STRETCHING EXERCISES FOR BACK PAIN

NB: Upper knee should be directly above lower knee

1. Back Stretch
Lie on your back with your knees bent. Keeping your feet on the floor, slowly roll your knee over, first to one side and then the other, holding for a few seconds in each position.

2. Deep Lunge
Whilst kneeling on one knee in a forward-facing position, slowly lift the other knee upwards, holding for a few seconds each time.

3. One-Leg Stand-Front
Using a wall for support, bend your leg behind you as shown (holding for a few moment each time).

4. One-Leg Stand-Back
Placing one leg on a chair as shown, bend your supporting knee to stretch the hamstring out.

5. Knee To Chest
Lying on your back, bend one leg and gently hug it to your chest for a few moments.

YOUR BACK PAIN MANAGEMENT

It is important that you work with your doctor to formulate a pain management plan that is tailored to suit your individual needs.

Pain management plan should aim to:
- relieve your pain symptoms
- help you to recover from acute attacks of pain within 6 weeks
- minimise theamount of time you spend off work
- allow you to resume your normal level of activity
- prevent episodes of acute low-back pain from recurring and becoming chronic problems
- effectively manage back pain if it does become chronic

Over the course of your back pain management, you may come into contact with a number of different healthcare professionals. Quite often, people with chronic pain are seen by a combination of doctors, nurses, physiotherapists, pharmacists, psychologists and occupational therapists, who offer their expertise and help them to deal with their pain.

As well as receiving treatment on a one-to-one basis, some people with chronic pain may be able to attend specialist pain clinics for treatment and advice on living a fuller life inspite of their pain. Some healthcare teams may bring together groups of patients with similar pain problems and look at how best to tackle them. Pain servives may vary from hospital to hospital.

WILL I BE REFERRED?
For vast majority of people with back pain, a referral to a specialist is not necessary. However, for some people, referral may help to confirm, establish or exclude a diagnosis. Raarely, it may be appropriate for a specialist to arrange or undertake a surgical treatment procedure.

Referral may be appropriate if:
- nerve root pain has not resolved after 4 weeks
- sciatica has not resolved after 6 weeks
- there are other symptoms such as bowel and bladder problems
- feelings of weakness or numbness are getting worse
- your GP suspects you may have an inflammed spine
- you have not got back to normal within 3 months

LIFESTYLE CHANGES
After 12 months, 9 out 10 people who stayed active during their pain were back at work. Only 5 out 10 people who did not stay active had resumed work by this time.

Before, or indeed as well as, using drug treatment to alleviate pain, there are a number of lifestyle changes you can make that may improve your back pain. These include:
- staying as active as possible
- losing weight
- learning how to bend and lift objects properly
- improving your posture
-avoiding bed rest

The number one misconception surrounding back pain is that putting your feet up or staying in bed will help you to get better. In fact the reverse is probably true - bed rest may slow down your recovery. Medical evidence has shown that staying in bed for 2 to 7 days is worse than a palcebo (is an inactive substance which may look like a medicine but has no medicinal value) or ordinary activity.

If you are able to, staying active is one of the best things you can do to relieve back pain. This is because it maintains your muscle strength, fitness and flexibility and speeds up your rehabilitation, helping you to resume your normal way of living more quickly. You should consult your doctor before taking up any new form of exercise and always remember to warm up properly before exercising.

WHY IS BED REST BAD FOR YOUR BACK?
- It stiffens your joints.
- It weakens your muscles.
- It can weaken your bones over long periods.






TOP TIPS FOR A 'BACK-FRIENDLY' BED

- Choose a mattress that is supportive enough to
take the weight of your body without sagging.
- Turn your mattress regularly (every 6 to 12
weeks).
- Choose a mattress that is comfortable to lie on
with sufficient 'give' to cushion your bony bits.
- Buy a mattress with a strong base. Always try
out the mattress and base together in the shop
before buying.
- Consider a water bed- they support the body
without distorting the spine, and are popular
with some people.







Sports that can help to relieve back pain:




- gentle exercises
- walking
- cycling
- swimming (very good because it strengthens
muscles whilst supporting the body with
water).
















Sports which are not very good for back pain:
- jogging
- football
- golf
- ballet/gymnastics
- weight lifting

WHAT MAKES BACK PAIN EASY OR DIFFICULT TO MANAGE?

The degree to which your back pain impinges on your way of living depends on a number of factors:
- how severe your back pain is
- how long it persists
- how active a life you lead
- how old you are

Mild cases of back pain may mean a couple of days aways from work, or that you miss a couple of activities that you had planned. If the pain resolves itself quickly then things will soon return to normal. However, if back pain is severe and/or persists over a long period of time then it may stop you from carrying out your day-to-day activities, lower your self-confidence, disrupt your sleep and in some cases, cause depression.

For the majority of people (90%), back pain will resolve, largely by itself, within 6weeks or so. Most people (60-70%) end up taking less than a week off work as a result of back pain and 90% of these people are back at work within 2 months. It is when back pain lasts for longer than 3 months that recovery becomes more difficult. In the most extreme cases, some people with chronic pain never return to work.

Considering the potentially devastating impact that back pain can have on our lives, it is vital that we are able to recognise and manage it effectively. However, it is important to remember that back pain management means different things to different people. For most of us, mild pain relief and simple changes to our lifestyles are sufficient to make sure that we are able to cope with our pain and to ensure that it does not return.

