Back pain

Dead bodies can’t feel pain, or why biomechanics and ergonomics haven’t reduced back pain
I know, it should make sense: reduce the biomechanical load on the body bits and pain/injury should reduce, right?  I mean, the maths adds up, cadaver experiments ‘prove it’, it has ‘face validity’, there is a whole industry based on the idea of  ‘safe lifting’ and injury prevention – physical ergonomics works, doesn’t it?

Well, sad to say, this very recent paper (this week’s BMJ no less!) by very respected researchers in the field has once again found that the evidence is at the most low to moderate that “physical and organisational ergonomic interventions were not more effective than no ergonomic intervention on short and long term LBP and neck pain incidence/prevalence”.

Not only does this finding fly in the face of common sense, the quality of the evidence is pretty low – and yet the amount of research has been going on for how many years?

I don’t know if many readers know, but for some years I worked as the ‘safe handling’ advisor in a large public hospital.  The whole drive of that position was intended to reduce the number of incidents of back pain (the most common ‘injury’) and the overall cost of that problem by teaching staff members that manual handling (including patient handling) needed to be carried out with thought.

Early in my career I have studied human biomechanics and I have several papers in ergonomics – but to say I haven’t been convinced that changing manual handling techniques will reduce the prevalence of back pain is understating the blindingly obvious.

So why, oh why, did I try to do this job?  Well, my main idea was that by working in that position I could begin to influence the way this organisation managed the work situation of people who developed low back pain – by supporting the person to return to work as soon as possible, by making it slightly less physically demanding for them when they did return, and to encourage staff members to support each other and to feel supported (working on the psychosocial aspects of the workplace).

I failed, not entirely miserably, but I did fail because no matter how hard I tried to show the research, very few people believed the evidence.  It simply doesn’t fit with ‘common sense’ – because ‘everyone knows’ that how you lift will affect your risk of back pain.  Not.

Why doesn’t it work?

Well, lots of reasons – one of which is pointed out in this review.  People don’t always ‘follow the rules’ when it comes to ‘safer lifting’.  This is because we don’t live in a nice, controlled environment.  While people might be taught a specific method – in the real world, the item to be moved isn’t a nice box shape, it’s a lumpy human being who squeals and flops and does the unpredictable.  In the real world, there might be little time to think and plan.  Other people might not help when needed.  The equipment might be too far away.

Oh, and maybe the assumptions of the biomechanical and physical ergonomics approach might not be correct.

You see, biomechanical equations, even sophisticated models, are still a simplistic picture of the multiple forces acting on structures – and the maths is pretty complex.

Probably more importantly, biomechanical models don’t factor in the brain – there’s a thinking, feeling, deciding, processing, dynamic neuromatrix involved in the human that is doing the moving.

Low back pain (and other musculoskeletal pains) are not a simple A + B = low back pain equation.  Researchers still haven’t narrowed down the suspects in the causal equation for low back pain.  It’s one of those delightful problems that are called ‘multifactorial’.  No single two or three or even eight factors are reliably associated with low back pain – or at least, not physical factors.  It seems that fuzzy and difficult things like attitudes, beliefs, work satisfaction, social support, supervisor interactions, peer pressure, fatigue, mood – they’re the things that seem to be associated more strongly with problems with back pain than simply the movements and forces acting on the body.

When I think of the money that is spent on training, equipment, systems and even penalties applied to reduce the physical and biomechanical demands on bodies – without addressing the brain and the person and their social setting, I despair.  Wouldn’t it be wonderful if this funding was spent on researching the psychosocial interventions that could (and do) make a difference?

Driessen MT, Proper KI, van Tulder MW, Anema JR, Bongers PM, & van der Beek AJ (2010). The effectiveness of physical and organisational ergonomic interventions on low back pain and neck pain: a systematic review. Occupational and environmental medicine, 67 (4), 277-85 PMID: 20360197

Work conditioning, work hardening and functional restoration for workers with back and neck pain

In New Zealand most people who have been off work with chronic pain, and receive compensation from ACC, will have been a participant in some sort of fitness programme.  It’s almost a rite of passage for people to have a programme of functional restoration before or during an attempted return to work once the person has been off work for around 3 – 6 months.

There are a lot of different types of programme available:

  • two of the Prof Mick Sullivan’Goal attainment’ programmes for sub-acute pain,
  • Functional restoration programme – for sub-acute pain, involving activity with some ‘education’
  • Pain management psychological services – for psychological strategies for pain management
  • Activity focus programme – for chronic pain, involving activity and cognitive behavioural therapy approach for self management
  • Multidisciplinary programme – a three-week intensive interdisciplinary programme with a cognitive behavioural approach, including reactivation


World Bellydance Day!

If you have ever recommended ‘core stability’ for back pain, here’s a way to really work on it while having loads of fun!
OK, while core stability HASN’T proven to be the ‘cure’ for back pain, belly dance is still a great way to have fun and work the core muscles…

It’s for men and women, although more women than men dance (but that’s probably true of most dance forms!), the music is very catchy and has great rhythm, and it’s pretty low impact while toning and improving posture, body awareness and adding to your 30 minutes a day exercise routine. Oh and it doesn’t take up much room to practice, in fact you need no equipment at all! (apart from some music)

If you want to learn more, take a look at Kashmir’s site , she’s based in Christchurch and is my teacher.
Or if you’re looking for information on World Bellydance Day – go here
For information on styles (OK it refers to the US, but in NZ we probably have the same range) go to Shira’s website
And for some great video’s, YouTube has plenty, but to find them can be a leeeetle bit difficult, so take a look at Oriental Dancer’s video section.
And for a taste of what real dancing can look like? Take a look below…

Orit Maftsir is a dancer originally from Israel, but dancing all around the world – and she’s been to NZ, and danced for us! I wish I’d seen her live, she really enjoys her dance and represents to me what dancing is all about.

