Back and Neck Trouble
The background to treatment in Primary Care by your GP and Manual Therapist.
This is an overview of current thinking arising from recent research about the possible origins of back pain, how it is diagnosed and how it might be appropriately treated in Primary Care. What follows is referred to as evidence-based information and it informs practitioners like your GP and myself which keeps us updated.
Research tells us that if you the patient is given honest and accurate information about your problem in a way that you understand and may learn from, then you are more likely to respond to treatment and understand why through better informed self-care you can reduce the risk of further trouble. (Technical words - Cognitive Reassurance)
Practitioners of manual therapy can only achieve this through listening to your story as told by you and with your permission undertaking a thorough clinical examination. The clinical information thereby yielded informs the practitioner who begins a process of thinking, comparing findings, drawing on experience and creating tentative diagnosis which assist develop a treatment plan or perhaps referral of patient to other specialists.
Research also tells us that practitioner empathy plays a very great role and therefor the sharing of all the assessment process and discussion between you the patient and practitioner is so very important towards developing a positive therapeutic sharing relationship.
80% of the population will report at least one episode of back pain at some time in their life. On any given day, 30% of the population will be reporting some back trouble – and that is not including those who already manage their trouble themselves. Back trouble is part of our natural lives - it is not a disease and therefor should not be treated as such.
Both UK and international research over the last decade have come to suggest a more broad and pragmatic approach for understanding how we investigate every persons’ back pain and treat it at the primary care stage appropriately at an affordable cost for the NHS and at an affordable cost for the patient wanting to fund their own treatment.
From 10th March 2016, this is no longer to be the case in North East Essex. A local NHS decision has been made such that the choice of service and choice of practitioner is now to cease. The patients who need NHS funding to see primary care practitioners from the privare sector for back and neck pain will no longer have the opportunity of choice.
When and why do back and neck pains occur?
• Back pain is a common condition with a broadly consistent pattern from early teenage years to old age. For most of us, some low back pain is usually a recurrent, intermittent complaint.
• The bio-mechanical/“injury model” of low back pain:
Much used over forty years by the NHS and manual therapists in private practice is now largely considered to be inappropriate. It may still be relevant for some people but for many, particularly those with recurring trouble, it is just one part of their presenting problem and is not helpful if considered the only issue when planning treatment.
It does not take account of important psychological and social influences we all experience throughout our lives which affects the way each of us perceive and manage our own pain experience if they arise.
Myths to be de-mystified!
Myth - The notion that back pain can be easily prevented.
• This is seriously unrealistic.
Myth - Imaging - taking X-rays and MRI scans will “pin-point the cause of
your pain” and therefor the treatment you need.
• Imaging gives very limited clinical information and may even be misleading. When used in Primary Care it is poor value for money. If necessary where response to Primary Care therapeutics is inadequate, it becomes a valuable tool in hospital care for the surgeon and pain management team.
Myth - The view that “injuries” start disc aging, wear, tear, and arises from
the workplace and elsewhere.
• The process of disc aging begins around teenage. The main drivers of disc aging appear to be genetic. Environmental factors play a small and as yet, poorly understood role and the idea of the work place being a sole cause of back or neck trouble is now being challenged by many from the research world.
Myth - Prolonged courses of physical treatment will maintain improvement for a problem back.
There is no evidence that prolonged courses of physical treatment will have a positive effect on the natural history of bio/mechanical back problems.
Myth - Over the counter (OTC) medication and prescription medications from your GP will “cure” back pain.
At best, they will facilitate comfort and are of positive value along with the patient receiving appropriate advice offered by professionals for self-management while natural healing occurs.
At worst – the patient feels comfort but does not self-manage and the problem becomes more severe and/or persistent.
OTCs may ease the pain but they do not “cure” the problem being signalled to the brain which in turn is expressing the sensation of pain.
Are all back pains the same? No … or at best, they should not be seen to be!!
Why is that? Because of that word “diversity”. We are all … different!
Remember, pain does not come from the back, it comes from the brain alone.
Signals from the back about problems it is experiencing (E.g., overload, inflammation of the small spinal joints which lie behind the your back bone "discs") are sent along the nerves which connect your back to your brain.
The brain "signals-out" pain to you in a way which reflects your own whole life experience and human diversity. You are different from everyone else!
Hence, “standard treatments” by a very long way do not help everyone. [See neuro-science and back pain a section coming soon]
Each clinician, depending on their therapeutic speciality will take a broad view of each presenting back pain but in ways which guide their decision for a logical treatment strategy for that patient consulting them at that time.
GPs and therapists always have to resolve the blurring of the distinction between:
• phases of extremely painful (acute) pain,
• where there are phases of no pain interspersed with phases of pain,
• very persistent long-term (chronic) low back or neck pain.
• For working-age people early return to work even if the back remains troublesome is an important health-giving goal. The idea that the workplace can be dangerous is diminishing.
• Most common treatments in primary care show no consistent evidence of therapeutic effect and where there is evidence, as for example manual therapy, the evidence is limited and to some extent is thought to be dependent on the health-provider. (One stage further "maybe" the relationship developed between health provider and you the patient).
• For every health-provider, the quality of their own knowledge, experience and beliefs utilised to clinically assess, create and implement an appropriate treatment plan for each individual patient, are of critical importance.
• Long-term persistent back pain is not an isolated symptom focused on the lower back. It quite often reflects an inability by the brain to manage the information flow from your body to your brain in a proportionate way. The way this occurs is different for each of us. The genome may be a factor since it is fundamental for how the brain is constructed before real-time life begins.
• Much research evidence is providing knowledge-based information appropriate in different ways for each patient and appears to be of benefit when delivered through one to one discussion in parallel with manual treatment.