WHEN SHOULD I SEEK MEDICAL HELP?
Many people will be able to manage their back pain without requiring medical advice. Although most back pain usually gets better on its own, within a few days or possibly a few weeks, it is important that you do not suffer in silence. If you become worried about your back pain or it does not seem to be getting any better, then you should make an appointment to see your GP.

In particular, you should consult your GP if your pain lasts longer than a week or is as a result a fall or a blow to the back (eg. a car accident or sport injury). You should also consult your doctor if your back pain is accompanied by any of the following symptoms:

- high temperature
- redness or swelling on the back
- pain down the legs and below the knees
- numbness or weakness in one or both legs
- loss of bladder or bowel control

DIAGNOSING THE CAUSE OF YOUR BACK PAIN
Whilst pain itself does not need to be diagnosed by the doctor, the underlying reasons why we experience back pain may be more difficult to pinpoint.

Pain is very difficult to put into words. In the vast majority of cases, your doctor will try to work out what is wrong with you by asking you to describe what your back pain feels like. It may help you to think about how you would answer the following questions before you visit your doctor.

- Where is your pain?
- Does it stay in the same place?
- What sort pain is it?
- How long does it last for?
- When did your back pain start?
- What were you doing when it started?
- Have you had any back problems in the past?
- Do you have any other symptoms elsewhere in your body?
- Does your back pain restrict your movement?

To understand how severe pain is, doctors sometimes use a scale of zero (none) to ten (severe) or may ask you to classify the pain as mild, moderate, severe or excruciating. It may

also help to use a visual analogue scale to try to verbalise how bad your pain is. These scales are usually with word anchors at each end, such as 'no pain' and 'severe pain'. By marking on the line where you think your pain lies, you are giving your doctor a better idea of its intensity.

For children, drawings of faces in a series - from smiling (none) to frowning and crying (severe) - can be used to determine the severity of pain.

Your doctor may also examine you, and will also refer back to your medical history to work out if there are any other health conditions that might be contributing to your pain. They may also:

• perform a pinprick test to check that your sense of touch is working properly
• test the strength of your muscles by asking you to push against their hands
• test the reflexes in your knees and ankles by gently tapping just below your kneecaps and above yor heels with a special hammer
• perform the 'straight leg test' in which you lie on your back and raise your leg without bending your knee

'RED FLAGS'
There are a number of signs and symptoms that will alert your doctor to a specific cause of pain, so-called 'red flags'. These include:
- your age (if you are younger than 20 or older than 55)
- whether you have sustained a serious injury (eg. road accident)
- pain that is getting worse
- pain in the upper part of your spine
- you have, or have had, cancer
- you are taking steroids
- you have HIV
- you are a recreational drug user
- you have lost a lot of weight
- you are experiencing numbness or significant weakness

Rarely, your GP may be unable to find the cause of the pain and may refer you for further tests (including X-rays, computed tomography(CT) and magnetic resonance imaging (MRI)scans). These tests are not usually painful themselves, and won't take very long to carry out. They will usually take place in a hospital or a specialist pain clinic.

CT and MRI scans
CT and MRI scans are relatively quick and easy ways of obtaining detailed imges of the inside of the body, without needing to perform surgery.

During a CT scan, X-rays are passed through the body at various angles. As they leave the body, the X-rays are detected by a scanner which uses the information to produce a two-dimensional image of the internal structures of the back. CT scanners are increasingly being replaced by MRI scanners, which use radiowaves (which are safer than X-rays) and high-powered magnetic fields to create two-or-three dimensional images. MRI scanners can distinguish between bone and soft tissue and therefore provide a more detailed picture of the inside of the body.

Myelography and discography
Patients undergoing myelography have a coloured dye injected into their spinal canal and are then tipped up and down on an X-ray table whilst radiograhic images are taken. Although these days myelography is not so risky, in the past, some patients experienced arachnoiditis-painful inflammation of the spinal cord after they were injected with the dye.

In discography the dye is injected into the disc that separates one vertebra from the next. This outlines the damaged area of the disc and can help to pinpoint the cause of the pain.

DIAGNOSTIC TESTS USED TO DETERMINE THE CAUSES BACK PAIN
X-ray
Advantages
- can usually rule out any serious diseases.
- shows wear and tear of the spine and broken bones.
- quick and painless.

Disadvantages
- will not show up nerve problems.
- cannot be used alone to determine the cause of pain.
- exposure to too many x-rays can be dangerous.

Blood tests
Advantages
- can be used to determine very specific causes of pain (eg. infection,
tumours,arthritic, diseases).

Disadvantages
- only detect very specific causes of pain.
- resuts must be confirmed by other tests.

CT scan
Advantages
- quick and painless.
- can be used to rule out serious diseases.

Disadvantages
- increasingly replaced by MRI scan
- exposure to too many x-rays can be dangerous

MRI scan
Advantages
- the most advanced type of scan
- quick and painless.
- gives high quality images of bone and surrounding tissues.
- can be used to rule out serious diseases.
- radiowaves are 'safer' than x-rays.

Disadvantagaes
- waiting lists can be long.

Myelography
Advantages
- can pinpoint exact causes of back pain.

Disadvantages
- injection of dye can be uncomfortable.
- more complicated than CT and MRI scans.
- exposure to too many x-rays can be dangerous.
- arachnoiditis (painful inflammation of the spinal cord) is a rare side-effect.

