A news article popped up on the BBC today regarding the treatment of back pain and how in a recent study, paracetamol was found to be no better than placebo. This got me thinking about the way in which we diagnose, treat and medicalise back pain. It’s not a particularly widely discussed problem within paleo circles as it’s not something which obviously lends itself to treatment via diet. But, perhaps taking an evolutionary approach to this common problem might provide some answers that the general medical establishment is overlooking.
80% of people will suffer from at least one episode of lower back pain in the their lifetime. It’s often quoted as the number one cause of absenteeism from work and results in whatever silly amount of money to be lost from the economy. The general advice on treatment involves carrying on as normal and taking painkillers to allow you to do your usual activities.
Causes of Back Pain
I have two main problems which this line of treatment. Firstly, many people don’t understand what might have caused their back pain in the first place.
Back pain is usually caused by an over-stretch (or sprain) usually of the ligaments but sometimes of the muscles of the lower back. This can occur from a sudden high force movement. Rapidly moving in any direction followed by a sudden deceleration, either from a contracting muscle or from a ligament reaching it’s elastic limit, can cause a sprain. Examples of this include the sudden jolt from a car running into the back of your own, or trying to kick a football with a little too much gusto, and falling short. Sprains can also occur from putting too much force onto a ligament, such as going too heavy on a set of deadlifts or trying to tear your shirt in two like the incredible hulk.
However, the majority of back pains cannot be attributed to a single event. These sprains which occur are due to holding an unnatural position for a long period of time. This can apply to any joint. Sitting cross-legged on the floor can cause pains in the knee for this reason. Sleeping with your head to one side for the whole night can cause a crick in the neck the next morning. Similarly, holding your back in an unnatural position for too long can cause a sprain of the ligaments. What often exacerbates the problem in the back however, is the disposition of the discs which lie between vertebrae.
The usual prolonged position which causes back pain is when the lumbar spine is kept in flexion. The lumbar spines likes to assume a nice concave shape. Any engineer will tell you that an arch is the strongest structure. For this reason, evolution has caused the spine to form a succession of arches to help support the body. The lumbar spine is in a concave arch, but unfortunately many of the positions we find ourselves in, force the lumbar spine out of this natural alignment. Sitting is the main culprit, whether it be at a desk, in a car or on the sofa. An incorrect sleeping or standing position can also cause problems. Many people think that their back pain is caused by partaking in a sporting activity, but without a specific knock or fall, the most likely cause is the position assumed when resting after the activity is over. Muscles and ligaments are warmed up and relaxed by the activity, and when you then relax in an unnatural position, e.g. sat on the floor with your arms crossed around your knees, the sprain can occur.
All of these postures cause prolonged flexion of the spine, so the posterior ligaments which support the spinal alignment are put under strain. The disc becomes pinched at the front between the two vertebrae above and below, which causes the disc to bulge backwards, putting even more pressure on the posterior ligament. In severe cases, the ligament can weaken so much and the disc can bulge so far that it presses on the sciatic nerve and can cause severe pain and/or numbness to radiate down the leg.
Secondly, drugs do not solve the problem. They can be very useful in the very short term if the back pain is so severe that you can’t even walk, but using them for longer than a week is rarely a good idea.
As the study mentioned above shows; paracetamol is no better than placebo for pain control. In a way this might be a blessing in disguise. In my opinion, medication is massively overused in all aspects of medicine, with pain control being no exception. There is too much of a culture of reliance on a quick fix solution which often comes in the form of pharmacology. This does not address the root of the problem and only serves to cover it up until it becomes so severe it’s impossible to ignore. A back pain is due to a mechanical problem, not to a lack of painkillers.
Ibuprofen and other similar drugs can help to reduce pain but cause stomach irritation and sometimes even stomach ulcers if taken for long enough. These can be very unpleasant and sometimes event fatal. Codeine and other opiate drugs are also good painkillers but frequently cause constipation, drowsiness, nausea and can lead to addiction. Diazepam is used in extreme muscular spasm and is great in the short term but is very addictive and has been linked with dementia over the long term. Drugs don’t have side effects, they just have effects.
As we’ve seen, the drugs are either ineffective or cause unpleasant effects which we’d rather avoid. Furthermore, the drugs don’t fix the problem. Unnatural movement caused the problem in the first place so it makes sense to fix the problem using natural movement.
Walking is possibly the only universally agreed remedy to curing back pain between doctors, physiotherapists and osteopaths. Time and time again, patients tell me that they’ve cured or reduced their back pain by walking regularly. It makes sense, as to walk comfortably, you need to hold your spine in correct alignment. This is opposed to sitting on chair, where the most comfortable position is often to hold your spine out of alignment.
Any one who has gone through the drudgery of a health and safety training day will have been educated on correct sitting and lifting postures in the work place. This advice is well supported and definitely should be followed if you’re forced to lift things or sit for long periods of time for your job. However I can’t help thinking more offices like this would help reduce the incidence of back pain.
Various forms of physiotherapy, osteopathy, chiropraxy, massage therapy and postural realignment are a bit hit and miss. I think that anything that focuses on manipulation of the spine, although might help in the short term, can often cause a reliance on that particular therapy. Alternatively, therapies which focus on encouraging correct posture, and to a certain extent, strengthening the muscles which promote this posture, are much more beneficial.
I am personally quite a fan of yoga, although again, it really depends on the practitioner. Over-stretching any joint in any direction can make a problem worse and increased flexibility of joint can often sacrifice it’s strength and stability.
I am also a big fan of ‘Treat Your Own Back‘ by Robert McKenzie. It’s a short, clear guide on the exercises which any good physical therapist should be teaching you, but which can be done yourself at home and costs less than the price of the UK prescription charge. The main focus is to force the spine into extension, to correct the damage which prolonged flexion has done. This helps to pinch the disc on the other side, forcing it back between the vertebrae and taking the pressure of the posterior ligament. The easiest way to do this is to lie face down on the floor and then gradually come up onto your elbows, then hands and bend into the lower back.
I tend to get back pain when I ride my racing bike too much as it forces my back into flexion. Using the exercises in the book really helped and although it sounds a bit like I’m writing a puff piece, I do not receive any commission from Mr McKenzie and he only flies me out to Milan for a weekend break once a year.
Don’t do drugs. Drugs are bad. Don’t treat you mechanical back pain by just continuing your normal activities which caused your back pain in the first place, that’s dumb. Focus on correct posture when sitting, sleeping, walking and resting. Do exercises to actively extend your lower back joints and realign your discs. And if your legs stop working, you should probably go and see a doctor.
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