Friday funny! or ‘Look how far we’ve come’

If you ever think that things in our world haven’t improved a bit, take a look at this advertisement!

See? Hopefully we won’t see anything like that again – there are a few other adverts I’d like to see the back of too, like the ‘magnetic woollen underlay to relieve pain’ and the ‘back brace’. Until they go, we’ll just have to be satisfied with this.

Mind, body and pain

For lots of therapists, the connection between mind and body is so clear that we forget many people just have no concept of how the two might be connected. So often in the web there are wild statements about pain that it’s tempting to think that no-one’s prepared to get it right or to spend some time (and web pages) discussing it…

So when I found The Psychology of Back Pain by Jonah Lehrer (with some stunning photography by Craig Cutler) I knew I had to link to it here!
Although many of us know this material through and through, it’s great to find someone who writes well and puts the pieces together for nonclinicians…
Jonah also writes this piece about MRI’s, Back Pain and Transparency – linking in to a couple of other people writing also about MRI’s and the myth that MRI can ‘show everything’. Take a look, enjoy – as a clinician, it’s always great to see someone in the media putting what I talk about ‘out there’ to people in the community!

Centenarians also get back pain…
Pain in the Back and Neck Are With Us Until the End
A Nationwide Interview-Based Survey of Danish 100-Year-Olds

I’ll bet you thought that at some point in life we might not be at risk of back or neck pain – guess what, we’re all wrong. This fascinating study by Jan Hartvigsen and Kaare Christensen looks at the prevalence and impact of back and neck pain amongst the oldest old – centenarians – in Denmark. What astounds me, apart from the thought that people would want to study this group, is that they had a 56% response rate and still obtained a sample of 256 people! The wonders of living in a place where everyone has a unique identifying number for all social benefits, medical care, or salary!!

So, what did they find… Well some of us would think that once we stop all that heavy work, we might find the prevalence of LBP and NP to reduce. After all, there are still many people ‘out there’ who believe that a major factor in the incidence of LBP is biomechanical demand. However, this study showed that over the past month, 27% of the respondents had experienced back pain, 22% had experienced neck pain, and 11% of the sample had both. A second study, reviewing Danish twins aged 70 years and over found a very similar result: 25% for back pain, 21% for neck pain, and 11% for both.

Among the 100-year olds, around 20% had been bothered by back pain either when moving (most common) or resting or sleeping. More than half of the centenarians rated their own health as excellent or very good. Poor overall physical function was associated with back or neck pain, higher depression score was strongly associated with back and also with neck pain, and rating ones health as less than very good was also associated with back and neck pain.

Diagnoses associated with low back or neck pain included: osteoarthritis, migraine headaches, current or previous diagnosis of disc prolapse, osteoporosis, and rheumatoid arthritis, hypertension, and heart disease were varyingly associated with back and neck pain.

The following quote, directly from the paper is, to me, the most important contribution of this study to our management of back pain:

the prevalence of these conditions at the very end of life is practically identical
to the prevalence in younger groups of seniors and similar to other ages from late childhood and youth over adulthood and into retirement. Furthermore, the many characteristics of back pain and neck pain seem to be quite similar between the ages, i.e., they are associated with poorer physical function, a number of comorbidities including depression and poorer self-rated health. It is therefore tempting to speculate that the occurrence of backand neck pain can regarded as fairly constant in the population, keeping in mind that the presence and intensity of symptoms tend to vary in individuals [my emphasis]

It’s a shame that the study didn’t go on to identify how many of the participants were actively seeking health care for their back pain, and that their measures don’t really ascertain severity. Ah well, you can’t get everything!

A further comment well worth reflecting on is: ‘…that there may be an underlying disposition to back pain and neck pain that is unrelated to age and age-related exposures resulting in a stable prevalence across age groups. Primary prevention may be an illusion since the pain is going to appear anyway and consequently we should focus on secondary prevention in order to avoid irrational pain behavior and chronicity, which is associated with over 80% of societal costs from back and neck pain.’

Given the observation that disability associated with back pain is the aspect that varies between populations in different countries, perhaps we could consider the negative influence on humans that medicalising a condition that, although painful and uncomfortable, is not fatal in itself.

Why do people have difficulty recovering from ALBP? On the whole it’s not the pain intensity – it’s the fear of experiencing pain that is disabling, as is the fear that pain equals damage. Where do these messages come from? Over the years, it’s come from medical and health care people and their messages that to have pain is bad, as well as a pervasive belief in Western civilisation that life should be happy and comfortable all the time.

And where is it written that life ‘should be’ happy and comfortable?

I’ll get back to you on that one, once I’ve found it!
Hartvigsen, J., Christensen, K. (2008). Pain in the Back and Neck Are With Us Until the End. Spine, 33(8), 909-913.


New clinical guideline for low-back pain from

A summary of evidence on the diagnosis and treatment of low-back pain has prompted the American Pain Society (ASP) and the American College of Physicians (ACP) to issue a new treatment guideline. The guideline is based on a thorough analysis of published research conducted by investigators at the Oregon Evidence-Based Practice Center at Oregon Health & Science University.


Click on the link to find out more!!

Floating effective for stress and pain from
Relaxation in large, sound- and light-proof tanks with high-salt water­floating­is an effective way to alleviate long-term stress-related pain. This has been shown by Sven-Åke Bood, who recently completed his doctorate in psychology, with a dissertation from Karlstad University in Sweden.