Back pain is the curse of the screen-starer and the long-haul truck driver. And the young woman whose toddler wants to be picked up and the schoolkid with a backpack full of books. And the gardener and the overweight dad and the supermarket cashier. In fact, it affects nearly all of us. In any given year, half the population will suffer from back pain lasting at least a day. Eighty per cent will suffer from it in a lifetime; it is the leading cause of disability and it costs the country an estimated 1-2% of the gross national product.
It is an extraordinary toll in suffering and expense. And yet the biggest problem about back pain is making it go away. That may seem self-evident, but while many other types of pain can be relatively easily treated, back pain can be difficult to diagnose and harder still to alleviate. Frustrated by the limited advice that GPs can offer, many people seek help from chiropractors and osteopaths. These two related disciplines (chiropractors generally focus on the joints of the spine, and the nervous system, while osteopaths put equal emphasis on the joints and surrounding tissue) are the respectable face of complementary medicine; both have professional bodies that provide training and regulation. Everyone knows a back-pain sufferer who will credit their chiropractor or osteopath with transforming their life.
So when, earlier this year, a leading professor of complementary medicine pronounced that chiropractic is a complete waste of time and osteopathy not much better, it was sure to cause controversy. The British Chiropractic Association was "outraged", declaring the study "flawed" by "bias" and "spin". The General Osteopathic Council more quietly suggested that Edzard Ernst, author of the troublesome review in the Journal of the Royal Society of Medicine, was "out of date". What is the truth? More importantly for those who suffer the agony of back pain, what is the best way to get better?
This row, it is clear, will simmer for a long time. And yet it comes just as the mists around back pain begin to clear a little. There is now some consensus - the caveat is absolutely necessary in such a contentious area - that back pain has been over-medicalised. In other words, the pain, and its treatment, is more straightforward than sufferers may like to think. The following, for instance, are the facts that are least disputed. Fact one: most back pain will get better of its own accord. Two: it is a disaster to go to bed, though some GPs still tell you to, according to the charity Back Care. Three: the best treatment is to stay active. Four: it is important to get back to work even if the pain has not completely gone.
That, at least, is the advice you will be given in Scotland, where the Health Education Board, Health and Safety Executive, medical organisations, patient groups and, yes, chiropractors and osteopaths have all been signed up to a major campaign called Working Backs Scotland. They talk of a "radical shift in medical thinking" since the mid-1990s, when advice tended to recommend staying still and hoping the pain would go away. The new approach, simply put, is to get on with life. The slogan is: "Stay active, take simple pain relief and seek advice if necessary."
The "get back to work" adage comes from the observation that the longer you are off work with a dodgy back, the less likely you are to get better. "If somebody is going to be off work longer than six months with a back problem, they are very, very unlikely to return at all," says Mike McKiernan, chairman of the trustees of Back Care and an occupational physician. "Even after six weeks you are on the slippery slope."
He is not talking about the so-called work-shy, who find life much more comfortable away from the office or the lorry cab, but about those whose genuine pain continues because they are not addressing their "obstacles to recovery". In other words, back pain for some is a real symptom of other things that are wrong in their life.
One in eight of the unemployed say they are not working because of back pain, 1.1 million are disabled by it and 430,000 are receiving social security support. That makes it a hot topic for the Department of Work and Pensions, which commissioned a publication with the catchy title Concepts of Rehabilitation for the Management of Common Health Problems from the spinal research unit at Huddersfield University. It says that back pain is one of a range of conditions where "the obstacles to recovery are often predominantly psychosocial in nature". Rehabilitation, for people with common health problems, must focus "on identifying and overcoming the health, personal/psychological and social/occupational obstacles to recovery and (return to) work".
But here is the problem and - if only in terms of the numbers - it is a huge one. People who experience pain in their back justifiably think they need medical treatment. If you had a pain in your leg or in your head, you would go to a doctor. A clued-up GP will tell you to take painkillers, keep active and it will get better. But if there are other things going wrong in your life - a bad boss, a miserable marriage - the stress may make it easier to give in to the pain rather than get over it. You don't resolve to knuckle down, start exercising and rethink your lifestyle - you take time off on sick leave.
The first port of call should be the GP - there are some conditions, of which back pain is a symptom, that are serious, though they are not the majority. But GPs can only offer treatment. Many do not have the time for counselling or lifestyle advice. That is where complementary medicine could really help and probably does in some cases. But unfortunately, say some critics, chiropractors and osteopaths also have a tendency to over-medicalise the problem. It is the assumption that there is something wrong that can be put right by treatment that can thwart some people's recovery, precisely because they don't try to help themselves.
