My alarm went off one morning about 18 months ago and I woke up to realise I was in agony. It was my back. I tried moving, I tried lying still, I tried sitting: everything hurt. I visited a physiotherapist recommended by a friend. I do not remember what she said, but I felt listened to. Over the next days and weeks, the pain lessened, but I was still terrified to move. It was most intense just above my left hip, but it had infused my whole being, taken my energy, taken any pleasure I had in life. It was exhausting, being in pain or worrying about being in pain. I felt very low. I went from exercising four times a week to doing none at all. I wanted it to get better straight away, so that I could get back to my old life. There is something about back pain that makes you desperate to find a magical solution. Bearing the pain, waiting for it to get better, is unthinkable.
This month, the Lancet published a series of three papers written by a large, international group of experts who came together to raise awareness of the extent of the problem of low back pain and the evidence for recommended treatments. The authors were scathing about the widespread use of “inappropriate tests” and “unnecessary, ineffective and harmful treatments”.
The papers tell us low back pain is an “extremely common symptom, experienced by people of all ages”, although it peaks in mid-life and is more common in women than in men. There are 540 million people affected globally at any one time and it is the main cause of disability worldwide. In the UK, over the last 20 years, there has been a 12% increase in how likely a person is to experience disability as a result of low back pain; globally, the amount of years people live with low back pain disability has risen by 54% in 25 years. In Europe, it is the most common reason for medically certified sick leave and for early retirement. According to the Office for National Statistics, almost 31m work days were lost in the UK in 2016 due to musculoskeletal problems including back pain. The costs attributable to low back pain in the UK are estimated at £12.3bn a year, with £1.6bn spent on treatment.
The findings in these papers were not surprising for Cathryn Jakobson Ramin, a veteran investigative reporter and back pain survivor, whose gripping takedown of the back pain industry in the US was published last year. Her story began 10 years ago, when she put a note on her calendar to “find a spine surgeon”. She says: “When I began this hunt, I was a patient. I was looking, as all of us do, for a solution. I’d experienced back pain from when I was about 16 years old and I’d always coped with it. But I couldn’t cope any more. I struggled to sit or walk for more than a few minutes.”
In her book, she writes: “I thought fixing my back would be as straightforward as fixing a broken wrist. I’d find a surgeon and get it done.” But as she began researching her options, she tells me: “I started to see ‘lack of evidence’, ‘absence of evidence’, ‘poor evidence’ and I’m thinking: excuse me? I started to wonder what the heck was really going on here.”
The six-year investigation that began as an attempt to find relief from her own pain and ended up exposing an exploitative, corrupt and evidence-free $100bn industry, is fittingly described in the title of her book: Crooked.
The proliferation of unnecessary and risky interventions has been far worse in the US, with its insurance-based healthcare system, than in the NHS. But the UK is far from immune. When a healthcare system functions as a marketplace, there will inevitably be incentives for certain treatments to be pursued over others, for services that can generate a surplus. It is a struggle for patients and clinicians everywhere to resist pain medication that is incredibly effective in the short term, even if it is incredibly harmful in the long term.
“Nearly everybody gets back pain at some point in their life,” says Martin Underwood, co-author of the Lancet series, a GP and a professor at Warwick Medical School. “For most people, it’s a short-term episode that will resolve over a period of days or weeks, without the need for any specific treatment. They catch or twist or stretch something, and it’s awful, and then it gets better.” Of those who experience a new episode of back pain, under 1% will have serious causes that need specific treatment for issues such as cancer in the spine, a fracture, diseases or infection, he says. But there is another group, in which, “after the natural period of healing – normally six weeks for most things – people go on to get pain lasting months and years, which can be very disabling, even though the original cause of the pain is no longer there. We would label this as nonspecific low back pain, simply because we don’t know what is causing the pain.”
The question of how to treat back pain has plagued humankind for all time. The earliest surviving surgical text is thought to be the Edwin Smith papyrus, which dates from around 1,500BC. In their paper, An Historical Perspective on Low Back Pain and Disability, David B Allan and Gordon Waddell quote at length its instructions for how a patient should be examined and diagnosed, but when it comes to treatment all we are told is: “Thou shouldst place him prostrate on his back …” The rest of the papyrus is blank. The sentence is left unfinished, because, the authors explain, “at this tantalising point the unknown Egyptian scribe copying a much older text ceased his labours and subsequently died”. Today, approximately three and a half millennia after this papyrus was originally transcribed, we know how much harm has been done due to the gaps in knowledge represented by the empty space at the end of that sentence.