Discography
Advantages
- can pinpoint exact causes of back pain.

Disadvantages
- injection of dye can be uncomfortable.
- more complicated than CT and MRI scans.
- exposure to too many x-rays can be dangerous.

Even after performing these tests,it may still be unclear why you are in pain. This does not mean that nothing can be done to ease the pain and make it easier to live with. Your doctor- in consultation with you will be able to put together a personal pain management plan to help you to control your pain.

SIMPLE SCIENCE

Pain transmission (or nociception)is the series of events that takes place in our bodies which allows us to feel and react to pain. It is a very complex process.

WHEN PAIN HELPS US OUT

• We are exposed to something that is painful (a painful stimulus). For example, we walk barefoot onto a hot sandy beach.
• Specialised structures on the soles of our feet called pain receptors detect painful stimulus.
• The pain receptors send messages to the brain via the spinal cord (time frame - fraction of a second).
• The brain receives the pain message and interprets it (time frame - fraction of a second).
• The brain co-ordinates a response to the pain (eg. get off the beach, run into the sea, put shoes on).

Pain receptors are locted throughout our bodies. Different types of pain receptor detect different types of stimuli (like temperature, pressure andd chemicals).

WHEN PAIN 'GETS ON OUR NERVES'
Pain becomes a problem to us when it affects the way in which we live our lives (i.e becomes chronic). For example, if we injure our backs or are suffering from a disease like arthritis, we can experience pain that is persistent. But when does pain become 'a pain'? When our pain machinery becomes sensitised and is activated when it shouldn't be. Pain can be triggered by the irritation of nerve endings (one cause of which is inflammation) or by damage to the nerves.

Pain is generally divided into three types:

• Acute nociceptive pain usually originates from the site of injury.
• Inflammatory pain involves the activation of the immune system.
• Neuropathic pain is usually caused by damage to the peripheral or central nervous systems.

Type of pain
Acute nociceptive - injury to muscle, soft tissue, bones, joints or skin. It feels as sharp, stabbing, aching, throbbing. Can be excruciating but is not usually long lasting. Examples: twisted ankle, bee sting , childbirth.

Inflammatory - generation of inflammatory mediators following a painful stimulus. It feels as burning, dull ache. Can be excruciating, can come and go, or be virtually permanent. Example: rheumatoid arthritis.

Neuropathic - damage to nerve tissue. It feels as aching, tingling, numbness. Can be excruciating, can come and go, or be virtually permanent. Example: trapped or compressed nerve, nerve damage caused by diabetes.

HOW DO PAINKILLERS WORK
All painkiller work by interfering with the pain-transmission process. Although there are many different types, painkillers - or analgesics usually relieve pain in one of two ways:
- by predominantly reducing inflammation or
- by predominantly affecting the central nervous system.
The central nervous system is made up of the brain and the spinal cord.

PAINKILLERS THAT ACT BY REDUCING INFLAMMATION
Inflammation is the body's way of responding to injury, infection or invasion by foreign bodies. Inflammation is controlled by inflammatory mediators, substances that are made by the body and which may make inflammation worse by sensitising pain receptors.

Drugs like aspirin and ibuprofen are called non-steroidal anti-inflammatory drugs NSAIDs). As their name suggests, they work by preventing or limiting inflammation- specifically by blocking the manufacture of prostaglandins. Although prostaglandins do not cause pain themselves, they sensitise nociceptive nerve endings to other inflammatory mediators (like bradykinin and histamine) and thereby amplify the basic pain message.

PAINKILLERS THAT ACT ON THE CENTRAL NERVOUS SYSTEM
The opioids (eg. morphine and codeine) are the major group of analgesic drugs that work in the brain and spinal cord. These are substances that are derived from the opium poppy and their effects closely resemble those of the endorphins - home made pain-killing chemicals produced by the body itself.

The effects of the opioids are dediated by opioid receptors, pain-sensing structures which are located both inside and outside the central nervous system. When a drug like morphines acts on an opioid receptor, it blocks the firing of the nerve cell it is attached to, thereby blocking the basic pain message and preventing it from reaching the brain.

Unfortunately, it is very easy to develop tolerance to the pain-relieving effects of opioids. This means that after using these drugs for a prolonged period of time, you will require a larger amount of opioid to give you the same amount of pain relief. Put simply, opioids dampen down pain transmission.

ERGONOMICALLY SPEAKING

In recent years, we have seen an upsurge in the popularity of specially adapted, 'ergonomic' furniture and equipment, particularly in the workplace. 'Ergonomic' means 'designed for ease of use'. Common examples of ergonomically designed equipment include:

• chairs designed to prevent the user from sitting in positions that may have a detrimental effect on the spine
• desks with adjustable keyboard trays
• desktops of adjustable heights

But have the ergonomic improvements we have made to our working conditions made any difference to the incidence of back pain? Although the overall incidence of back pain is increasing for the reasons describe previously, there is some evidence to suggest that changes made in the workplace have reduced many serious occupational health risks, including back pain.

