Backpain

The National Institute of Clinical Excellence (NICE) offers back pain guidelines for the NHS. These guidelines list the following three approaches, for which there is some evidence from research trials:

1. Structured exercise programmes are generally in a group supervised by a physiotherapist or qualified exercise instructor. Exercises include aerobic movement, strengthening, posture and stretching. A series means eight or so sessions over 8-12 weeks, with homework between sessions
2. Manual therapy – this can involve sessions of deep massage, with or without spinal mobilisation (e.g. osteopathy or chiropractic).
3. Acupuncture – it is not clear how this works, but there is good evidence that it can help improve long-term low back pain.

Supervised exercise programmes are safe for most people. But at first you might feel more tired. If you’re not used to doing much exercise, you should gradually increase your activity until you can manage a moderate level. If you feel worse, cut back and build up more slowly. If you think it isn’t helping or that you’re getting worse in any way, check with your doctor. Anyone with severe osteoporosis, joint problems, acute back pain or recent injuries should avoid strenuous exercise.

Summary
Acupuncture is a traditional form of treatment that began in China thousands of years ago. Thin needles are inserted into the skin at special points on the body, which practitioners believe will help restore health. The treatment sometimes also involves heat, pressure, electrical currents or soft-laser light. In the UK, acupuncture is most commonly used for pain relief.

Evidence
Research shows that acupuncture improves chronic low back pain. However it does not seem to be more effective than some other treatments such as manipulation and massage.

Safety
Acupuncture is generally safe if practised by a trained acupuncturist. The most common side-effects are slight discomfort (common) and bruising (occasionally).

Cost
A session may cost £40-£60. Frequency of treatment will depend on you and your practitioner.

Find out more
The following professional organisations can help you find a qualified practitioner:
Acupuncture Association of Chartered Physiotherapists
British Academy of Western Medical Acupuncture
British Acupuncture Council
British Medical Acupuncture Society

Summary
Many of us store a lot of tension in our back. Alexander Technique teaches you to notice how you move and breathe and how your body reacts in stressful situations. Alexander Technique helps you spot longstanding habits of movement, and change them, so it calls for very active participation and concentrated effort.

Evidence
One study showed that one-to-one lessons in Alexander Technique from a registered teacher can help with back pain long-term.

Safety
There are no safety issues with if you have a qualified teacher.

Cost
One-to-one Alexander lessons may cost between £30-50, and you will usually be asked to attend a series of five or six.

Further information
It is important to find a qualified teacher such as someone registered with
The Society of Teachers of the Alexander Technique.

Summary
Osteopathy is an established hands-on diagnosis and treatment method, whose main emphasis is on the way muscles and joints work. It assumes that pain and disability often stems from physical strains and tensions in the body, rather than from damage caused by disease or injury.

Chiropractic is an approach to treatment based on the idea that illness stems from misalignment of the spinal column.

Osteopaths and chiropractors use their hands to relax the body and stretch the joints of your spine. This can help improve mobility and relieve low back pain.

Evidence
Spinal manipulation from a chiropractor or osteopath seems to help with symptoms and stiffness. It is less helpful for people who have a definite disc problem, so seek advice if you have much pain or tingling down the leg.

Safety
Side effects are rare and mainly linked to manipulation of the neck. Some mild after-effects from treatment can happen (aches) but they usually last less than 48 hours.

Cost
A session may cost £40-£60. Frequency of treatment will depend on you and your practitioner.

Further information
All qualified osteopaths are registered with The General Osteopathic Council
All qualified chiropractors are registered with The General Chiropractic Council

Summary
If you haven’t been active for some time, you should start slowly and build up when putting together a regular exercise programme.

Evidence
Programmes that include stretching or strengthening, designed to ease pain and improve movement, help reduce and prevent back pain.

Safety
Supervised exercise programmes are safe for almost everyone. Don’t exercise strenuously if you have severe osteoporosis or inflamed joints, acute back pain, sprains or fractures. If you have heart or chest problems, get medical advice first.

Cost
There will probably be a small cost (around £10 a class) if you join an organised programme. Your GP can also refer you to the local physiotherapy department.

Further information
Classes and exercise programmes are run in most areas by both local authority leisure services and private gyms.

Summary
In an ordinary aerobics class, your feet are pounding away on hard floors. Doing the same sort of exercise in water has several advantages: it’s far easier on the joints; your muscles have to work harder to move your body through the water; and the buoyancy takes the weight off your back while you stretch and mobilise.

Most classes exercise in the shallow part of the pool, or use buoyant jackets, so you don’t need to know how to swim to do water aerobics.

Evidence
Research suggests that exercising in water is helpful for people with low back pain, though the effects are small and only last for a short time.

Safety
Supervised exercise programs are generally safe for most people. Choose a class at the beginner’s level and check whether the class requires you to swim.

Cost
Classes are run in most areas by both local authority leisure services and private gyms. The former are likely to be inexpensive and then the exercise can be carried for the cost of pool admittance.