The ancient Greeks blamed back pain on “rheuma, a watery discharge or evil humour which flowed from the brain to cause pain in the joints or other parts of the body”, according to Allan and Waddell. Sciatica, Ramin writes, “was believed to be the result of excessive or ill-considered sexual activity”. Allan and Waddell report that in the dark ages, in north-east Scotland, it was believed that the mother or child of a breech birth had special powers in their feet to treat low back pain, while in Derbyshire “the legs of people with sciatica were smoked in a fire of ferns”. It was only in the second half of the 19th century, with the Industrial Revolution and the building of railways, that a series of serious injuries led to the discovery that back pain could be linked to physical trauma. But since reading Ramin’s book, I have found myself questioning how much progress we have really made.
Let us start with magnetic resonance imaging (MRI), the scans that use a combination of magnetic fields and radio waves to produce a picture of our insides. They are a miraculous feat of technology and invaluable for clinicians in certain circumstances – but they can also be harmful. Underwood explains: “There is a very poor relationship between changes on MRI scans and the presence or absence of low back pain.” While people with low back pain are more likely to have disc degeneration show up on an MRI, so will a large number of people without back pain. As Underwood puts it: “If you get into the business of treating disc degeneration because it’s shown up on an MRI, the likelihood is that, in most of those people, it is not contributing to their back pain.”
Of course, says Underwood, MRI scans are appropriate for people who are experiencing neurological symptoms in their legs, for which surgery is being considered. But for nonspecific low back pain, he says: “MRI scans probably do more harm than good.” A scan can change a patient’s behaviour, he explains, “because they’re told there’s some wear-and-tear damage in their back; but most people have wear-and-tear damage in their back and when you get to my age, I’m sure everybody does.” It also changes clinicians’ behaviour: “They’re more likely to offer invasive procedures if they can see something on an MRI scan that they can treat,” he says.
So why are MRIs used so often? The Lancet papers tell us that “although imaging has a very limited role, imaging rates are high: 39% of patients with low back pain are referred for imaging by general practitioners in Norway, 54% in the USA, and 56% in Italy.” Ramin says: “It’s not because the primary care physician is itching to have them have that MRI, but because the patient insists upon it; they insist upon it because their neighbours and colleagues have had them.” I remember, with quiet shame, requesting an MRI for my low back pain last year.
The case against invasive treatments such as injections and surgery is even more shocking. Underwood says that facet joint injections, a mix of anaesthetic and steroid injected into the small linking joints of the spine, “are very widely used in the public and private sectors. There is no evidence to support their use, but nevertheless the numbers done in the NHS go up year on year.”
Ramin says that. at an American Academy of Orthopaedic Surgeons conference in 2010, 100 surgeons were asked whether they would have surgery on their spine for nonspecific low back pain. “The answer – from all but one – was ‘absolutely not’.” Spinal fusion surgery, which is sometimes recommended when disc degeneration is identified on an MRI, is a procedure in which the offending disc is cut out and the surrounding vertebrae are re-connected, either with bone graft or with titanium screws and plates.
“At best, these spine surgeons define success as a 38% improvement in pain and function,” says Ramin, “but if a hip or a knee surgeon had a 38% success rate, that physician would no longer do that surgery. And 38%? I think that’s really optimistic.” In her book, she describes the scandal of the Pacific Hospital in Long Beach, California, which carried out more than 5,000 spinal fusion surgeries. “Surgeries were being performed on large numbers of patients who were often immigrants – Spanish-speaking labourers – and being billed to workers’ compensation insurance or public health insurance. Could you do worse than butcher these Latino field workers who don’t understand what’s happening to them, but are being told they can get free medical care?”
We like to think that this could never happen in the UK, and Underwood admits there is a huge difference between the two healthcare systems. “Most spinal surgeons in the UK will avoid operating for nonspecific low back pain because they’re aware of all these problems,” he says. “But there is still pressure from patients for something to make them better, and some people are still getting operated on. My advice for anybody is: don’t have surgery for back pain unless there is a clear, specific indication.” In 2017, the Medical Defence Union, which provides insurance to British doctors, announced it was no longer providing indemnity insurance for private spinal surgery because of the “prohibitive cost of claims”. If the insurers are running for the hills, it cannot be worth the risk.
The US opioid crisis is well documented, but prescription of the drugs for chronic pain has been rising year on year in the UK too, and Underwood believes we need to take it seriously. “It is a really important problem – it’s massive,” he says. “They [opioids] don’t really work for long-term back pain, they make the pain worse in the end, and they have all sorts of other effects on how you think, your quality of life and your risk of falls or accidental overdose.” He encouraged me to look up the regional differences in the number of opioid prescriptions issued around the UK, using openprescribing.net. At one end of the graph is Ealing, with just under 10 prescriptions for opioid analgesics per 1,000 patients; at the other end is NHS Durham Dales, Easington and Sedgefield CCG, where the rate is nine times higher. A study published in February found that, despite their ineffectiveness in treating chronic pain, opioid prescriptions by GPs are higher in deprived areas and northern England. The alternative, says Underwood, is better support for GPs and better services to help patients manage their pain, such as self-management support services including groups that help participants learn techniques and strategies for dealing with the challenges of living with daily pain. “If people are getting really bad, disabling pain, and if the only thing GPs have in their arsenal are strong opioids, they’re going to end up prescribing them,” he says. “The self-management support services are not there.”