TEN WAYS TO MAKE YOUR OFFICE MORE ERGONOMICALLY FRIENDLY

• Make sure you're not stretching for your keyboard and your neck is not bend.
• Use foot rests and wrist rests if you need to.
• Keep your feet at right angles to your lower legs.
• Get your eyes checked regularly so that you are not leaning forward to read your computer screen.
• Make sure your chair is comfortable and can be adjusted.
• If possible choose a desk that can be adusted to the right height for you.
• Keep your mouse next to and on the same level as your keyboard.
• Position your keyboard in front of the direction you look to the monitor, not off to the side.
• Use a telephone headset if you are on the phone constantly.
• Try not to sit in the same position all day long.

Accidents that take place at work also account for a substantial proportion of back complaints. 35% of all reported accidents in the UK are due to slips, trips and falls. If you have an accident at work, it is important that you report it using the appropriate channels. Not registering and acting on symptoms quickly enough can sometimes make you feel worse. Your employer or your safety representative will be able to advise you of the accident reporting procedure where you work. It is your employer's legal responsibility to carry out risk assessments in order to identify possible hazards associated with certain jobs.

In some cases, using lifting and handling aids can remove or reduce the risk of back injuries. They should accomodate your needs and you should not suffer discrimination as a result of your back problems. You may even be eligible for compensation if you have had an accident at works.

EXERCISE FOR OFFICE WORKERS

Alternately, turn head 90 degree to the right and the left, holding for a few moments in each position.

Slowly raise heels upwards and downwards, holding for a few moments each time.






Cross arms. Exerting a downward pressure with the arm on top, raise the lower and hold for a few moments.

BACK PAIN AND THE WORKPLACE

Back pain is particularly common in adults who are of a working age. It has been estimated millions of working days were lost as a result of musculoskeletal disorders. The majority of these were back pain that was caused or made worse by work. On average, each person with back pain was absent from work for an estimated 18.9 days during this 12-month period. About 13% of unemployed people cite back pain as the reason they are without a job.

WHICH JOBS ARE MOST OFTEN ASSOCIATED WITH BACK PAIN
Back pain can arise in many work situations, but certain occupations carry a greater then others. These include:

• heavy manual labouring
• heavy equipment operating
• nursing
• delivery work
• manual packing of goods
• office work involving sitting at a computer station

SITTING CORRECTLY (AS IN THE SECOND DIAGRAM) CAN HELP TO PREVENT BACK PAIN

In general, jobs that involve heavy lifting, handling bulky loads in awkward places, handling vibrating equipment like pneumatic drills or driving long distances over rough ground, can all make back pain worse. Office jobs can also aggravate back pain. Spending all day sitting at a badly adjusted workstation performing a repetitive task like typing or answering the phone, can make the problem worse. A number of exercises can be performed whilst you sit at your desk, which can minimise the chances of suffering from back pain.

WORK-RELATED TASKS THAT CAN AGGRAVATE BACK PAIN
Back aggravator & Workers at high risk

• Lifting heavy objects - Factory workers
• Lifting awkward - Removal men, nurses
• Repetitive actions - Typists, telephonists
• Stretching, twisting, reaching - Mechanics
• Cold temperatures - Fishermen
• Vibration - Driller
• Sitting uncomfortably - Train or bus drivers, supermarket cashiers

DISEASES THAT CAN CAUSE BACK PAIN

Although they are much less common than the mechanical causes of back pain, certain diseases can contribute to back pain and are likely to need long-term treatment.

Arthritis
Arthritis is a disease that causes pain in the joints that is usually accompanied by swelling and sometimes changes in their structure. Although arthritis usually affects the knees, ankles and wrists, it can also affect the spine and hip joints, causing chronic back pain. One-quarter of all people over the age of 60 have significant pain and disability from arthritis.
There are two major types of arthritis:

• osteoarthritis - caused by wear and tear of the joints
• rheumatoid arthritis - caused by inflammation in the joints. It comes about when the immune system, the system in the body responsible for fighting diseases and infections behaves abnormally and starts attacking itself with antibodies.

Ankylosing Spondylitis
An extremely rare disease, (affecting about one person in every 1,000) the cause of which is largely unknown. Spondylitis means inflammation of the spine and ankylosing means fusing. The disease is characterised by low-back pain that may spread to the buttocks or thighs but never below the knee. It mainly affects people under the age of 30 and is more common in men than in women.

Fibromyalgia
A muscle disease that can cause pain all over the body, but mostly affects the neck, spine, shoulders and hips. It can occur as a result of stress, muscle injury or muscle overuse. Fibromyalgia is more common than ankylosing spondylitis and affects between 4 and 20% of people in UK. People with fibromyalgia often have trouble sleeping.

Osteoporosis
Although osteoporosis itself does not cause back pain,its long-term consequences can result in significant pain. Vertebral osteoprorotic collapse, in which a vertebra breaks down because of underlying osteroporosis,is an example of this.

Osteoporosis is a condition that affects bones and makes them more likely to fracture or break. Our bones are made of thick outer shell and a strong inner mesh filled with collagen,calcium and other minerals.

Osteoporosis occurs when the holes in the mesh become bigger, making it more fragile and liable to break easily. Osteoporotic fractures occur most often in the hip, wrist and spine. Spinal fractures are also called vertebral fractures.

Women who have gone through the menopause are particularly susceptible to osteoporosis because they have lower levels of the bormone, oestrogen, which normally slows down the deterioration of bone.

