THE BACK4GOOD® PROGRAMME
FOR THE PREVENTION AND MANAGEMENT OF LOW BACK PAIN
More than 80% of the adult population suffer from low back pain at some time in their life. It is one of the most common reasons why people take time off work, and may be distressing and frustrating as quality of life often suffers.
Yet gentle, effective exercise, delivered by a properly trained exercise professional, can often help with the prevention and management of low back pain. This was underlined by the publication by NICE (National Institute for Health and Clinical Excellence) in 2009 of medical guidelines recommending that people with persistent non-specific low back pain should be encouraged to stay physically active and exercise. GPs and medical practitioners are encouraged to refer patients, where appropriate, to properly qualified exercise professionals.
Back4Good® Practitioners are exercise specialists who are trained to help people with non-specific low back pain. Practitioners are already experienced Body Control Pilates teachers, having been certified by Europe’s foremost Pilates organisation. They have additionally undertaken extensive training exclusively related to exercise referral and low back pain to become a Back4Good® Practitioner and a Level 4 Advanced Exercise Instructor.
This training has been externally accredited by SkillsActive and The Register of Exercise Professionals who oversee quality and standards for the UK health and fitness industry.
All Back4Good® Practitioners are registered as ‘BackCare Professionals’ with BackCare, the charity for healthier backs.
What is Back Pain?
At some stage we all have experienced pain, perhaps in your back or perhaps in another part of your body.
But what is pain? What does pain tell you? Is all pain the same? Below you can find more information on what pain is. Understanding back pain is the first step towards taking control of back pain.
Pain as a warning signal or not?
If you, accidentally, cut your finger with a knife, you experience pain. This pain signal is triggered in the cells of the tissue in your finger that are being damaged by the sharp knife. Although unpleasant, the pain is actually a useful response from your body since it alerts you that your finger is damaged and you need to take action to prevent further damage and/or ensure recovery from the damage. This is called acute pain. Similarly, when you sprain a muscle in your back, you will feel a sudden jolt of pain. Again this pain signal warns you need to take action in order to recover or prevent further damage.
“Does pain equal damage?”
However, persistent back pain is very different from the above examples. Persistent pain no longer acts as a warning signal and it does not refer to any tissue damage. The warning system goes into overdrive and sends out repeated pain signals, which are not needed or are out of proportion. The pain signals in persistent pain, also called chronic pain, no longer serve a useful purpose. But nevertheless you experience pain and it is virtually impossible to distinguish the useful pain signals from the disruptive pain signals. However knowing that persistent pain is often not a warning signal, means that you can respond differently to the pain. While you may think that rest is best when experiencing pain, for persistent back pain it is actually much better to stay active. Knowing that your pain does not mean that any structures in your back have been seriously damaged can take away some of the concerns you may have about using your back whilst in pain.
Definition of pain
Pain is not only a physical response; your mind also plays an important role in how you perceive pain.
One of the world’s leading organisations in the area of pain research (the International Association for the Study of Pain, IASP) has defined pain as: ‘An unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage’.
In this definition you can see that pain is not only a signal that your body sends out in response to a certain trigger (a sensory experience), but also an emotional experience. In other words, how your mind responds to pain is an important aspect of how you perceive pain.
“Back pain is not only felt in the back – it is also an emotional process”
You may have heard of people overcoming great pain when their mind was focused on something else. This is a good example of how the mind or your emotions can influence your pain experience. Secondly, the definition of the IASP also shows that pain could be, but is not necessarily, associated with tissue damage. This refers to the difference, explained above, between acute pain and persistent or chronic pain.
Causes of Back Pain?
Knowing what causes back pain is a big step towards preventing back pain and controlling back pain when it occurs.
We now know that psychological and even social factors play an important role.
Back pain can originate from various structures in the back. Sometimes the exact location of where the pain comes from can be found while in other cases it is less clear where the pain originates.
Irrespective of where in your back the pain is coming from, the question is what actually caused this pain and what can I do to prevent the pain from becoming worse or re-appearing. The list of factors that may contribute to back pain is long. Not all these factors are physical factors and we now know that psychological and even social factors also play an important role. Some of these possible causes may be surprising, but are nevertheless important if we want to understand and control back pain.
Where does my pain come from?
As explained in ‘About your back’ your back consists of many different structures that all have to work together. You may think that any abnormalities in the structure or functioning of your back result in pain, but this is not necessarily true. People have very different backs and it is difficult to define a ‘normal’ structure. Some people with severe deformities may not experience any back pain while others who appear to have ‘normal’ backs experience severe pain.
