does it work? Mr Lam says that this operation can reduce pain but can also reduce mobility in the spine long-term. It may also cause accelerated wear and tear or herniation of the other discs.
A study published in May 2016 in Spine Journal involving 294 patients with chronic low back pain compared those who received a spinal fusion to those who had physiotherapy. While 65 per cent of the patients who underwent spinal fusion were satisfied with the results, only 30 per cent of the physiotherapy group were.
Can I get it on the NHS? Under NICE guidelines, patients with low back pain should only be offered spinal fusion if they are part of a randomised controlled trial helping to build up a body of evidence. Surgery can be offered to those who also have leg pain caused by sciatica who’ve not responded to other treatments.
It costs £20,000-£30,000 privately.