Vertebral fractures can cause back pain, immobility and muscle spasm, to the extent that turning over, sitting up and getting dressedm for example, can become extremely difficult. Interestingly, however, many people with vertebral fractures do not complain of pain and may be unaware that they have a fracture in the first place.

FIVE WAYS TO AVOID OSTEOPOROSIS

• Eat food rich in calcium (eg. milk, fish, vegetables)
• Eat food rich in Vitamin D (eg. oily fish)
• Do regular weight-bearing exercise
• Stop smoking
• Don't drink too much alcohol

FIVE WAYS TO AVOID FRACTURES IF YOU HAVE OSTEOPOROSIS

• Take osteoporosis treatments as prescribed by your doctor
• Fit anti-slip mats around your home, especially in the bathroom and kitchen
• Take care when walking on icy or slippery surfaces
• Wear sensible (low-heeled) shoes
• Make sure your home is well lit

MECHANICAL CAUSES OF BACK PAIN

Mechanical problems are by far the most common cause of back pain. There are many possible causes of back pain. There are many possible reasons why mechanical pain - in which specific part of the spine, like a disc, a ligament or or a joint, does not work correctly - can occur. As well as strains, knocks and other accidental injuries, a number of diseases can contribute to, or worse, the mechanical causes of back pain (mentioned in the next post). Remember, underlying disease is not the most common cause of back pain. Some of the mechanics of back pain are discussed below.

Growing Older
Sometimes, back pain is a natural consequence of the ageing process. As we get older the discs that separate the vertebrae lose their flexibility and shock-absorbing properties and are damaged more easily.

Herniated Discs
This is the process by which one of the discs ruptures and its inner core bulges out through the outer layer of ligaments that surround it. This is painful enough in itself, but if the bulge presses on a spinal nerves the pain may spread to the part of the body that is served by the nerve. Herniated discs are most common in the lower back and most often affect people between the ages of 25 and 45. Only about 1 in 25 people who have pain in their lower back that is caused by a physical problem have a herniated disc.

Facet Joint Problems
Like the discs, the facet joints that connect the vertebrae together can wear down or degenerate, and the two halves of the joint can grate against each other, causing back pain.

Spinal Stenosis
Spinal stenosis describes the abnormal narrowing of the spinal canal which then exerts pressure on the spinal cord. Spinal stenosis is usually associated with feelings of weakness or tingling sensations. Another type of stenosis is that of the nerve root canal. This can be linked to the narrowing of the foramina, the space between two vertebrae through which the nerve root passes.

WHY ME?

If you or someone you know suffers, or has suffered from back pain, you are by no means alone. Back pain is very common. Almost half of all adults suffer from back pain that lasts for at least a day each year.

HOW COMMON IS IT?
Back pain is the second common medical complaint, after the common cold. Back pain is so common that it is highly likely that the majority of us will suffer from it at some point. It been estimated that 60-80% of people are affected by back pain at some time in their lives. Back pain is one of the main reasons for absence from work, and each year millions of working days are lost due to back pain.

Low-back pain is the most common cause of limitation of activity in the young and middle-aged and is one of the most common reasons for seeking a medical consultation Every year about 5 million people see their GP because of back pain.

CHANGING TRENDS IN BACK PAIN
Back pain is becoming a bigger problem than it once was. But why is this? Many possible explanations have been proposed.

• We are more aware of our health and well-being than we used to be. If we have a problem we are more likely to seek medical help than suffers in silence.
• We expect more from our health services. When we go to see the doctor with back pain, we expect them to be able to do something about it.
• We work longer hours than we used to and are under more stress in our everyday lives.
• Changes to our diet and the popularity of convenience foods (coupled with our reluctance to exercise) means we are more overweight than we used to be.
• We lead increasingly sedentary (or inactive ) lifestyles. We drive for longer periods, take less exercise and spend hours sitting in front of the television or computer.

WHO GETS BACK PAIN?
Whilst we are all at risk of experiencing back pain, some people are more susceptible than others. Back pain becomes more common as we grow older and is most common between the ages of 35 and 55. Even so, children increase their risk of developing back pain by spending too much time hunched over a computer, or by lugging heavy school bags to and from school. Some 30% of children carry school bags that weigh over 10% of their own body weight.

Whether or not (and how frequently) you experience back pain depends on:

• how active you are (your mobility)
• mechanical causes
• underlying diseases
• your job
  

BACK PAIN AND IMMOBILITY
There are many reasons why we are less active than we used to be. Cars, television and computers may make our lives easier, but they are also causing us many health problems. By becoming less active (as well as eating more 'junk' food) we are becoming heavier and in some cases obese and our muscles and bones are becoming weaker. These are all risk factors for developing a back complaint.

Adult obesity rates have almost quadrupled in the last 25 years.

CALCULATE YOUR OWN BODY MASS INDEX (BMI)
It's very simple to work out your own BMI, to see whether your weight has put uyou at risk of back pain. Grab a tape measure, bathroom scales and a calculator. Follow these two steps.

• Measure your height in metres. Multiply this number by itself and write down the answer.
• Measure your weight in kilograms. Divide it by the number you wrote down in the first step. The number you get is your BMI.

