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- Herausgeber: Geddes and Grosset
- Kategorie: Ratgeber
- Sprache: Englisch
- Veröffentlichungsjahr: 2015
An effective guide to managing a bad back with straightforward, useful information about the workings of the human back and the things that may go wrong to cause pain. It also provides guidance on the management and alleviation of such pain.
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The aim of this book is to provide straightforward, useful information about the workings of the human back and the things that may go wrong to cause pain. Also, to explore the complete experience of back pain from many different angles, some of which may, at first sight, seem surprising. An example is the usefulness of analysing one’s own personal attitudes, beliefs and possible misconceptions with regard to this condition. Finally, it is hoped that the book will provide guidance on the alleviation and management of back pain, from self-help measures to medical approaches and from complementary therapies to lifestyle factors. A broadbrush approach is particularly appropriate in relation to back pain as it is a problem that has many ramifications, not only for the individual sufferer but also for friends and family, the work place, economy and society as a whole.
However, this guide should not be used as a substitute for obtaining sound medical advice, especially in the event of severe and prolonged pain or if other symptoms are also present. As with all conditions and illnesses, if you are worried about your back pain you should always seek advice and reassurance, either from your own general practitioner (GP) or from a reputable substitute such as the NHS. Call 111 in England and in Scotland for the NHS free-to-call single non-emergency medical helpline. NHS Direct Wales continues to operate via 0845 4647 but it is intended that the 111 service will be offered at some point in 2015.
In over 90% of all cases, the episode is one of acute simple back pain and the person recovers completely within 4–6 weeks. However, even a single event increases the risk of recurrence. In up to 7% of people, the problem persists to become chronic. A diagnosis of chronic back pain is applicable when the pain has been constantly present for 3 months or longer.
In the UK, 40% of people with back pain seek help from their GP and 10% choose to consult a specialist in complementary medicine, particularly an osteopath, chiropractor or acupuncturist. The cost to the National Health Service of the treatment and management of back pain is in excess of one billion pounds each year. Of this total, more than £500 million is spent on hospital-based care, £140 million on GP consultations and £150 million on physiotherapy treatments delivered by the NHS. Additionally, approximately £565 million of private health care costs are devoted to back pain on an annual basis. A considerable proportion of these costs (approximately 80%), relate to the treatment of those with chronic back pain in whom the overall impact is high. These people frequently experience a reduction in their quality of life since chronic back pain often has adverse effects upon employment and leisure activities and on family and social relationships.
The economic impact of back pain is considerable. In the year 2003–4, 1% of the working population was absent from the work place on any one day due to back pain, equivalent to the loss of 5 million working days. Back pain is the most common reason for prolonged sickness leave among manual workers and the second most prevalent among those in other occupations. All in all, it has been estimated that these losses account for 1–2% of GDP in Western countries. Not surprisingly, these factors ensure that back pain features quite highly on the agendas of most national governments.
The type of pain that is most easily understood is termed sudden onset or, more commonly, acute. Acute pain is something that everyone experiences from time to time, whether the cause is relatively minor – perhaps a cut, bump, fall, sting or bite – or something more serious such as a fractured bone. The pain in this case may vary in intensity but it instantly alerts the individual to the fact that something untoward has occurred, usually involving some degree of tissue damage. It serves as a warning to stop and take action, both to nurture the hurt and to avoid the risk of incurring further harm. Acute pain serves a useful purpose, both for the person concerned in the incident and in a wider, evolutionary sense. It hopefully ensures that the individual survives the experience and is able to appreciate its value. Acute pain may have evolved, and persists, as a survival tactic for our species and it works at its best when it acts as a warning to prevent damage from being sustained in our day-to-day encounters with potentially harmful elements in the environment. Examples might include withdrawal of a hand that has strayed too close to a fire or stepping back, when barefoot, if something sharp has been trodden on.
Of course, in many instances of acute pain, tissue damage is sustained as a result of some accidental event. In this case, the sensory receptors in the affected part are stimulated and electrical impulses are sent to the brain where they are evaluated and interpreted as pain and damage. The term nociceptive pain is sometimes used to describe pain associated with tissue injury. In all these situations, the pain usually subsides and eventually disappears as healing takes place and this generally happens over a fairly limited time period.
A more complicated type of pain to consider is termed persistent or, more usually, chronic. A person is said to be suffering from chronic pain when the pain has been present for 12 weeks (3 months) or longer. The most significant difference between these two types is that chronic pain does not act as any form of warning signal. In some cases, especially if a known, ongoing problem is present, such as a condition affecting an organ or a degenerative disorder of the musculo-skeletal system, a cause can be diagnosed and action can be taken to relieve the situation. Chronic pain can have its origin in discernible nerve damage or abnormal nerve function in which case, the cause is termed to be neuropathic. Examples include foot problems in diabetes and ‘phantom limb’ pain, where an amputee continues to feel persistent, painful sensations coming from a limb that has been surgically removed. However, in other cases of chronic pain it is recognized that the cause does not lie with any actual nerve or tissue damage. One theory is that, for reasons remaining not fully understood, the central nervous system becomes sensitized and enters ‘overdrive’ mode so that signals that should be felt as harmless are experienced as pain. This type of chronic pain syndrome is quite often at work in cases of persistent back pain.