This is not, however, what Ernst was arguing. His criticism is more fundamental - that studies of the spinal manipulation techniques used by chiropractors and osteopaths have not been proved to have any real effect. According to the evidence he cites, they are better for back pain only in comparison with "sham manipulation" in trials - which suggests there is a placebo effect.
Chiropractors and osteopaths, as well as rubbishing Ernst and insisting that he selectively cites only those studies that back up his argument, say they offer far more than manipulation and massage to the back-pain sufferer. In fact, the General Osteopathic Council completely toes the modern line. "Spinal manipulation is but one potential element of the osteopathic treatment package, which also includes guidance on lifestyle, diet and exercise," it says in its rebuttal to Ernst. "All recent scientific research suggests that back pain is rarely a simple problem, is influenced by psychological and social factors and requires treatment tailored to the patient's needs."
Does any of this matter? Surveys show that patients really like their therapists. Arguably, if spinal manipulation didn't work, it wouldn't matter as long as going to the therapist made them feel happier and started them on a better lifestyle. But that only holds if the treatment itself is harmless, and some argue that that may not be the case. In 1998, 20-year-old Jean Laurie Mathiason from Saskatchewan in Canada had a stroke and died after an artery in her neck was severed while a chiropractor rotated her head. Other incidents came to light and in February 2002, 62 clinical neurologists in Canada issued a warning about the dangers of neck manipulation.
In the same year that Mathiason died, a British woman, Frances Denoon, then in her 20s, went to see her GP, convinced she had pulled a nerve in her neck while exercising at the local sports centre. The GP said to take painkillers. "I wanted something that would get me back to work quicker and that was more active than rest and exercise," says Denoon. She went to a registered chiropractor. She says she remembers a gut-wrenching "crack". "I felt funny and couldn't focus and realised I wasn't saying the words clearly," she says. It was an immediate reaction, affecting her speech, vision and balance. She was rushed to hospital and suffered a brain-stem stroke. She nearly died. Now she has poor balance and cannot write with her right hand. There was no doubt that her artery was severed, but a court cleared the chiropractor of negligence.
Chiropractors argue that the risk is very small - they suggest one in a million, although there is insufficient research to be sure. They also say that some people will be more prone to severing an artery than others and that it could equally happen when painting the ceiling. Haymo Thiel of the British Chiropractic Association says that "any therapy, any intervention - even advice - has some risks to it." In 2004, he adds, there were 3.8m neck manipulations in the UK, yet very few reports of damage. He also says patients are informed of the slight risk when they go to see a chiropractor and that it is less than that of some painkilling drugs.
Would people take even that very slight chance if they believed their back pain or neck pain would clear up by itself eventually as long as they got fitter? Probably not. But one thing is clear: physically and psychologically, we have become dependent on medical treatment. The quest for a quick-fix cure has left us unable or unwilling to do something to help ourselves.
"Osteopathy and chiropractic are essentially passive treatments," says Nia Taylor, chief executive of the charity Back Care. "We try to encourage people to be active in managing their back pain. Osteopaths and chiroractors can give you some understanding and the best ones will tell you if they don't think they can help you, but the best results will come when you are prepared to do something for yourself."
Beat backache for good
There are three crucial elements to keeping your back healthy - mobility of the vertebrae, elasticity of the muscles, and strength exercises to maintain posture and daily function. Here is Joanna Hall's fitness programme.
Cat curls with limb lift
A combined mobility and strength exercise that can be adapted according to ability.
On your hands and knees form a box position, knees over hips and shoulders over wrists: your limbs should form straight sides of a square box and your back should be flat. Pull your tummy muscles in firmly and arch your spine up towards the ceiling. Hold this position, breathing smoothly, feeling your belly being scooped up towards your backbone. Now reverse this position, passing through the flat back position you started with, gently arching your spine in the opposite direction so it dips down to the floor. Ensure your stomach muscles and pelvic floor are pulled in to support your spine. Aim to do four to eight complete arches.
To make this exercise harder, you can challenge your balance, and strengthen your back extensor muscles. In the flat back position slowly lift one leg off the floor, extending it back into a straight line behind you, while extending the opposite arm out in front. Pull tightly up through your abdominals, pelvic floor and bottom to provide internal stability. Lower the leg and arm and repeat on the other side. Once this feels relatively easy, you can challenge yourself further by performing the leg lifts with your eyes shut. This tests the sensory receptors responsible for good balance.