For example: if your height is 1.80 metres, when you multiply this by itself you get 3.24. If your weight is 80 kilograms, divide 80 by 3.24 to give 24.7

As a general rule, for adults aged over 20:
- less than 18.5 underweight
- 18.5 ideal weight
- 25 overweight
- 30 obese
- 40 very obese

Remember though that your BMI is only a broad indicator - it is affected by your body style - people with a very muscular build will have a higher BMI but may not be unhealthily fat. Your age and gender also affect your BMI. Some experts say that men can have a slightly higher BMI before they are at risk, probably due to the fact that they are usually more muscular than women. However, it is best to stick to the guidelines above - they are internationally accepted boundaries for both genders. The BMI scale does not apply to children though, or during pregnancy.

BACK PAIN AND DRIVING
People who drive over 25,000 miles a year take about 22 days off work every year with back pain, compared with 3 days for low-mileage drivers.

Our fondness for driving goes hand-in-hand with our tendency to shy away from exercise . Often, we will hop in the car, rather than walk down to the shops or to school or work. Whilst this may save us time, in the long term it may also increase our chances of developing back problems and other health problems. It is well known that people who lead active lifestyles are less likely to die early, or to experience major illnesses such as heart disease, diabetes and colon cancer.

Unfortunately for some people, spending long periods of time sitting in a car is unavoidable (eg. taxi drivers, bus drivers, sales people). The constant vibration of the wheels on the road , hunching over or gripping the steering wheel, sitting in the same position and stretching to depress the clutch or see out of the mirror, all take their toll on your back. It's not just the driver who can stiffen up in a car either - passengers care often seated for long periods of time in a fixed position.

If you do spend a lot of time in your car there a number of things you can try to make yourself more comfortable:

• bring your seat forward so that you can depress the clutch without having to stretch
• adjust your mirrors properly
• take regular breaks, ideally once an hour
• try to avoid twisting when getting into or out of the car
• keep a small cushion in the car to support your lower back
• choose a car that is suited to your needs

CHOOSING THE RIGHT CAR
The Praying Test - Place both hands together, pointing forwards. You should be pointing straight at the centre of the steering wheel.

The First Test - Make a fist with your left hand, keeping the thumb to the side of the index finger. If you have sufficient headroom then it should be possible to insert the first on the crown of the head.

The Look Down Test - Place both hands evenly on the steering wheel and look down at your legs. You should be able to see equal amounts of both legs between the arms.

The Right Leg Test - After driving the car for a short while, look down and examine the position of your right leg. Your right foot should still be roughly in line with your right thigh.

The Kerb Height Test - Swing your right leg out of the car as though you are getting out, and place your right foot on the ground. The surface of your right thigh should be slopping downwards (not upwards) towards your right knee.

THESE TESTS SHOULD ONLY BE PERFORMED WHEN THE CAR IS STATIONARY AND CAREFULLY PARKED.

BACK PAIN - THE BASICS

Back pain is not a disease in itself. It is a collection of symptoms that signifies something is wrong. If managed properly, back pain can resolve within a matter of days or weeks.

WHAT IS PAIN?
We all know what pain means to us but it is often a very difficult thing to describe. Pain can be defined as an unpleasant sensation that occurs when we experience trauma or damage to our bodies. Pain may be aching, burning, throbbing, shooting, tingling or stabbing.

WHEN DOES PAIN BECOME A PROBLEM?
Pain becomes a proble to us when it affects the way in which we live our lives. This is usually because it lasts a long time, or becomes chronic.

DIFFERENT TYPES OF PAIN
There are three major types of pain - acute, nociceptive, inflammatory and neuropathic.

• Bee stings and twisted ankles are examples of nociceptive pain. This is pain that occurs following damage to the bones, joints, skin or soft tissue of the body.
• Pain in the joints caused by rheumatoid arthritis is an example of inflammatory pain
  
  

• Headaches and trapped nerves can be neuropathic in their origin. Neuropathic pain usually follows damage to nerve tisues.

Pain is also described in terms of how long it lasts. Acute, or short-lasting, pain is pain that lasts for less than 8 weeks and chronic, or long-lasting, pain generally lasts for more than 2 months. This is true no matter where the pain is, or what's causing the pain.

Acute pain is important because it warns us of the potential for or extent of an injury, allowing us to adapt our behaviour accordingly. In contrast, chronic pain does not serve a protective, or adaptive purpose. Instead, it disrupts our sleep and our normal way of living.

WHAT IS BACK PAIN?
Most back pain is simple back pain (or backache), pain that is linked to the way in which the bones, ligaments and muscles of the back work together. This is usually pain that:

• occurs as a result of lifting, bending or straining
• comes and goes
• most often affects the lower back
• does not usually signify any permanent damage.

Some back pain is linked to nerve root pain. This is much less common than simple back pain and accounts for about 5% of back pain cases. Nerve root pain is usually caused by compression of the start of a nerve as it leaves the spinal cord. Herniated discs (commonly, but incorrectly, called 'slipped discs') are one cause of nerve root pain.

Sciatica in which the sciatic nerve that runs down the legs becomes irritated- is a relatively common example of nerve root pain.