In medical and scientific circles, pain is acknowledged to be a highly complex response, the understanding of which remains the subject of considerable research and debate. Pain studies in human subjects continue to reveal that pain is even more complicated than was previously suspected and unravelling it lies at the heart of understanding the workings of the brain itself.
It has long been known that our perception and interpretation of pain is mediated within several areas of the brain, with the cerebral cortex being of critical importance. In the classical view of pain represented by the convergent model, pain is held to be closely related to the sense of touch, with neurons (nerve fibres) located in the deep dorsal horn of the spinal cord (a distinct part, also known as the posterior column where sensory signals are relayed) being particularly involved. These dorsal horn neurons are activated by sensory signals of pressure, temperature, touch and damage from all areas of the body and relay onward signals to the brain. It is believed that the signals converge and messages are sent to a specialized part of the cortex that deals with touch – the somato-sensory cortex. This is believed to form the heart of a widely distributed neuromatrix that is able to distinguish pain from other sensations. The convergent model is able to explain certain types of pain, such as referred pain (pain that has its origin in a deep structure but is felt to be coming from another distant area), allodynia (in which a person feels pain in response to a non-painful stimulus such as a light touch), and hyperalgesia (a greatly increased sensitivity to pain which may be felt in discrete areas or more widely from all over the body), in terms of sensitization and ‘crossed wires’. It is thought that in these cases not only are inappropriate signals being sent but also there is misinterpretation in those areas of the brain responsible for processing them. The convergent model appears to provide answers but also has its shortcomings, one of the most apparent being the inability to adequately explain why human beings experience different pain sensations – pricking, stabbing, burning, gnawing, aching and so on.
Some recent research has provided evidence that painful stimuli may in fact travel along their own special pathways to the brain. The neurons believed to be involved are called lamina 1 neurons and they occur in the superficial layer of the dorsal horn of the spinal cord. It is thought that particular, specialized groups of lamina 1 neurons may be able to distinguish the different types of pain and are activated in response to specific stimuli. Additional scientific evidence may point to the existence of pain centres in the brain, with a region called the parieto-insular cortex or interoceptive cortex being crucially important. The interoceptive cortex has only been found to occur in primates and is especially highly developed in human beings. Another area lying within the frontal cortex, called the anterior cingulate, is activated when pain is being experienced along with other regions that include the cerebellum, amygdala and striatum. Some researchers believe that the anterior cingulate is critically involved in the emotional aspects of pain. Hence, in this alternative homeostatic model of pain, it is proposed that there is a physical component centred on the parieto-insular cortex and an emotional element centred on the anterior cingulate. In this model, it is believed that the perception of pain evolved in primates as an extension of the mechanisms that alert the brain to the internal, physiological state of the body (homeostasis).
Both models offer insights into the workings of the brain in relation to pain but there are many questions that remain. One of the most important is the influence of the mind on the actual experience of pain – that whole complex of interaction between intangible beliefs and emotions and the physical entity that is pain. The umbrella term psychosocial factors deals with the influence of the mind and emotions upon our individual experience of pain and it is wide-ranging, including as it does anxiety, stress, depression, familial and social isolation and the many aspects of life that have a bearing upon these. Psychosocial factors have a considerable bearing on pain and are particularly influential with regard to chronic pain, both in its development and as a barrier to recovery.
One final factor to be considered is the concept of the pain threshold, defined as the degree or extent of stimulation that needs to be applied before pain is felt. A discovery made within the last few years may help to explain the variation seen among people in their ability to withstand pain. The answer may partly lie with a gene that exists in two forms or variants known as val and met. Both are involved in the manufacture of an enzyme called catechol-O-methyltransferase (COMT) that is responsible for breaking down neurotransmitters (chemicals that allow messages to be sent) such as dopamine. However, there are slight differences in the efficacy of the COMT produced, with the val gene generating a more potent version of the enzyme. It is believed that an accumulation of biochemicals, such as dopamine, restricts the brain’s ability to produce its own natural painkillers, the endorphins (endogenous opiods). Individuals inherit one copy of the gene from each parent so some possess two val, others two met and the remainder, one of each. Some studies have suggested that those with two val genes possess a greater ability to remove dopamine and experience less pain than those with two met genes. Critically, those who are ‘two met’ also reported fewer negative emotions connected with pain. People with one copy of each gene showed varying responses lying somewhere between the two extremes. While this may seem to be a matter mainly of scientific interest, it should perhaps have a broader application in challenging attitudes. This is because, all too often, someone complaining of a pain that is not considered by others to be significant or bad enough to merit sympathy is treated with a dismissive or negative response. Such attitudes are sometimes encountered by those suffering from back pain and usually have a negative effect upon the person’s morale and are certainly not helpful.