Summary
There are many different types of massage, some more vigorous and going deeper into the muscles than others. Massage has traditionally been used for relaxation. It may be just on one part of the body (for example, the back and shoulders), or it can be done on the whole body. Aromatherapy massage uses pleasant-smelling essential oils.

Evidence
Research shows that massage can help ease low back pain. It seems to be particularly helpful in people who also take some sort of exercise.

Safety
Massage is safe if carried out by qualified massage therapists, and it rarely causes problems. Vigorous massage should be avoided if you have blood disorders, some forms of cancer, skin problems or are on blood-thinning medications (such as warfarin). Allergies or skin irritation can occur with some essential oils used in massage.

Cost
Monthly cost will depend on how regularly you receive treatments.

Further information
It is important to find a qualified practitioner such as one registered with The General Council for Soft Tissue Therapies.

Summary
This physical fitness system was developed in the early twentieth century by Joseph Pilates. Core strength is the key idea in Pilates exercise. The core muscles are the deep, inner muscles in your abdomen and back. When they are strong enough, they do a lot to support your spine. If your core isn’t strong enough, your back will easily get tired and sore. But when your core muscles work well together they take the strain off your spine so it can move freely and efficiently.

Evidence
Pilates exercises are popular and seem to help with long-term low back pain, but there is not yet much research in this area.

Safety
Start slowly in a beginners level class and get advice if you aren’t improving.

Cost
Pilates classes are available for low cost if provided by a local authority or up to £10 per class.

Summary
When people think of ‘talking therapies’ they usually mean either counselling or psychotherapy. Counselling and psychotherapy aim to help people change thoughts, feelings and attitudes. Counsellors help you talk about difficult feelings and understand conflict. It can be helpful just to have time alone with a counsellor to talk in confidence about how you feel. Spending time reflecting on problems often brings insight and puts things into perspective. Psychotherapy helps people learn better ways of thinking or behaving that can reduce their symptoms, disability and distress. Some psychotherapists are trained to help you explore possible causes of distress or symptoms in your past. Cognitive behavioural therapy (CBT) is the type of psychotherapy that is currently most widely available in the NHS.

Instead of exploring causes of distress or symptoms in the past (like many other types of therapy), CBT looks for ways to improve your state of mind right now. The therapist does this by helping you spot unhelpful thought processes and change them. The Royal College of Psychiatrists says “CBT can help you to change how you think (‘cognitive’) and what you do (‘behavioural’)”. For instance, CBT can help you make sense of what seem like overwhelming problems by breaking them down into smaller parts. This makes it easier to see how they are connected and how they affect you.

A recent piece of research showed that six 90 minute group therapy sessions helped people who had long-term back pain. The sessions based loosely around CBT and relaxation techniques helped them overcome worries about getting active again and learn how to avoid flare-ups. People said they were still feeling better a year after the programme.

Evidence
There is good evidence that CBT and relaxation techniques can help you if you have long-term, persistent, low back pain. It probably helps in at least two ways: by helping people overcome their fear of getting active, and by teaching relaxation skills.

Safety
CBT techniques are generally safe if carried out by or under the guidance of a qualified counsellor or psychologist.

Cost
In most areas your GP can refer you for CBT or a psychological therapist in the NHS. There are often long waiting lists. A session of CBT or psychological therapy may cost between £20-£50. Frequency will depend on you and your therapist. A typical course of CBT lasts between 6-12 weekly sessions

Further information
It is important to find a qualified counsellor or psychologist. Contact The British Psychological Society.

Summary
Tai chi is also known as ‘moving meditation’ It is a series of slow, graceful, controlled movements, which develop strength, balance, posture and inner peace. It is a discipline that has to be learned in a class from a teacher and can then be practised at home.

Evidence
There is some research suggesting that tai chi can help people cope with back pain and move more easily.

Safety
Tai chi is safe for most people. Though it is slow and gentle, anyone with severe osteoporosis, joint problems, acute back pain or recent injuries should avoid strenuous exercise and build up gently.

Cost
Once you have learned the movements, you can do the exercises at home, at no cost.

Further information
Classes are run in most areas by both private tutors and by adult education services or you can contact the The Tai Chi Union.

Summary
Yoga, as taught in the UK, generally includes physical postures or stretches, breathing techniques, meditation and relaxation. There are several different types of yoga. Some of them are mainly based on the physical exercises (some types are much more strenuous than others). Others focus more on meditation.

Evidence
Three trials (one of which was a good-quality study) have compared yoga with other types of exercise. All three suggested that yoga can help with chronic low back pain.

Safety
Yoga is generally safe when practised appropriately and at the right level. Classes are run for different ability levels so look for one that is right for you. Yoga stretches should be increased slowly. If in doubt, check with your doctor, osteopath or physiotherapist. Avoid with severe osteoporosis or acute joint or back pain, or recent injuries.

Cost
You will have to pay for the classes but once you have learned this technique you can practise it at home at no cost.

Further information
Classes are run in most areas by both private tutors and by adult education services. To find a qualified teacher near you see also the The Yoga Alliance
and the The British Wheel of Yoga.