SYMPTOMS OF BACK PAIN
Pain itself is a very subjective feeling and its perceived severity is highly influenced by personal opinion and the circumstances under which it occurs. The symptoms of back pain can vary hugely from one person to the next. They include:

• aching
• stiffness
• numbness
• weakness
• tingling (pins and needles)
  

Coughing or sneezing can often make back pain much worse by causing the muscles of the back to go into painful spasm. The pain may start in your back but may travel elsewhere. It often goes into the buttocks, but may go further down the leg and even into the foot. If pain gets really bad, or lasts for a long time, you may experience:

• difficulty passing urine
• difficulty sleeping
• sexual problems

WHAT CAUSES BACK PAIN?
There are a whole host of reasons why you might experience back pain. Your pain might be a consequence back pain. Your pain migh be a conseguence of everyday life (such as bad posture whilst driving or sitting at your desk) or, less often, it might be as a result of some underlying disease. The majority of cases of back pain are linked to simple mechanical problems, less than 5% signify nerve root pain and less than 2% reflect serious spinal pathology.

Back pain can be felt as a result of (most likely first):

• sprains ( an injury to the ligament of a joint)
• injury (eg. a car or sport accident)
• muscle damage (eg. from over-exercising)
• fractures caused by underlying bone disease (eg. osteoporosis)
• underlying inflammatory disease (eg. rheumatoid arthritis)
• degenerative diseases (eg. fibromyalgia)
• cancer (eg. prostate and pancreatic cancer)
• infections (eg. bladder infections and spinal infections like tuberculosis)

Simple back pain can be worsened, or triggered, by a number of factors including:

• poor posture
• a lack of exercise
• standing or bending down for long periods
• sitting on an unsuitable mattress
• driving for long periods without a break
• being overweight
• being pregnant
• lifting, carrying, pushing or pulling loads that are too heavy

THE WRONG WAY TO LIFT

WHEN SHOULD I SEE A DOCTOR ABOUT MY BACK PAIN?
Most simple back pain gets better on its own after only a few days. Simple painkiller may keep the pain under control (provided they are used as directed on the dosing instructions).

However, you should consult your GP if your pain lasts longer than a week or is as a result of a fall or a blow to the back (eg. a car accident or sport injury).

You should also consult your doctor if your back pain is accompanied by any of the following symptoms:

• a high temperature
• redness or swelling
• pain down the legs and below the knees
• numbness aor weakness in one or both legs
• loss of bladder or bowel control (can indicate pressure on the spinal cord)

DIAGNOSING BACK PAIN
In majority cases, your doctor will be able to work out what is wrong by examining you and asking you to descsribe what you back pain feels like. However, one of the biggest problems with pain is that sometimes we do not have the words to describe it. Rating pain on a scale of 1 to 10 may help you to describle it more easily.

If your pain lasts longer than it should , or if your doctor suspects that there may be other reasons for your pain, you may be referred for further tests and a specialist.

X-rays

• Shows wear and tear of the spine and broken bones

Blood Tests

• Can help to identify very specific causes of pain (eg. infection, tumours, arthritic diseases)

CT and MRI scans

• Provide detailed pictures of bone and surrounding tissues. Can be used to rule out serious diseases.

Even after performing these tests, it may still be unclear why you are in pain. This does not mean that your pain is not genuine or would not be taken seriously, or that nothing can be done to make it easier to live with. Our understanding of pain ( and the methods used to bring it under control) has improved dramatically in recent years.

MANAGING BACK PAIN
Managing back pain does not just mean taking painkillers or undergoing back surgery. There are many other ways in which you can bring your back pain under control and prevent it from recurring.

Adopting simple changes to your lifestyle can bring about immediate improvements in your back pain. These include:

• staying as active as possible
• losing weight (if you are overweight)
• learning how to bend and lift objects properly
• improving your posture (or adjusting your seating position in the car, at work, at the dinner table, in front of the TV, or your sleeping position)

Contrary to popular opinion, bed rest is not recommended for back pain. It is far better that you try to stay as active as possible. Your doctor will be able to advise you which types of exercise are most suitable.

ANALGESIA
Painkillers - or analgesics are drugs that work by interfering with the pain transmission process. Although the stronger analgesivcs are only available by prescription from your doctor, many painkillers that you can obtain over-the-counter from your pharmacist for advice and never exceed the stated dose.

THE DIFFERENT TYPES OF ANALGESIC DRUGS
Drug (Over-the-counter)

• Paracetamol (Calpol, Dispol, Hedex, Panadol)
• Aspirin ( Alka-Seltzer, Anadin, Disprin)
• Ibuprofen (Advil, Cuprofen, Nurofen)
• Compound analgesics:
  - Paracetamol and codeine (Solpadeine Max, Ultramol, Panadol Ultra)
  - Aspirin and codeine (Codis 500)
  -Ibuprofen and codeine (Nurofen Plus,Solpaflex)

Prescription only Medicines

• Aspirin (Caprin)
• Ibuprofen (Arthrofen, Brufen, Ebufac, Motrin)
• Naproxen (Arthroxen,Nycopren, Voltarol)
• Diclofenac sodium (Acoflam, Defenac, Dicloflex, Volraman)
• Compound analgesics:
  - Paracetamol and codeine (Co-codamol, Tylex)
  - Ibuprofen and codeine (Codafen Continus)
  - Aspirin and codeine ( Co-codaprin)

Muscles relaxants:

• Diazepam (Rimapam, Tensium, Valium)
• Baclofen (Baclospas, Lioresal)

Antiepileptic drugs (for neuropathic pain):

• Carbamazepine (Tegretol)
• Gabapentin (Neurontin)
• Pregabalin (Lyrica)

Opioids

• Dihydrocodeine (DF 118 Forte, DHC Continus)
• Buprenorphine (Temgesic, Transtec)
• Diamorphine (heroin)
• Fentanyl (Durogesic, Actiq)
• Morphine (Sevredol, MST Continus, Zomorph)
• Tramadol (Zydol, Zamadol)

Drugs often have more than one name. A generic name, which refers to its active ingredient, and a brand name, which is the registered trade name given to it by the pharmaceutical company. Ibuprofen is a generic name and Nurofen is a brand name.

