An estimated 80% of the Western population has seen a health professional about their bad backs at some point. When we’re in pain, we often turn to the internet and we can quickly get overwhelmed by the amount of information available to us (over 48 million websites to choose from if you type in “back pain”!)
NICE Guidance for Back Pain – Management, 2016
In November 2016, the National Institute of Clinical Excellence (NICE) published evidence-based best practice for treating lower back pain in adults (www.nice.org.uk/guidance/NG59), as summarised below:
1 Firstly, the healthcare professional who assesses the person with back pain should make sure that there are no potentially-dangerous reasons (infection, trauma, inflammation, tumour) for having back pain.
2 The person with back pain should be given advice on how to keep active and encouraged to return to work as soon as possible. Support services such as group exercises (Back Class), individual exercises (Physiotherapy) or help with coping mechanisms (cognitive behavioural therapy) may be useful.
3 Only consider imaging the back (e.g. MRI) if the scan is likely to change the routine advice given.
4 Do not try lumbar supports or braces, shoe alterations, TENS machines, acupuncture, spinal injections, traction, ultrasound treatment or disc replacement surgery and only have a spinal fusion operation if you are enrolled in a clinical trial. Use a low dose of anti-inflammatories for a short period of time if safe, and don’t use paracetamol on its own for back pain.
So, the main take-home message from NICE is that when dangerous causes of back pain have been excluded by your health care professional (i.e. usually our GP), which has a possibility of 1% or less, then we should take a short course of combined paracetamol and anti-inflammatory such as ibuprofen if it’s medically safe, and exercise our backs.
Healthcare professionals give advice based on evidence from clinical trials reported in peer-reviewed medical journals, but they also give advice based on their experience working in their field. Patients will often feedback to their healthcare provider if a particular treatment has been helpful or otherwise. Similarly, when online shopping, many people are willing to provide customer feedback online to help others. Now that online shopping is such a big industry, we can draw on customer feedback to help us decide whether something is good. So, NICE does not recommend lumbar supports for back pain, but what does public opinion say?
A lumbar support is like a weight-lifter’s belt in that it is wide, stretchy and conforming. A French study in 2009, involving just under 200 people with back pain (http://insights.ovid.com/pubmed?pmid=19179915) demonstrated that a lumbar support reduced the intensity of back pain and reduced the amount of pain killing medication taken over a three month period. Multiple scientific papers pooled together, however, have not proven that lumbar supports are useful when treating low back pain.
Let us now turn to Amazon UK, a large online shopping website which encourages customer feedback online.
Type “lumbar support back pain” and choose “back braces” department. Sort the results by “Average Customer Review” and you will have 24 different lumbar supports on the first results page. Two of the supports are obviously not supports in the photos, which leaves us with 22 different lumbar supports, which all look very similar. 3507 customers have given online ratings for these 22 supports, ranging from one star (poor) to five stars (great). If we group the four and five stars together, we get a total of 3268 (93%) of people reporting four or five stars for their lumbar supports bought for back pain. If we group the one and two stars together, we get a total of 104 (3%) of people reporting a disappointing outcome from buying a lumbar support for back pain. This leaves 4% of customers feeling ambivalent about their purchases.
For lumbar supports, therefore, what do we do? NICE does not recommend them, but the vast majority of thousands of people who have bought supports online for back pain have reported satisfaction with buying these devices. The lumbar support does not appear to harm us and there are good quality supports available for five pounds online, which compares well in relation to, for example, a takeaway cup of coffee which lasts a few minutes.
All types of exercises appear to help back pain – there are no published exercises in medical journals which have been proven to make back pain worse. There is published evidence, however, which links poor spinal posture with back pain.
A physiotherapist from New Zealand called Robin McKenzie realised the import-ance of having good spinal posture in order to avoid getting back problems in the first place. He also felt that we needed to perform extension exercises to improve spinal flexibility and help us to improve back pain.
If we look at published evidence in medical journals, there isn’t conclusive evidence to support McKenzie’s spinal exercises. A study in 2006 (www.ncbi.nlm.nih.gov/pubmed/16641766) pooled a total of 1431 people who were divided into different treatment groups including McKenzie back exercises, manipulative therapy, chiropractic intervention and exercise classes. McKenzie seemed to be as good as any other type of treatment for back pain.
Public opinion, on the other hand, has recommended Robin McKenzie’s book “Treat your own Back” as an effective way of helping back pain. On Amazon UK, we can pool the opinions of 700 customer with 626 (89%) reporting four or five star feedback and 22 (3%) reporting one or two stars. The American Amazon reviews are very similar, with 89% of 1041 people giving the book between four and five stars and 5% giving the book between one and two stars.
The “Treat your own Back” book costs less than the cost of a takeaway coffee online and it can be borrowed from any local library for free. There are no reports of the advice doing any harm, so, despite the lack of scientific evidence to support McKenzie’s advice, I suggest that you consider reading this book.
What else can I do to help my back pain?
TENS machines are popular for muscular pain, but it’s difficult to get a good idea of how the public gets on with using TENS for back pain, since the 90% of 1314 people who found TENS useful used the device for lots of different types of pain. Again, TENS appears to be a safe device (check the contraindications e.g. pace-maker) and can be inexpensive to buy, so this may be worth a try.
Pain killing medication is probably best discussed with the GP if over the counter tablets aren’t helping the back pain. If you are medically able to take them, a combination of paracetamol and ibuprofen can be useful for back pain when taken together.
Most back pain is horribly incapacitating at first, but it gradually tends to improve as we improve our posture, exercise our backs appropriately, buy simple pain killers and consider using a lumbar support (if we listen to Amazon shoppers). But, if the back pain gradually gets worse rather than better as the weeks go by, it’s worth seeing your GP to see whether you can have tests to rule out unusual causes of back pain which need medical attention.
So, the next time you try getting out of bed and feel that your back is awful, maybe you can try the following:
1 Take paracetamol and ibuprofen together (if you’re medically- safe/allowed to take them).
2 Put on the lumbar support which you bought for a fiver the last time you had your back pain. Feel the slight but definite improvement in pain as you firmly fasten up the brace.
3 If the lumbar support and pain killers are not enough to get you comfortable, it may be worth trying the TENS machine to see if this provides a little extra help.
4 Get out the McKenzie Treat Your Own Back book and start working on your spinal posture. Do your best to avoid the temptation to walk with a stooped posture, even if it feels less painful to do this.
5 Keep going with the correct posture and gradually introduce the spinal extension exercises, as pain allows.
6 As the back pain starts to settle down, remove the lumbar support and continue with the extension exercises for the spine. Do them as often as you can throughout the day.
I hope this helps your back pain.