Wall rolls
This simple Pilates-style exercise helps to maintain functional mobility throughout the spine as well as assisting the abdominal muscles to provide support.
Stand with your back to a wall, adjusting your feet so they are a little way from the wall and each part of your back, hips, lower spine, waist, torso and head touches the flat surface. With the knees slightly bent, slowly drop your head forward, chin to chest, as you peel off each part of your spine, from your head to your hips, slowly to the floor. Try to create as tight a curl as possible through the spine, challenging each vertebra to progressively come off the wall; your arms will be hanging loosely by your side as you roll down. Keep the hips in contact with the wall throughout and slowly uncurl to an upright position, placing each vertebra back in contact with the wall. Try not to rush: one whole roll-down cycle should take at least four counts down and four counts up. Aim to do four to eight repetitions.
It is likely that you will experience "sticking points". This is when you find it difficult to peel your spine bit by bit off the wall and instead the spine seems to come away in sections. You own personal sticking points will depend on the mobility of your spine and any muscular imbalances. Do persist - you will see big improvements.
Seated back press
This is a simple back-strengthening exercise that can be done at home or in the office - all you need is a chair with a high back.
Sit upright and forward in the chair. Have both feet flat on the floor directly under the knees. Make sure your abdominals are contracted and your back is straight. Place your hands across your chest with the fingers resting on the shoulders. Slowly start to lean back until your shoulders touch the back of the chair (about 110 degrees) and flatten the abdominals as you move into position. Slowly come back to an upright position using the abdominals to support your back. If you have a weak back, keep your hands on the side of the chair for extra support and reduce the range of movement. Add a small weight across the chest to make this more challenging.
Repeat five to 10 times.
Lower lumbar back stretch
This stretches one of the hard-to-isolate back muscles, the quadratus lumborum. It is a difficult muscle to stretch, and tightness can cause limited mobility and discomfort.
Stand with your back against the wall. For this exercise you need to keep the whole of your spine flat against the wall; to avoid the lower spine coming away from the wall, position your feet a little way from it and soften your knees. Extend your arms up over your head. Keeping the spine and arms in contact with the wall, slowly stretch over to one side, extending through your arms as you reach. This is a gentle exercise and you will not be able to bend too far. You should feel a gentle stretch in the lower part of your spine and across the pelvis. Hold for 10-30 seconds, slowly return to start position and repeat on the other side.
Lying side rotation
This helps to maintain rotational function of the vertebrae, as well as flexibility of the back muscles.
Lie flat on the floor and gently bring one leg in at a time so your knees are lifted off the floor and over your hips. Take the arms out to the side, level with the shoulders, to provide balance. Slowly keeping your stomach muscles contracted and both knees together, lower your knees to the left. Try to keep the knees close to your waist, as opposed to stretched out away from the body. You should feel a gentle stretch to your spine, across your outer thigh and waist. Exactly where you feel the stretch will depend on where you are most tight. Hold for 10-30 seconds, pull your stomach muscles in and repeat on the other side.
The good cardio guide
Warming up and cooling down are essential components in any cardio work, but are particularly important if you are prone to back problems. A warm-up should consist of gradually increasing your body temperature to assist physiological responses, as well as mobility work to help your joints and vertebrae to move smoothly through their full range of motion.
Start with small movements and gradually progress to larger ones; think hip circles in both directions, standing pelvic tilts and side bends. Raise your body temperature gradually by increasing the pace of activity. For example, when walking progress from an ordinary pace to walking briskly and when swimming use a float before using full strokes. What you can do in your cardio work will depend on the nature of the back problem, so listen to your body and aim for a small and gradual progression of intensity rather than a no-pain-no-gain approach.
Activities such as recumbent cycling in a gym or on an old-fashioned Schwinn bike may not be the best activities for back-pain sufferers as they can compress the vertebrae. Similarly, it is best to focus on brisk walking rather than jogging or running. As for swimming, breaststroke may not be most appropriate; instead switch to backstroke, front crawl or, easier still, flutter kicks on your stomach holding a float in front of you, keeping your head in line with your spine.
Posture is always important, but drawing in the deep transversal muscles of the abdominals (the muscles you pull when you try on a tight pair of jeans) will help to provide an essential girdle of support in your cardio activity.
When you are cooling down, perform the mobility exercises again but this time gradually reduce the size of the movements.
