London - Back pain affects one person in three every year. Bad enough news, you’d think.
But then it was reported that the most common remedy - paracetamol - is ineffective.
A review published in the British Medical Journal analysed 13 clinical trials and found that the drug made little or no difference to back pain. What’s more, people who took it regularly were four times more likely to have abnormal liver-function tests - a warning sign that the liver could be irreversibly damaged.
The BMJ review supports the findings of a study published last year in The Lancet, which found that paracetamol is no better than a placebo for lower-back pain.
But if a drug recommended as the first-line treatment by the National Institute for Health and Care Excellence (NICE) doesn’t work, what does?
The difficulty with treating chronic lower-back pain is that it’s ‘very complex’, explains Dr Beverley Collett, a pain consultant. ‘In the past, we tended to treat it as if everyone is exactly the same.’
Pain relief is a ‘very personal thing’, adds Dr Martin Johnson, a pain expert at the Royal College of GPs.
The good news is that many people can control back pain with regular exercise or by losing weight, says Dr Collett.
Yet a recent survey found that two-thirds of back-pain patients didn’t follow their GP’s advice or do the recommended exercises. Indeed, many may be prolonging the problem by doing the wrong thing - for instance, resting a sore back.
‘While rest can be beneficial for the first 24 to 48 hours after an acute attack, beyond that you’ll be compounding the problem,’ says Bob Chatterjee, a consultant spinal surgeon at BMI The Kings Oak & Cavell Hospitals, London.
‘Too much time in one position will cause muscle fibres to stiffen and shorten, increasing your pain. You need to start moving and doing some gentle exercise, such as walking, as soon as possible.
‘In other parts of the body, pain is a warning to rest but the back is an exception - you may feel discomfort when you exercise, but this is entirely normal and not dangerous.’
Here, we look at what works best for back pain - as well as the daily habits that can help...
POPPING PILLS
So, should you continue taking paracetamol for back pain? Dr Johnson’s view is yes: ‘If it works for you then keep taking it - just ask your GP to carry out regular liver-function tests, which involve taking a small blood sample.’
However, there are other effective over-the-counter options.
Aspirin and ibuprofen: These are types of non-steroidal anti-inflammatory drugs (NSAIDs). Under NICE guidance, they should be used for back pain only if paracetamol fails to work, though this may change following the latest findings.
Muscle and tissue inflammation is a key feature of back pain and these drugs dampen swelling and irritation, reducing pressure on the nerves that transmit pain signals to the brain. However, aspirin is rarely used as it is weaker than ibuprofen.
The problem is that prolonged use of NSAIDs can raise the risk of potentially fatal gastrointestinal bleeding, especially as we age.
Patients over 45 are also advised to take a daily proton pump inhibitor, a drug that protects the gut lining, reducing the bleeding risk.
Recent studies suggest repeated use of some NSAIDs may also raise the risk of heart attacks and strokes. If over-the-counter medicines don’t work, your GP may prescribe stronger drugs.
Codeine: This doesn’t work very well on its own as a pain reliever. It is more effective when combined with paracetamol in a single pill called co-codamol.
Paracetamol helps to block the nerves that transmit the pain impulse to the brain; codeine helps to reduce the brain’s awareness of these pain impulses.
Codeine/paracetamol combinations can be bought over the counter, but higher doses are available only on prescription.
But be warned: codeine is addictive and should not be taken for more than three days at a time, so it is more suitable for sudden back pain than recurring aches.
Another over-the-counter option is Paramol, which contains dihydrocodeine. This is twice as strong as codeine but also addictive.
HEAT PATCHES
Stick-on patches that generate heat can provide temporary pain relief for sore backs. The patches generate heat by a chemical reaction triggered when the patch is exposed to air.
Manufacturers say they provide relief for eight hours or more. But they can lead to burns and are not suitable for children or those with poor circulation, such as people with diabetes, who may not feel it if the patches are causing damage.
A study at Johns Hopkins University in the US in 2006 showed that patients who had heat therapy for three days experienced a 52 per cent reduction in the intensity of their pain. ‘When my back flares up after I’ve been sitting at the computer, I use them and have found them very effective,’ says Dr Johnson. ‘Heat relaxes the muscles, which stops the spasms that cause pain.’
RUB-ON GELS
Gels that contain the same anti-inflammatory drugs found in aspirin and ibuprofen can reduce the risk of the pills’ side-effects by bypassing the stomach.
But because they are applied to the skin, they are less effective for back pain, as less of the drug reaches the spine. However, Dr Collett says there is evidence that gels containing NSAIDs can help.
ANTIBIOTICS
A recent study published in the European Spine Journal suggested that some types of lower-back pain could be treated with antibiotics.
Research by scientists at the University of Southern Denmark found that up to 40 per cent of chronic back pain was linked to a bacterial infection.
A subsequent study found that antibiotics reduced back pain in 80 per cent of patients who had suffered with it for more than six months (crucially, the patients also had signs of damaged vertebrae, as revealed by MRI scans).
It is unlikely that antibiotics will become a frontline weapon against back pain any time soon, though, because of concerns about the rise in superbugs.
OSTEOPATHY
While there is limited research to show that osteopathy works for back pain, NICE says doctors can offer it as a treatment to their patients (a maximum of nine sessions over 12 weeks).
Osteopaths use spinal manipulation, moving and stretching joints around the affected area, and say this helps bones, muscles, ligaments and connective tissue to function smoothly together.
‘Osteopathy definitely has a place in back-pain treatment,’ says Dr Johnson, ‘but we don’t, as yet, have the very large randomised controlled trials to show it works.’
BEING ACTIVE
‘Thirty years ago, my senior GP partner recommended telling patients with back pain to retire to their beds for ten days,’ says Dr Johnson. ‘We now know that the best thing to do is get moving.’
This is because it keeps the muscles working, reducing the risk of painful spasms, and builds up the abdominal muscles, helping to support the back.
It’s important to stay mobile with regular walks, but there are also specific exercises to help. These include lying on your back with knees raised and turning your legs to one side while keeping your back flat on the floor.
ACUPUNCTURE
Numerous studies suggest that acupuncture is better at easing lower-back pain than over-the-counter medicines. But it’s still not clear whether this is down to the placebo effect.
NICE says it can be offered as a treatment of up to ten sessions over a period of up to 12 weeks.
But it may have a bigger role to play, especially in acute cases. ‘When patients go to A&E with such severe back pain they can only walk bent over, 99 per cent of the time it’s due to severe muscle cramping around the damaged area,’ says Dr Johnson.
‘In many cases, if a doctor trained in acupuncture pops in two needles for 20 minutes, they can walk out of the door.’
Daily Mail