(Written on September 17, 2016 for Victorian Pain Specialists)
WHAT’S THE PROBLEM?
The concerning prevalence of back related problems in today’s society may suggest that we really haven’t got a handle on the diagnosis and treatment of back pain.
The Australian Bureau of Statistics, National Health Survey (2011-12) found that three million Australians suffered from back related problems. This problem was similar amongst men and women and is most prevalent in the 65+ age groups. 
The Australian Institute of Health and Welfare (AIWH) disease expenditure (2015) reported a spending of $1.2 billion for back related problems in 2008-9.
WHY IS BACK PAIN AND NECK PAIN A CONCERN FOR GENERAL PRACTITIONERS?
2012-13 data suggested that 2.9 out of every 100 consultations were due to patient complaints of back pain. That’s equivalent to 3.7 million annual GP encounters. Yes, 3,700,000 GP encounters every year are related to spinal pain.
Hospitalisation due to back pain is flooding our health system.
The National Hospital Morbidity Database (2012-13) documented 104,350 hospitalisations with a principle diagnosis of back pain. Low back pain was the highest concern (28.5%), lumbar and disc disorders with radiculopathy presented in 14% of cases, and lumbar spinal stenosis in 8.9%.
WHAT DOES THE BACK PAIN SUFFERER LOOK LIKE?
An acute episode for low back pain puts patients at risk of vulnerabilities for the future. There is a 50% likelihood that a reoccurrence will occur within the year. And with every reoccurrence the outcomes worsen.
My thoughts here are simple: treat the acute presenting back pain well and ensure rehabilitation for the prevention of reoccurrence. We need to do everything we can to maximise the chances of a full recovery.
AIWH (2015) data reported that of the above cases, a patient with back pain is:
2.4 times more likely to report poor general health
2.6 times more likely to report psychological distress
2.5 times more likely to report pain that is severe; and
3.4 times more likely to be struggling with simple activities of daily living.
Pain, or the fear of pain, may mean people stop doing participating in meaningful activities. It important to keep engaged in these things – even though patients may worry they will trigger pain, or they might not be feeling motivated to do them. (If they have stopped doing a favourite activity for some time, they may need to get their body moving again. SLOWLY.) Low impact exercise such as stretching, yoga, walking and swimming can also be beneficial for physical and emotional wellbeing and pleasant experiences produce endorphins which can help people cope with pain.
The sole reason this blog article has eventuated may be one of the reasons why back pain is not getting better…..technology. It’s all around us and it’s not always good for us.
A good ergonomic work setup is paramount to achieving postural endurance. Sit to stand work stations are becoming more and more accepted in the work place, and postural variation is encouraged to have time away from screens and get bodies moving regularly. Kneeling chairs are also growing in acceptance.
2. Smart phones
Smart phones in both personal and professional environments have changed the way people communicate, and the portability of technology often does not support good ergonomic use, especially related to neck related spinal pain.
Although the evidence is limited as to how smart phones can detrimentally affect us, we are learning more every day:
The musculoskeletal disorders related to smartphone use include muscle fatigue and loading of the neck and shoulder muscles, both caused by repeated motions of hands, wrists, and arms. As a result, pain, stiffness, and quivers in the neck, shoulders, and arms may appear. Shoulder-arm-neck syndrome is mainly found in people who do repetitive work for more than six months.  Pain and fatigue worsened with longer smartphone use. This study provided data on the proper duration of smartphone use. They say correct posture and breaks of at least 20 minutes are recommend when using smartphones. 
We are all not moving our bodies enough and bigger people even more so. Obesity statistics in Australia are a serious concern.
Findings indicate that overweight and obesity increase the risk of low back pain. Overweight and obesity have the strongest association with seeking care for low back pain and chronic low back pain. 
A nutritional diet to support busy lives is an important consideration in the management of back pain, especially when long-term activity is limited by persistent pain and an individual’s every day function.
4. An ageing population
This must be considered as one of the main reasons why chronic back and neck related problems are not going away. Our bodies are ageing and when that is combined with low levels of physical activity and other poor lifestyle choices, our bodies will get older before their times.
Arthritis Australia is a wonderful advocate in this space . Some suggestions for general health and arthritis management include:
5. Lifestyle & pacing
Access to immediate information online has contributed to a faster-paced environment for many individuals and families. We have forgotten how to slow down or to stop!
Taking time out to be in the present moment is vital to wellbeing.
Practice mindfulness and prioritising ‘the-self’ will lead to greater awareness of presenting problems and even guide one in how to engage in pacing activities.
Take a few minutes to be mindful, right now! Yes, right now!
Just sit for 2 minutes and become aware of a few of the following things and focus on each of them for 30 seconds. You’re focusing on your senses: What are you thinking? What are you feeing? What can you hear? You are now being present and mindful.
Here are 4 short mindfulness practices
Resting your body is vital. Your patients should be spending between 6-8 hours a night resting and regenerating their bodies.