‘In most cases scans, such as X-rays and MRI’s, cannot show where back pain comes from’
This is why medical imaging such as an X-ray, MRI scan or CT scan is not necessarily an appropriate method of assessing back pain. Nowadays your GP or consultant will only use these scans when he or she thinks that your back pain is associated with a certain structural abnormality in your spine. This is only the case in a minority of the people with back pain. In most cases scans and test show no clear explanations for the pain. It should be noted though that even although the exact cause of the pain may be difficult to identify, the pain is real and fortunately there are a number of options when treating this type of back pain.
In some cases the back pain can be traced to a specific cause, for example:
Muscle sprain: sometimes you can ‘pull a muscle’ in your back, resulting in a small tear or sprain in your muscle.
Disc protrusion: sometimes the discs between the vertebrae may become weaker and bulge out. In an extreme case this may lead to a prolapsed disc.
Prolapsed disc (‘slipped disc’ or ‘herniated disc): Sometimes a disc bulges so far out that it puts pressure on the spinal nerves running in your back. You may feel this as pain in your legs (sciatica) since these nerves in your lower back run all the way down to your legs.
Spinal stenosis: the spinal column runs through a narrow opening in your vertebrae. If this opening becomes too narrow the nerves may become trapped, which causes pain.
Collapsed vertebra: the vertebrae give much of the structural support to the spine but these may become damaged as a result of disease or injury. Severe osteoporosis may result in a vertebra collapsing and by doing so disturb the surrounding structures.
The above causes may explain where the pain originates, but may not necessarily explain the degree of pain.
This is where the risk factors that are discussed below may play a role.
One of the most important risk factors for back pain is a previous history of back pain. This suggests that if you have experienced back pain in the past, you are more likely to have back pain re-occurring. This makes it even more important for those people with a history of back pain to take good care of their back and know what to do when back pain strikes. Furthermore, it also seems that genetic factors play a role in back pain. The fact that many of your relatives experience back pain may not mean that you will be affected by back pain, but it does imply that you probably will have to take good care of your back.
PHYSICAL RISK FACTORS
Most people associate back pain with physical risk factors such as heavy lifting, twisting and bending and awkward postures. These can indeed contribute to back pain or exacerbate existing pain. Therefore you should pay attention to controlling these factors by, for example, using manual handling aids (lift, carts etc) and ergonomically assessed workstations. Other risk factors of a physical nature include vibration (for example the vibrations that a driver experiences when driving a car or truck), repetitive work and static postures.
PSYCHOLOGICAL RISK FACTORS
It may seem strange to think that psychology plays a role when the problem seems to be in the back. However as explained in the ‘About your back’ section, pain signals can be interfered with by many factors. You may all know an example from yourself or someone around you who had to endure much pain and discomfort in order to achieve something they really wanted to achieve. Think about a marathon runner who ‘forgets’ about the pain once the finish line gets closer and the crowd starts cheering. This may be an extreme example of how your mind can alter your pain sensation, but it plays a role in our everyday life.
“Fact: Stress and work satisfaction can influence back pain”
Mental stress, dissatisfaction at work, depression and distress can all play a role in back pain. These factors may re-enforce relatively minor pain signals resulting in a much more present pain sensation. By no account does this mean that people with back pain are mad, it merely shows that our mind and our psychological well-being plays a very important role in any pain experience. When treating back pain it is therefore very important to address all of these factors.
SOCIAL RISK FACTORS
After physical and psychological risk factors, there is a third category; social risk factors. Again you may wonder how can these impact on my back pain? Social factors do not necessarily impact on your back, but have an important role to play in how we respond to pain. Over the past decades, the medical profession has made great progress and we can now treat many conditions that were previously untreatable. The same expectation that everything can be treated exists for pain. However it has also become clear that a (back) pain free society does not exist. But this does not mean we should accept the burden that pain gives us. It has become clear that by showing people how to respond to pain, we can control pain and live a life that is not restricted by pain.
“There are cultural differences in how back pain is perceived”
A famous example of this is from Australia; the aboriginals in Australia seek very little medical help for back pain compared to the other groups of the Australian population. However if you ask them, many will tell you that they have back pain. This shows a fundamental difference in how people respond to pain. Pain itself may be manageable but it becomes a much bigger problem when it impacts on our daily life and people become disabled as a result of back pain. This is when action is needed. Hopefully you now understand that back pain is a complex symptom that can be caused by a range of different factors and in most cases it is a combination of these factors that result in back pain becoming a real problem. Any attempt to control back pain should therefore address those factors that are important and relevant to you.