THE DOS AND DON'TS OF EFFECTIVELY CONTROLLING BACK PAIN

• Don't panic - most spells of back pain will get better
• Don't rest in bed for too long (2-3 days at most)
• Do gradually increase your level of activity
• Do back exercises regularly, perhaps take up a new form of exercise (after checking with your doctor)
• Do contact your doctor if pain persists for more than a week

NON-DRUG TREATMENT
Physiotherapy, osteopathy and chiropractic treaatment are all forms of therapy that involve manipulating parts of the backbone to relieve back pain. Transcutaneous Electrical Nerve Stimulation (TENS) and acupuncture can also offer relief from symptoms. Back surgery is rarely necessary and is usually only undertaken as a last resort.

WHAT DO OUR BACKS DO FOR US?

Our backs are an essential part of who we are. Without them, we would be unable to stand, walk, twist, turn, bend or lift. We use our backs in almost every activity of daily living. Therefore, when we experience pain in our backs, we must take it seriously.

The term 'back' describes the trunk of the body below the neck, right down to the tailbone. The upper back is called the thoracic spine and the lower back is the lumbar spine. The back is made up of bone, muscle and other types of tissue. Thirty-three small bones called vertebrae (shaped like irregular rings) are stacked on top of each other to form the spine which supports the weight of the body and houses and protects the spinal cord. Topped by the skull, the spinal column sits in a large bony bowl called the pelvis. The tailbone or coccyx, is a set of fused vertebrae at the base of the spine and serves no real function.

The vertebrae, which give our back flexibility, are stacked on top of each other and connected by discs at the front and by facet joints at the back. The discs that separate the vertebrae provide cushioning and act as shock absorbers. Facet joints (found only in the lower back) are cup-shaped surfaces that form movable joints with our hips. At each of the vertebrae, nerves branch out to the rest of the body. Tough ligaments help to bind the vertebrae together and strengthen the back.

WHY IS IT IMPORTANT THAT WE FEEL PAIN?

Pain is our body's way of telling us that something is wrong. It works as an alarm system, a signal to tell us to stop doing something that may be harmful to us, and in this way protects from dangerous situations. For this reason, pain should always be taken seriously.

Pain is a subjective feeling and it is influenced by personal opinion. Our ability to withstand pain depends a lot on the mood we are in, our personality and the circumstances under which our pain occurs. In the heat of the moment (eg. during an exciting football match), we may be able to override our feelings of pain to get the job done.

OUR NERVOUS SYSTEM
Nerve cells can transmit nervous impulses at 225 miles per hour. Pain gets on our nerves, quite literally. Our perception of pain is controlled by our nervours system, the part of our bodies that records and distributes information throughout the body. Our nervous system is in two parts, the central nervous system and the peripheral nervous system.

The smallest unit of the nervous system is the nerve cell or neuron. These are highly specialised structures that are able to conduct messages to and from the brain as fast-moving nerve impulses (electrical signals). Nerve cells communicate with each other via their dendrites, spindly extensions that act as antennae and gather information for the nerve cell to deal with. Nerves themselves are made up of bundles of the axons of the nerve cells.

They transmit electrical nerve impulses between the peripheral and central nervous systems. To look at it another way, nerves are the electrical wiring of the body and the brain and spinal cord are the nerve centre - the mission control of pain perception.






The central nervous system is made up of the brain and the spinal cord.








The peripheral nervous ystem comprises the nerves that transmit sensations between the central nervous system and the rest of the body.

BACK PAIN

Getting involved in managing your own medical condition or helping those you love or care for to manage theirs is a vital step towards keeping as healthy as possible. Whilst the healthcare team can help you with epxert advice and guidance,nobody knows your body, your symptoms and what is right for you as well as you do.

There is no long term (chronic) medical condition or illness that I can think of where the person concerned has absolutely no influence at all on their situation. The way you choose to live your life, from the food you eat to the exercise you take, will impact upon your disease, your well-being and how able you are to cope. You are in charge!

Being involved in making choices about your treatment helps you to feel in control of your problems, and makes sure you get the help that you really need. Research shows that when people living with a chronic illness take an active role in looking after themselves, they can bring about significant improvements in their illness and vastly improve the quality of life they enjoy.
Of course, there may be occasions when you feel particularly unwell and it all seems out of control. Yet most of the time there are plenty of things that you can do in order to reduce the negative effects that your condition can have on your life. This way you feel as good as possible and may even be able to alter the course of your condition.

So how do you gain the confidence and skills to take an active part in managing your condition, communicate with health professionals and work through sometimes worrying and emotive issues?

The answer is to become better informed. Reading about your problem, talking to others who have been through similar experiences and hearing what the experts have to say will all help to build up your understanding and help you to take an active role in your own health care.

I hope this post will provide an invaluable source of help,giving you the facts that you need in order to understand the key issues and discuss them with your doctors and other professionals involved in your care. I also hope that you will be able to play an active part in the successful management of your condition.