Fundamental to understanding chronic low back pain, Ramin says, is the biopsychosocial model: the idea that pain is not just a biochemical reaction, but is also experienced within and influenced by our psychological and social lives. “Your brain and body are absolutely integrated in every way, there is no separating them. Most patients who suffer for a long time lose that sense of control over the body. They feel separate from their bodies, feel their bodies are taking terrible advantage of them. Altering that perception is what it’s all about.” The fear-avoidance model illustrates this well. “You find it hurts when you move,” says Underwood, “so you don’t move, you don’t do things, you get deconditioned, so your back pain gets worse, so you become even more frightened of moving – you get into a negative cycle. Breaking that cycle, managing your life and moving forwards has great potential to help.”
There is another way in which the mind can have an impact on back pain: through psychological trauma. In some cases, says Tim Kent, a consultant adult psychotherapist at the Tavistock and Portman NHS Trust, “the back pain, at some level of the patient’s mind, is associated with something terrible and traumatic that interrupted their development and that has been cut off from consciousness”. There may have been some abuse or trauma that cannot be spoken, that has had to be repressed, and that comes out in physical rather than emotional pain. “The body becomes the vehicle for communication. The body talks,” he says. “The back is the main highway of our musculoskeletal structure; when it is broken or doesn’t work properly, it can be a visual and social communication: look, I’m broken.”
In one project, he is working with Turkish and Kurdish women on a city farm, where gardening and therapy take place at the same time. He says: “Very often people come talking about their physical pain – ‘I don’t know if I can come next week, my back is really bad’ – and sometimes after a month or so a person starts to feel relieved by being around others who have been in a similar situation. And, eventually, they start talking about their trauma. It can reduce the need to focus so strongly on the symptom; it can make them feel more able to face life. The pain dominates less.”
So if you have low back pain, what should you do? Ramin swears by Dr Stuart McGill’s Big Three exercises for stabilising the core – the modified curl-up, side bridge and quadruped bird dog – exercises that the professor of biomechanics at the University of Waterloo in Ontario, Canada, says “spare the spine, enhance the muscle challenge, and enhance the motor control system to ensure that spine stability is maintained in all other activities”. They should be performed every day. She also practises Feldenkrais, an approach that combines movement, breathing, body alignment and mindfulness. She has gone from struggling to walk for a few minutes to walking two miles a day. “I hate to tempt fate, but I think suffering and I, in terms of back pain: we’re done,” she says.
When I ask Underwood what works, he tells me: “Whatever you do for a patient at a time when their back is really bad, the chances are they’re going to be a lot better three weeks later. So we treat people and we see them getting better and we ascribe their improvement to the treatment we’ve given, but we know that natural improvement over time is always much larger than the positive effect you get from the treatment.” The evidence is strongest for therapist-delivered interventions such as the cognitive behavioural approach, based on the same principles as CBT, exercise treatment and physiotherapy. He has also worked on a trial that showed training physiotherapists to deliver the cognitive behavioural approach in a group, combining movement and reassurance about movement, is helpful to patients and could be delivered in the NHS at low cost.
But perhaps the most helpful thing we can do is challenge the assumption that, if our back hurts, there is a pain generator in there somewhere that can be scanned, identified, injected or surgically removed, and fixed. “That whole notion is erroneous,” says Ramin. “The truth is that low back pain is a many-faceted problem, emerging from your life situation, the state of your body and the social factors surrounding you.” Rather than trying to find a doctor who can make the pain disappear, we need to be aware that to a certain degree, it is a part of life and the best approach is to keep physically active in the right way, to find a strategy to manage stress and to keep on with normal activities. Like all complicated pain, avoiding it, trying to use a substance to blot it out, investing in one person the belief that he or she can cure you: that all makes it worse.
Perhaps that is what the scribe was about to write on the Edwin Smith papyrus before his untimely death. We would not have listened if he had. I look back on the eight months when I suffered from back pain as a dark period in my life, a time that I feared might never end, when I felt desperate and on the edge. I am so grateful nobody offered me injections or surgery or opioids – I would have said yes to everything, paid anything to make the pain go away. My back has healed, but it took longer than everyone told me it would.