A supportive pillow and mattress should be considered for individuals with back related spinal pain. Consider a contoured pillow made of latex or memory foam. Back sleepers should use a low profile pillow. Side sleepers should use a medium to high profile pillow. Remind your patients to make sure the midline of their chin is in line with suprasternal notch.
HERE ARE 5 WAYS TO STOP THE PROGRESSION OF CHRONIC BACK PAIN AND CHRONIC NECK PAIN IN ITS TRACKS
1. Get patients stronger
Building postural endurance that is functionally specific to the patient’s daily activity demands is a priority. This may be managed under an individual’s physiotherapist or exercise physiologist.
In an ageing population bone density must be considered. Weight bearing exercise that a patient can do and tolerate within their activity demands may provide functional benefits and optimise bone health.
In the obese population, dietary consideration may be required, and a gentle medium such as hydrotherapy may be offered under the guidance and supervision of a physiotherapist.
Regarding the specific exercises; this is dependant on the presentation of pain and the clinical examination and really needs to be specific to patients individual goals. For example:
If patients have stairs at home, then weight bearing exercise that builds tolerance to stairs are a must.
If they have to catch public transport to work, then building standing tolerance, sitting tolerance and walking tolerance should be a point of focus.
If they need to repetitively lift kids, then weight bearing exercise simulating gradual and appropriate lifting load, in good ergonomic posture should be taught.
For axial neck pain (with no radiculopathy), focus on postural variation at work. Gentle stretches of sniffing the underarm, and chin tucks (reverse emu position) are done.
For axial lower back pain (with no radiculopathy), focus on walking, function, stairs and even incline walking. Look at walking with grocery bags. Standing on one leg whilst brushing the teeth. Another trick might be to get patients to sit-to-stand 5 times, every time they go to the loo; this will build up squat tolerance and their ability to get on and off a chair much easier. Another great tip is to get them to stand on tipped toes whilst they are waiting for the kettle to boil.
2. Get patients walking
Suggestions of parking further away from shops and public transport may be a reasonable way to encourage patients to strengthen postural muscles and lower limbs with a view to pace up these distances when ready and appropriate.
3. Get patients moving
Any activity that gets your patients moving can help their flexibility and strength. These activities might include:
Water exercise, such as walking in water, water exercise class or doing physiotherapy exercises in the pool
Yoga, pilates or tai chi
Strength training with supervision, using weights, resistance bands or gym machines.
Don’t forget to remind patients that they should do things that they love or loved doing. If they love swimming, get them in the pool, not on a yoga mat!
4. Individualise therapy
This is the trick to good chronic pain management.
The secondary bio-mechanical changes (adaptations) in chronic pain are vastly different for each and every patient we see. This is based on the demands of their life and how much their chronic pain has influenced their ability to participate in normal everyday activities. So therapy has to be seriously individualised here.
5. Get the environment right
A supportive work environment that allows for postural variation and encourages movement is worth its weight in gold.
A balanced and supportive home life where household chores are shared, and exercise is encouraged should be considered. As patients do more exercise, that should be combined with a reduction in screen-time. These steps will promote an environment conducive to rehabilitation and long-term well being.
6. Use goals to drive recovery
One barrier to participate in new activities and exercise is motivation! Another barrier is fear and lack of confidence in resuming what previously may have been easy for them to do. So motivate your patients, and deal with their fears and lack of confidence.
A good way to do this is make therapy goal-driven. It needs to be fun, and most of all it needs not to be scary.
Sneaking under the pain radar and initially just integrating into an individuals life, through incidental exercise may be the important first step to re-engagement.
Work together with your allied health team and specialists! Focus on an active and pro-active approach.
And finally remember, changing fixed ways and changing culture takes time. Be patient. Keep it simple. Yes! But do the simple things well and address all of the facets of an person’s pain puzzle, which will lead to better health outcomes and the prevention of chronic disease for our patients and and the wider community.
The following link provides the latest evidence-based clinical guidelines for acute musculoskeletal pain. Read it. Digest it. Point your patients to it. NHMRC 2003 - evidence based management of acute musculoskeletal pain.
Australian Institute of Health and Welfare 2015. Musculoskeletal fact sheet: back problems. Arthritis series no. 21. Cat. no. PHE 185. Canberra: AIHW.
Hyo-Jeong Kim,1 DH,1 and Jin-Seop Kim. The relationship between smartphone use and subjective musculoskeletal symptoms and university students. J Phys Ther Sci. 2015 Mar; 27(3): 575–579.
Kim SY1, Koo SJ1. Effect of duration of smartphone use on muscle fatigue and pain caused by forward head posture in adults. J Phys Ther Sci. 2016 Jun;28(6):1669-72.
Shiri R1, Karppinen J, Leino-Arjas P, Solovieva S, Viikari-Juntura E. The association between obesity and low back pain: a meta-analysis. Am J Epidemiol. 2010 Jan 15;171(2):135-54.