First Response When in Pain
Many of us will occasionally experience back pain. It is therefore useful to know what to do when back pain occurs and when to seek medical help.
With a correct first response to back pain, you can reduce the impact that back pain has on your life and promote a swift return to your normal activities. Most people with back pain find that their pain disappears within days or weeks. The appropriate action can:
• increase your rate of recovery
• help you in continuing your daily activities when in pain;
• prevent future onsets of back pain.
The key message when back pain strikes
The most important thing to do when you experience back pain, is to continue your normal activities as much as you can. Although you might be tempted to rest and move as little as you can, this will only make your pain worse and lengthen the period that you are in pain. Extensive research has shown that prolonged bed rest does not result in a quick recovery.
In some cases, the pain might interfere too much with your normal lifestyle. In such cases you could take some simple pain killers (e.g. paracetamol, aspirin or ibuprofen) to control your pain (if in doubt, consult your GP or pharmacist).
The above recommendations would be most effective if you integrate them in your daily life. That will give you the best chance of controlling back pain and continuing your normal activities.
Here are some more specific aspects when dealing with back pain:
The evidence shows that you are most likely to reduce your discomfort from back pain if you continue your daily activities as normally as you can. In the past, bed rest was often prescribed, but this has now been shown to be counterproductive. The support and reassurance offered from a professional movement specialist trained in the management of lower back pain, enables you to regain the confidence and trust in your body, helping you to return to your normal activities and lifestyle as soon as possible.
In some cases the pain might be too severe to continue your daily activities. In such cases, you can consider taking over-the-counter painkillers. Many recommend you should first try paracetamol, if that doesn’t give you sufficient pain relief, you could try ibuprofen. Also, more effective pain relief can be achieved by taking pain killers regularly instead of waiting until the pain is bad. You should discuss any concerns you have about medication with your GP or pharmacist, especially when you are taking these medications over prolonged periods of time.
A large number of research studies have shown that exercise is a very good method of reducing back pain. Joining a structured and supportive exercise programme like that offered by Back4Good® Practitioners is one of the most effective ways of staying active. Such a structured programme is the best way to move towards a healthier and happier back as well as lifestyle.
HOT AND COLD PACKS
Some people find that applying hot or cold packs to the painful area can give some pain relief. There are special hot or cold packs available in most pharmacies or drug stores, however you can also improvise by, for example, using a bag of frozen peas as a cold pack. It is advisable not to apply the hot or cold packs directly onto the skin, but to wrap the packs in a thin towel or cloth.
Choosing between applying heat or cold is often a matter of trying; some prefer hot packs while others get more pain relief from cold packs. If you think the back pain comes from a muscle sprain or tear, it is probably better to try hot packs first. If you think that the pain originates from an inflammation, it would be better to apply cold packs. Try it out, and you’ll see what works best for you.
PREVENTING RECURRENT BACK PAIN
Many individuals with persistent back pain have flare-ups and periods of no pain. Learning how to manage this effectively is key to maintaining a normal lifestyle. For further information refer to our section on Prevention & Maintenance.
If in doubt you could always consult with your GP or other qualified healthcare provider. You can find more information on when to seek medical help in our section ‘When to seek medical help’
Persistent Back Pain
Although most people find that their back pain disappears within days or weeks, some may experience more persistent pain or pain that returns regularly. When this is the case you may want to explore some other alternatives that allow you to take control of your pain.
Back pain can be persistent and many people find that their pain re-occurs regularly. The tips given in the section on ‘First aid for back pain’ can also be useful when the pain is more persistent, but we have collected some more tips and information for people with more persistent back pain.
What to do when pain is persistent?
If you have tried to manage your back pain by staying active, the use of medication and the other tips explained in ‘What to do when back pain strikes’, and found that after a number of weeks or months your pain is still bothering you, you may want to explore some other options. This however does not mean that the tips in the ‘What to do when back pain strikes’ section are no longer applicable. Staying active, medication, exercise, hot or cold packs can also be of use in managing persistent back pain.
The chances are that you have days of fairly minimum pain and also days of more severe pain. When feeling good, you may tend to do most things that you have to do, while on the bad days you cannot get yourself to do your daily activities because the pain is bothering you too much. There is however the risk that you over-do it on the good days and that this leads to more pain on the subsequent days. To avoid this ‘yo-yoing’ between good days and bad days, you may want to try to pace yourself on the good days and spread your workload over a longer period. This pacing will need some practice but after a while you will know how much you can do without over-stretching yourself and paying the price in the days after.
What is persistent back pain?
As explained in the ‘What is back pain’ section, there is a difference between acute pain and persistent pain (also called chronic pain). Acute pain, that pain you feel when you cut your finger or sprain a muscle, is a warning signal that tells your body that a part may have been damaged and needs your attention. However, persistent pain, that may have been present for weeks or months, no longer acts as a warning signal. Instead your body has gone into overdrive and the pain that you perceive no longer refers to possible damage.
Finding treatments for persistent back pain
There is a range of different treatments and products you may use to help you in controlling persistent back pain. Some people find that these treatments or products cure their back pain completely, but most people find that these treatments or products reduce the pain and make their back pain much more manageable. It is important to be realistic about your expectations from any treatment or product. Obviously everyone would prefer not to have any pain, but this is not realistic. Reducing pain to a level that is manageable and does not interfere with most of your activities is perhaps a more achievable goal.
There is a large range of treatments and products available. The Back4Good Programme offers a structured pathway to manage your pain and move towards recovery. There are also other options you may wish to consider in conjunction with our programme. To get more information about back pain and additional and suplementory treatments, you should visit BackCare.org.uk. Like us, BackCare strongly believe that there is always something that can be done about back pain. It is important to work through the various options objectively to find the best solution for you and your lifestyle.
What works for most people?
Even when your back pain is persistent, it is important to remain physically active. Spending too much time in bed or on the couch is likely to result in further de-conditioning and this will impair recovery from back pain. It may not always be easy to remain physically active due to your pain. If this is the case you can consider using medication to control the pain. Some people find that applying hot or cold packs to the painful area can give some pain relief.
Good Back Care
It is important to keep your back fit and healthy. This does not only put you in the best position to prevent back pain, but also enables you to control back pain when it strikes.
Preventing back pain
Research has shown that it is difficult to prevent back pain completely, but there are a number of things you can do to:
Reduce the risks of developing back pain, and
Reduce the impact back pain has on your life when back pain does occur.
As explained in the section on causes of back pain, there are many factors that can lead to back pain. To achieve this it is important to reduce multiple risk factors for back pain by:
It is important to keep your back fit and healthy by staying active and participating in regular physical activity. There is no need to run a marathon or become a fitness fanatic to achieve this; small changes to your life style can make a real difference. You can think of:
• Walking or cycling instead of taking the car.
• When using public transport, getting off one stop earlier and walking the rest.
• Gardening, hoovering, cleaning the house or walking the dogs are all examples of daily activities whereby you are being physically active.
Furthermore you should choose an exercise or activity that you enjoy and that gives you the benefits you want, such as walking, swimming, cycling, going to the fitness centre, aerobics, etc. You’ll find that you get most benefit if you do these activities 2 to 4 times a week for about 20 to 30 minutes at a time. You may want to alternate between activities or join a group to ensure that you keep enjoying your activities.
Besides using these activities to keep your back fit and healthy, your mind and the rest of your body will also experience the benefits.
Looking after your posture
Your spine is a very flexible and strong structure that can cope with many of the stresses in daily life. Ergonomists often say that the best posture for your back is the next one, showing that regularly changing your position is very useful.
You will see that your spine is a ‘S’ shape and it is important to keep this natural curve of your back when sitting. Good chairs follow this natural curve of the back. However, since all backs are different, good chairs should also be adjustable to ensure you can set them up for your needs.
When kneeling, bend from the knees and not from the back, especially when you are having to lift something at the same time.
Keeping your back flexible
Flexibility is one of the key characteristics of your back. To improve or maintain the flexibility in your back you can do mobilising exercises. You will feel that is especially important to do this after you have been in one position for a long period of time.
Besides doing some mobilising exercises at home, you can also take part in a structured exercise classes that focus on balancing mobilisation with stabilisation like Body Control Pilates classes and the ‘Healthy Back’ classes offered by Back4Good Practitioners.
Lifting heavy goods
Lifting heavy or awkwardly shaped items can be a risk factor for back pain, especially when you have to lift repetitively. To reduce the chances of lifting giving you a back injury, you should use manual handling aids and the correct technique. When lifting bend your knees and keep the weight as close to your body as possible. If the item is very heavy, ask for help, or use tools such as lifts to make the work easier. This is especially important when having to do repetitive lifting.
Healthy eating and drinking
A healthy diet and drinking sufficient water is important for everyone, including people with back pain. It has been suggested that drinking sufficient water is important to keep the intervertebral discs hydrated. Besides possible benefits for your back health, a healthy diet is good for your general well being, which gives another important reason to pay attention to what you eat and drink.